Therapy Progression for Proper Whiplash Coding

Published: 28th February 2011
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Coding for whiplash diagnosis might be a cakewalk, however don't take it too easy. Keep looking for situations when the patient's symptoms persist in spite of conservative therapy and demand more extensive treatment. Not paying heed to these diagnoses can mean missed pay.

Watch for move from therapy to scans

When a patient presents with whiplash symptoms, your pain management specialist will carry out a thorough exam and will carry out a comprehensive exam and will often order neck x-rays to rule out fractures.

Initial steps: Once the pain specialist diagnoses whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), he normally will prescribe conservative treatment. Common options cover physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also stand to gain from wearing a soft cervical collar or by using a portable traction device.

If conservative treatment fails to make an impact, the physician might order additional diagnostic imaging tests.

Count trigger point injections the right way

Your physician might also administer trigger point injections to relieve the patient's pain and muscle tenderness. Report these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (...three or more muscles).

Note of caution: The difference between the two codes is the number of muscles the physician injects, and not the number of trigger points or the number of injections he administers.

The descriptors clarify that if your provider documents a different muscle, you can count the number of muscles to determine the difference between 20552 and 20553. However if the provider injects multiple trigger points within the same muscle, you only count one muscle, irrespective of the amount of injections.

Watch out: Owing to the 'one or two muscles' and 'three or more muscles' distinction between codes, you will report a maximum of one unit for either 20552 or 20553 for an encounter - not both codes. For instance, if your pain management physician injects trigger points in a total of four separate muscles, compliant coding would be one unit of 20553.

For more pain relief, move to nerve blocks

When more conservative treatments for whiplash fail to help the patient, your physician might administer nerve blocks to help diagnose a patient's condition and/or provide therapeutic pain relief. Common options include lidocaine and/or steroids such as methylprednisolone acetate (J1020) into cervical facet joints (such as C3-4 and C4-5).

Report it: Code the block at the first facet joint level with 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level). Submit blocks at additional facet joint levels on the following lines of your claim with +64491 ( second level [List separately in addition to code for primary procedure]) and +64492 (... third and any additional level[s] [List separately in addition to code for primary procedure]) as proper.

Guidance: Physicians go for fluoroscopic guidance to help ensure they inject the proper site. Earlier, you reported fluoroscopic guidance in addition to the injection procedure code. Last year, CPT introduced codes 64490-+64492, which include fluoroscopic or CT guidance. Now you can simply code the injection.

Bilateral question: Often, providers administer facet joint injections unilaterally. If your doctor administers bilateral injections, remember to add modifier 50 (bilateral procedure) to the injection codes.

Be on the lookout for add-on diagnoses

Some factors (age, gender, and pre-existing conditions like arthritis) can have an impact on the severity and prognosis of whiplash injuries. When the patient doesn't respond to more conservative treatments or if her symptoms get worse, your physician may re-evaluate her for other disorders.

In these instances, report the additional diagnoses along with whiplash.

Depend on nerve destruction as last recourse

If nerve blocks don't bring the patient long-lasting relief, your pain specialist may consider paravertebral facet joint denervation.

Document it: Prior to taking the patient's treatment to this level, your physician should have thorough documentation of other treatments. The patient's chart should cover two important details:

  • The proper diagnostic paravertebral facet joint block or medial branch nerve block studies that identify the specific joint level

  • Documentation that the patient had significant however not long-lasting -- pain relief from the facet joint blocks. Some payers are beginning to need actual documentation and quantification of the patient's status. For instance, the payer might want details regarding the percentage of change in pain, duration of pain relief, and changes in the patient's functional status during relief from the diagnostic blocks.

    If the patient meets these criteria, your physician may use paravertebral facet joint denervation to treat back or neck pain following whiplash/post-traumatic injury and to relieve the pain of associated cervicogenic headache.

    In these cases, CPT includes two codes for denervation:

  • 64626 -- Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level

  • +64627 -- each additional level [list separately in addition to code for primary procedure].

    Just like nerve blocks, physicians often carry out the therapeutic destructive procedures as unilateral procedures. If your specialist carries out a bilateral procedure, add modifier 50 and document which joint levels he treated.

    Bottom line: With the prevalence of whiplash injury and range of treatment choices for whiplash and related disorders, physicians and codes need to know what payers cover and what they do not.

    For more specialty-specific articles to assist your pain management coding, sign up for a good Medical coding resource like Coding Institute.

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