Dx Coding Moves That Stop Denials for Chronic Pain Claims
Posted on 03. Feb, 2009 by Editor in Hot Coding Topics
Tip: Code prior conditions in these cases.
Imagine your pain management specialist treats a chronic pain patient, but during the visit your physician isn’t able to uncover a definitive diagnosis. While you know that altering or guessing a diagnosis to ensure payment is wrong, there are codes you can choose from to handle the situation–if you know the ropes.
“Using a non-specific diagnosis code, which may be ‘close’ but not exact, may mean you will not be paid for a service due to a Medicare Local Coverage Decision [LCD] or a third-party medical policy,” explains Mary H. McDermott, MBA, CPC. Or it may mean you are paid in error for a service for which there would be no coverage if you had used the right diagnosis.
Here’s how to use the most specific diagnosis appropriate for the patient and make sure it is well-documented in the medical record.
Imagine Patient A complaining of severe, chronic pain in the right side of his back. The pain began about 10 months ago. Your pain management specialist performs an examination and then provides two trigger point injections in the right lumbar multifidus muscle for pain relief. However, his chart notes reveal only “the patient has back pain.”
You receive this chart and note your physician performed trigger point injections on other patients in the past, using one unit (because trigger point injection coding is based on the number of separate muscles injected and not the quantity of injections performed) of 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]). Let’s say the most recent injections performed on the other patients’ backs were for myofascial pain.
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