Coding to New Heights Education Newsletter February 2019 Edition

Peak Health Solutions - Feb 19, 2019


Welcome to our Monthly Peak Coding Education Newsletter, Feb 2019 Edition! This month we'll discuss:
Complex Regional Pain Syndrome for ICD-10-CM, Neurostimulator Device Implantation for ICD-10-PCS, CPT Changes for Neurostimulator Evaluation, Spinal Nerves and Parts of the Body They Control, E/M ProFee Trigger Point Injection for Pain Management, Functional Quadriplegia: Definition and Clinical Indicators in our CDI Corner, Anticonvulsants used to control neuropathic pain in our Pharmacology Spotlight and test your knowledge with a a Code Puzzler that might give you a Migraine!

In This Issue

funny-documentation-fail-125X125-BFunny Documentation Fail

“He Had A Left Toe Amputation One Month Ago.  He Also Had A Left Knee Amputation Last Year."



Complex Regional Pain Syndrome CRPS

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

Complex Regional Pain Syndrome (CRPS) is just that – Complex. Categorized into two types; Type 1 previously known as reflex sympathetic dystrophy (RSD) occurs after an injury not directly impacting the nerves such as a fracture. Type 2 also known as causalgia occurs from a direct nerve injury. The exact reason this condition occurs in some people and not others is unknown.

Type 1: The most common form of CRPS occurs typically after an injury to the hand or foot. Diagnosis is only possible by assessing the patient’s symptoms against The Budapest Criteria. These criteria assess the patient’s signs and symptoms in four areas – sensory, vasomotor, sudomotor, motor. CRPS is diagnosed if at least one symptom in each category is present and if there are no other diagnoses to explain the symptoms. 

The most common complaint is an intense burning pain that’s disproportionate to the original injury. This pain can migrate to other limbs and skin can become overly sensitive, swollen, and even change color. The patient may also complain of excessive sweating in the affected area. Because pain is so intense physical and occupational therapy can be very difficult for patients making pain control the number one obstacle to treat. 

Therapy is multimodal including medication, sympathetic spinal blocks, psychologic therapy, neuromodulation, and mirror therapy. Surgical options are implantation of spinal neurostimulators or an implantable ? intrathecal drug pumps.

Coding CRPS Type 1 in ICD-10-CM is done by identifying the type, limb affected and laterality. The code category is G90.5xx and carries a CC (Complication/Comorbid) status as well as an SOI (Severity of illness) value of 2 therefore impacting reimbursement. 

Type 2: More uncommon than Type 1 has the same symptoms and treatment as Type 1 with one distinguishing difference - the pain doesn’t migrate to other areas. 

When assigning an ICD-10-CM code for Type 2 CRPS the coder is directed to see causalgia by the index under the main term syndrome. Causalgia has the choice of upper or lower limb leading the coder to G56.4x for upper and G57.7x for the lower limb. From there laterality is determined.


Neurostimulator Device Implantation

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Neurostimulator devices are used to treat chronic pain or movement disorders such as Parkinson’s and essential tremors. Devices used for pain control may be documented as spinal cord stimulator or (SDS) and devices used for movement control may be documented as deep brain stimulation or (DBS). 

The neurotransmitter device market is dominated by four companies: Medtronic, Boston Scientific, Cyberonics, and St. Jude Medical. Chances are that the medical record documentation you are reading will list one of these companies as the manufacturer. 

When assigning an ICD-10-PCS code for insertion of a neurotran smitter system, a code fo
the placement of the generator intosubcutaneous tissue of the chest, back, or abdomen is assigned and a code for the lead placement. Documentation must be reviewed to determine if the generator (battery) is rechargeable or non-rechargeable and if it’sNeurostimulator-Device-Implantation a single array or multi-array device. More commonly used is a multi-array pictured below. Multi-array refers to the number of ports on the generator where the leads can be “plugged” in.

Surgical approach can be open or percutaneous. For SDS percutaneous fluoroscopy is used for placement of a spinal needle into the epidural space. The lead is then threaded through the needle and advanced to the selected location within the epidural space. When done with open approach the target vertebra is exposed by dissection and hemilaminectomy is performed the expose the epidural space. The lead is then placed into the epidural space and advanced to selected location. The PCS code Table for stimulator Insertion is 0JH and Tables for lead insertion are 00H and 01H. From there Body part, surgical approach, device and qualifier are chosen.

