Neurology & Pain Management Coding Alert

What should you do if your neurologist provides pain management services for a patient with chronic and acute pain but who does not exhibit a definitive and exact diagnosis? Although you may be tempted to alter diagnoses to ensure payment, this is unnecessary and far from the best solution.

Report ICD-9 Codes Accurately, Every Time

 When reporting diagnoses, you should always be as exacting as possible. "Specificity is crucial," says Teresa Thompson, CPC, an independent coding and reimbursement specialist in Sequim, Wash.

 For instance, consider the following scenario: A patient comes to the office complaining of severe, chronic pain in her lower back, which started two months ago. Following examination, the neurologist performs two trigger point injections to relieve the patient's pain. His chart notes indicate that the patient had "back pain."

 The coder receives the chart and notes that the neurologist has performed trigger point injections in the past and coded them using 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). She recalls that the most recent injections performed on patients' backs were for sciatica, and she assumes in the absence of a more specific diagnosis that the present patient also has sciatica. She reports one unit of 20552 (because both injections were performed on the same site, which would not warrant billing two units) with a diagnosis of 724.3, and the carrier pays the claim accordingly. But just because the claim is paid does not mean that it was coded correctly.

 "If a patient does not have a diagnosis listed as acceptable on the local medical review policy [LMRP], you cannot create one just to get paid," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "Is back pain the same thing as sciatica? No. But the practice will probably get paid because sciatica is on the approved list." If your physician did not specifically document sciatica, you could be in trouble during an audit. "This is the kind of thing that the OIG [Office of Inspector General] is targeting," Jandroep says.

 For instance, some carriers reimburse for "backache, unspecified" (724.5) for trigger point injections, so you should read your LMRP carefully to determine whether the diagnosis fits the payer's rules. "You have to be as specific as you can," Jandroep says, "which may sometimes mean that your physician performs services that are not ultimately going to be reimbursed. If you anticipate that the payer will not honor the injection codes based on the diagnoses [such as "generalized pain," 780.99], you can ask the patient to sign an ABN [advance beneficiary notice] prior to the injection." Although an ABN may not be [...]