Phantom Limb Pain

I work at a pain management facility, and our physicians have been putting in diagnosis for phantom limb pain. However, all insurances deny both G54.6 and G54.7. At first I thought it because of coding with like radiculopathy, but then we had a visit where they only coded out the phantom limb pain. We usually have to change the Super Bill to remove the codes. One of our physicians is asking, "what if the patient does have phantom limb. what are they to use instead." I have tried coding it with the Z code for acquired absence of limb, below or above knee...it still denies. is there anyway we can still code for phantom limb? or what are we doing wrong.

It isn't clear that you are doing anything wrong. Even when coding one of the conditions listed in the Excludes1 note to G54 codes, ICD-10-CM guidelines state, "An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other." When phantom limb symptoms are distinct from radiculopathy affecting other sites, payers that added Excludes1 edits are likely to deny coverage and force an appeal (best to include the physician's diagnoses (eg, the assessment and plan of an E/M service) and the ICD-10 guideline in the appeal letter). I hear that multiple levels of appeal are often necessary. Also, the physician's specialty society can advocate to the ICD-10-CM Coordination and Maintenance Committee for change to the Excludes1 note to G54 (eg, change it to an Excludes2 or move the Excludes1 note to specific G54 codes excepting G54.6 and G54.7).

A combination of the G54.6 or G54.7 codes with Z89 codes for absence of a limb without a code for another neurologic/musculoskeletal condition shouldn't result in a denial. Suggest looking at the denial codes/messages to see if that is at all helpful. When correctly reported ICD-10 codes result in denials due to restrictive payer edits, your practice can file a complaint with CMS (https://asett.cms.gov/complaints).

Best wishes,
Cindy