Neurostimulator-Device-Implantation-image-2For placement of a DBS system the leads are placed through small burr holes in the skull. Burr holes are considered percutaneous approach in PCS. The generator is placed in the subcutaneous tissue of the chest and attached to an extension wire that connects the leads to the generator.





Medicine Section 2019 CPT Changes For Neurostimulator Evaluation

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educato

The 2019 CPT updates brought about numerous changes to programming and analysis services performed on existing previously placed neurostimulators. Analysis being one type of service and programming being another. These codes are found in the 95970-95984 series. In order to accurately assign the codes, the coder must determine if analysis alone was done on a neurostimulator placed within the brain, cranial nerves, spinal nerves peripheral nerves, or sacral nerve. If so assign 95970. 

If programming was also done the coder must then determine if programming was simple or complex. Simple programming is defined as adjustment to 1 to 3 parameters and complex is 3 or more. The parameters listed under the code series are: Amplitude, Burst, Cycling on/off, Detection algorithms, Dose lockout, Frequency, Pulse width, Responsive neurostimulation. IF A SINGLE PARAMETER IS TESTED MULTIPLE TIMES IT STILL COUNTS AS ONE PARAMETER. 

Codes 95971 and 95972 are for spinal stimulator programming, 95976 and 95977 are for cranial stimulators. 

Brain (Deep Brain Stimulators) programming require face-to-face time with the physician or other healthcare provider and are based on 15-minute increments with each 15 minutes being a unit of service. A unit of service is counted when the midpoint of 15 minutes has passed therefore, any unit of time under 8 minutes is not reportable.


E/M ProFee

Trigger-Point-Injection-image-1Trigger Point Injection For Pain Management

Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA
Pro-Fee Lead Auditor

What is a trigger point injection?
It is one option for treating pain in some patients. The procedure is used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, it can be felt under the skin and feel as small as a pea or as large as a walnut—embedded within muscle tissue. The pain one feels from pressing on a trigger point usually radiates in a region that is away from the trigger point. 

The illustration below identifies some trigger point locations, the primary referral area and a possible spillover referral area.


When is a trigger point injection used?

When trigger points are firmly pressed, the entire muscle can twitch or spring into spasm. These points are often located in the neck, back or shoulder muscles and can cause pain in all the muscles close by. Trigger points can appear in many myofascial structures, including muscles, tendons, ligaments, skin, joint capsule, periosteal and scar tissue. They can be caused by acute or chronic muscle overload, activation by other trigger points, disease, psychological distress, direct trauma to the region, infections or simply by pain nearby. Injections provider more immediate relief and can be effective when other methods fail. Various injections can be used, including saline, local anesthetics such as lidocaine, steroid, and Botox.

Tips for Documenting Injections Appropriately

Injections like facet injections, trigger point injections, and nerve blocks (all of which are used in pain management) require a significant amount of documentation, particularly when multiple levels are involved.

  • For facet joint injections determine the spinal levels involved in the injection
  • Route the needle took and the final position of the needle used
  • Whether any fluoroscopic guidance was used in the procedure
  • Diagnoses supporting the procedure
  • Medical necessity supporting the procedure
  • Specific medication that was injected
  • For trigger point injections, all muscles must be documented, as well as laterality (coding depends on the number of muscles injected)
  • See CPT 20552 and 20553 for specific trigger point injection codes

Per Coders’ Desk Reference for 2019

CPT 20552-20553
The physician injects a therapeutic agent into a single or multiple trigger points’ of one or two muscles in 20552 and into a single or multiple or multiple trigger points for three or more muscles in 20553. The physician identifies the trigger point injection site by palpation or radiographic imaging and marks the injection site. The needle is inserted and the medicine is injected into the trigger point. The injection may be done under separately reportable image guidance. After withdrawing the needle, the patient is monitored for reactions to the therapeutic agent.

Per CPT Assistant, June 2017, Volume 27, Issue 6, Page 10

Question: How many times may code(s) 20552-Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) and 20553-Injection(s); single or multiple trigger point(s), 3 or more muscles, be reported per session with imaging guidance?
Answer: The trigger point injection codes (CPT 20552 and 20553) are reported once per session based on the number of muscles injected, regardless of the number of trigger points injected in each muscle. CPT code 20552 is reported for trigger point injection(s) in 1 or 2 muscles and CPT code 20553 is reported for trigger point injection(s) in 3 or more muscles. If imaging guidance is utilized, report the appropriate Radiology CPT code (76942, 77002 and 77021) in addition to the injection codes.



Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA
Pro-Fee Lead Auditor

Can you find all the different words related to neuroanatomy in this puzzle? 
The words can be up, down or backwards.


Synaptic cleft




Spinal Nerves & Parts Of The Body They Control

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

There are 31 pairs of nerves that arise from the spinal cord which lie protected within the bony vertebra. Designated as pairs because they have two branches, one for sensory function (pain, touch, temperature, numbness, tingling, itching, etc.), and one for motor function (carrying impulses to muscles for movement). Each of these pairs are assigned an area of the body to control.

Understanding the area in which an injury occurs can assist the coder in better understanding the parts of the body affected. The chart demonstrates the parts of the body each of these pairs have in their command.







CDI-Coner-Functional-Quadriplegia-imageCDI Corner

Functional Quadriplegia – Definition And Clinical Indicators

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Functional quadriplegia is defined by ICD-10-CM as the inability to move due to a non-physiological condition, such as dementia. The patient has no mental ability to move independently. Some of those non-physiological conditions are multiple sclerosis, amyotrophic lateral sclerosis (ALS), Huntington’s Disease profound intellectual disability, progressive arthritis. The patients that fit into this category are at greater risk of pressure ulcer, malnutrition, moisture associated dermatitis infections, contractures, fecal and urine incontinence, pulmonary atelectasis, and aspiration pneumonia. All of which any good experienced CDI and Coding professional knows are conditions that have an impact on reimbursement. 

Functional quadriplegia is coded as R53.2 and is often overlooked as a secondary diagnosis. The term functional quadriplegia was created by ICD-10 (who?) meaning it did not originate from a clinical source therefore may not be documented as such by providers. This diagnosis carries the designation of MCC (Major Complication Comorbid) and impacts SOI (severity of illness) and ROM (risk of mortality) as it also carries an HCC (Hierarchical condition category) status.

In the excludes 1 note under code R53.2 the conditions of frailty, hysterical paralysis, immobility syndrome, neurologic quadriplegia, and quadriplegia are listed meaning NOT CODED HERE. So, if documentation is contradicting, we do what all good CDI Pros do and Query the provider.

The following list gives some potential places in the medical record to look for clues or clinical indicators:

  • If present review the Braden Scores in nursing documentation of complete immobility or very limited mobility and of the patient being bedridden or chair ridden
  • Review physical and occupational notes for mention of patient being total or maximum assist
  • Look for terms like “very limited mobility”, “bedbound”, “complete immobility” and “total care”


Pharmacology Spotlight

Anticonvulsants Used To Control Neuropathic Pain

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Anticonvulsants originally intended to treat only epilepsy are also being used to treat neuropathic pain because of their effect on nerve signals. Drugs such as Neurontin®, Lyrica®, Tegretol®, Dilantin®, and gabapentin are being prescribed to treat conditions such as CRPS, fibromyalgia, diabetic neuropathy, postherpetic neuralgia, trigeminal neuralgia, and migraines. Important to note here that these drugs can also put the patient at risk of suicidal thoughts or actions.  The interesting fact is that antidepressant medications such as Cymbalta®, Effexor®, Elavil®, and Pamelor® carry pain relief mechanisms as well and when combined with antiepileptic medications can have a positive impact on controlling neuropathic pain. Finding the perfect combination of these drugs can take a considerable amount of time.  


The Code Puzzler

A Code Puzzler That Might Give You A Migraine

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

A 33-year-old female presents to the ER complaining of a headache stating she suffers from chronic intractable cluster headaches. Her sister stated that just before her headache got worse, she was unresponsive and staring into space for a few minutes. The patient is treated and released with the diagnosis of intractable migraine with aura and status migrainosus, seizure and exacerbation of intractable chronic cluster headache.

ANSWER:  Highlight the text below to see if you were correct!

CPT® codes, descriptions and other data are copyright 1966, 1970, 1973, 1977, 1981, 1983-2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. U.S. GOVERNMENT RIGHTS. CPT is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which were developed exclusively at private expense by the American Medical Association, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015 (b) (2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1 (a) (June 1995) and DFARS 227.7202-3 (a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. This file may not be sold, duplicated, or given away in whole or in part without the express written consent of the American Medical Association. To purchase additional CPT products, contact the American Medical Association customer service at 800-621-8335. To request a license for distribution of products with CPT content, please see our Web site at or contact the American Medical Association Intellectual Property Services, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885, 312-464-5022.

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