Orthopedic Coding Alert

Evidence of previous treatments a part of successful CTS shot claims.

If you're coding for a patient's carpal tunnel syndrome (CTS) injection, be sure to check if the patient has had any less invasive CTS treatments previously.

Why? You could face a denial for the injection if it is an initial visit for CTS, as some insurers allow CTS injection therapy only when other treatments have failed.

Check out these FAQs to make each CTS coding scenario a snap.

Should the Physician Try Other Treatments Before 20526?

Yes. The orthopedist would likely try out less invasive treatments before resorting to CTS injection (20526, Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of Denver's MJH Consulting. These treatments might include, but are not limited to:

• splinting (or bracing)
• medication (non-streroidal anti-inflammatory)
• occupational therapy.

If the patient's symptoms don't improve, the physician may then proceed with a corticosteroid injection of the carpal tunnel," Hammer says.

Caveat: Check with the payer if you are unsure of its "previous treatment" requirements. Even evidence of previous treatments might not be enough to convince some insurers, says Jacqui Jones, office manager at an orthopedic practice in Klamath Falls, Ore.

"We have had a couple of contracted HMOs [health maintenance organizations] impose conservative nonsurgical treatment - even with previous treatment and positive nerve conduction velocities ordered by another physician," says Jones.

What Dx Codes Support Carpal Tunnel?

Patients that become candidates for may present initially with "complaints of progressively worse numbness and tingling in their hand and wrist, particularly the thumb, index and middle finger," explains Hammer.

As the CTS symptoms get worse, the patient may experience piercing sharp pain in the wrist, potentially radiating into the affected arm (719.43 Pain in joint, forearm or 729.5 Pain in limb). The patient's symptoms are usually worse at night, and the patient may also have complaints of burning sensation in the hand or decreased grip strength (728.87 Muscle weakness).

Documentation clues: For a patient with CTS, the physician may document that the patient has one or more of the following: a positive Tinel's sign (lightly tapping over the median nerve at the patient's wrist reproduces the tingling sensation in the hand) a positive Phalen's maneuver (wrist flexion test in that the patient's paresthesia symptoms are reproduced within 30 seconds to 1 minute after the patient holds their wrist in a maximally flexed position).

The physician may also order nerve conduction velocity studies to confirm the CTS diagnosis if the physical exam is not conclusive.

What Documentation Specifics Do I Need for 20526?

Most coders agree that some documentation indicating previous attempts to treat the injury will only help a 20526 claim.

"Best practice documentation of procedures should include the patient's response to previous [CTS] treatments. Even though the CPT code for carpal tunnel injection falls in the musculoskeletal surgery section of the codebook, only a few payers or providers view this injection as a 'surgery,'" Hammer relays.

A solid 20526 claim "should indicate all methods of 'non-operative' treatment that have been tried prior to the decision that surgery was needed," Nelson says.

"If the carrier needs additional information at that point, then the coder can submit office notes or any other information to support medical necessity," explains Nelson.

Example: Operative notes for a 20526 claim include the following phrases:

• "Nighttime wrist splint therapy began 11/22/10."
• "Weekly PT sessions and strength and stretching regimen began 9/31/10."
• "Steroidal therapy began 11/22/10."

How About a Clinical Example?

An established patient who has been to the office twice previously for right wrist pain returns to the office complaining of severe pain, tingling, numbness and poor grip strength in the hand. "I cannot even hold onto a plate," he says. The patient rates the pain as 9 on a scale of 10.

The patient has undergone physical therapy and used a night splint to ease the pain, but neither has proven effective. During a level-two E/M service, the patient has a positive Tinel's and Phalen's sign, which is conclusive enough to confirm CTS.

The orthopedist then performs a therapeutic CTS injection into the carpal canal, and instructs the patient to return in two weeks if the condition does not improve.

For this encounter, you should report the following:

• 20526 for the CTS injection
• 354.0 (Mononeuritis or of upper limb and mononeuritis multiplex; carpal tunnel syndrome) appended to 20526 and 95860 to represent the patient's CTS.