Pain Management Coding Alert

Published on Tue Jun 30, 2015 PDF

Here’s how to justify every level of treatment. 

Heel pain affects nearly 2 million Americans, which means it’s not uncommon for a neurologist or pain management specialist to be consulted if the pain escalates. The most common form of hindfoot pain is plantar fasciitis, a condition in which the plantar fascia becomes inflamed and painful. Physicians have several treatment options for plantar fasciitis, so encourage a good “paper trail” that documents every step and helps justify medical necessity at every level. 

Starting point: Most plantar fasciitis pain is located close to where the fascia attaches to the calcaneus, or heel bone. The exact cause of plantar fasciitis is unknown, but once your physician diagnoses plantar fasciitis you’ll report diagnosis 728.71 (Plantar fascial fibromatosis). When you begin coding with ICD-10, that diagnosis will change to M72.2 (Plantar fascial fibromatosis). 

Document the Move to More Official Treatment

Your physician will begin by treating the patient’s plantar fasciitis conservatively with pain relievers, home exercises, night splints, or rest. He then will alter the plan as needed. 

Tip 1: Verify that your physician includes detailed notes about the patient’s condition, pain level, any functional limitations, and response to treatment at each visit. Gathering that information over a period of time will help support the need for more involved treatments if the patient’s condition doesn’t improve.

Probable option: Your physician might administer a cortisone injection directly to the plantar fascia. Code this treatment with 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar “fascia”]). You can also code for the medication, such as J0702 (Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg) for Celestone Soluspan. 

Tip 2: Keep an eye on multiple procedures or services during the same encounter, such as an injection followed by strapping to further alleviate pain (29540, Strapping; ankle and/or foot). You might be able to report both services because the injection and strapping provide different therapeutic effects, but check your payer’s guidelines before submitting your claim. Correct Coding Initiative (CCI) edits bundle 29540 as a Column 2 component of 20550. 

Accept That Some Treatments Might Not Be Paid

Physicians sometimes successfully treat plantar fasciitis with extracorporeal shock wave therapy (ESWT) if injections and more conservative treatments fail to relieve the patient’s pain. The theory behind ESWT is that shock waves stimulate healing by promoting revascularization. You have two options for reporting ESWT, depending on whether your physician uses high or low energy: 

• 28890 – Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia 

• 0019T – Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy. 

Physicians give low-energy shock wave treatments as a series of three or more procedures. These shock waves either are not painful or are only mildly painful. High-energy shock wave treatments are given in a single session. These treatments are quite painful, and the patient needs some type of anesthesia. 

Heads up: Some payers reimburse for ESWT, but others don’t. “Coverage for this procedure is fairly rare,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. “Many payers [still] deem it an investigational procedure.” 

Prepare: Have clear documentation of other treatments that have failed over a period of months to help support your physician’s choice of ESWT. If the payer does not cover ESWT, obtain an advance beneficiary notice (ABN) from the patient prior to the procedure. 

Final option: Most cases of plantar fasciitis don’t require surgical treatment to stop pain and reverse damage. If all other treatments fail, however, your physician might feel that the patient requires surgery. At that point, he or she can recommend that the patient see a neurosurgeon or orthopedist to have surgical fascia release. Those procedures might include: 

• Endoscopic plantar fascia release (29893, Endoscopic plantar fasciotomy)

• Open plantar fasciectomy such as 28060 (Fasciectomy, plantar fascia; partial [separate procedure]) or 28062 (... radical [separate procedure])

• Open plantar fasciotomy such as 28008 (Fasciotomy, foot and/or toe) or 28250 (Division of plantar fascia and muscle [e.g., Steindler stripping] [separate procedure]) 

• Fascia and muscle separation (28250).

Although your pain management physician won’t perform the surgical release, his or her records will be shared with the surgeon. The coding and documentation based on the diagnosis of 728.71 are the foundation that will help the patient reach long-term relief.