Be on a look out for Scans, TPIs, and more
Though coding for whiplash diagnosis and treatment is pretty straightforward, you should still watch out situations when the patient’s symptoms persist despite conservative therapy and warrant more extensive treatment. You will miss your pay if you miss these diagnoses.
When a patient presents with whiplash symptoms, your pain management specialist will conduct a thorough exam and will often order neck x-rays to rule out fractures. On diagnoses of whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), he typically will prescribe conservative treatment. Common options include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also benefit from wearing a soft cervical collar or by using a portable traction device.
If conservative treatment fails, the physician might order additional diagnostic imaging tests. These could include:
- CT scans – 70490 (Computed tomography, soft tissue neck; without contrast material), 70491 (… with contrast material[s]) and 70492 (… without contrast material followed by contrast material[s] and further sections)
- MRIs – 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face and/or neck; without contrast material[s]), 70542 (… with contrast material[s]) and 70543 (… without contrast material[s], followed by contrast material[s] and further sequences)
- Bone scans – CT, MRI, and x-ray tests include basic bone scans. If your physician orders more extensive bone scans for the patient, you might to get authorization for 78300 (Bone and/or joint imaging; limited area) or 78305 (… multiple areas) instead.
Correctly Count Trigger Point Injections
Your physician might also administer trigger point injections to relieve the patient’s pain and muscle tenderness. Code these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (…three or more muscles).
Because of the “one or two muscles” and “three or more muscles” distinction between codes, you’ll report a maximum of one unit for either 20552 or 20553 for an encounter — not both codes. For example, if your pain management physician injects trigger points in a total of four separate muscles, compliant coding would be one unit of 20553.
When more conservative treatments for whiplash don’t help the patient enough, 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).
Physicians use fluoroscopic guidance to help ensure they inject the correct site. In previous years, you reported fluoroscopic guidance in addition to the injection procedure code. CPT 2010 introduced codes 64490-+64492, which include fluoroscopic or CT guidance. Now you simply report the injection.
Providers often administer facet joint injections unilaterally. If your physician administers bilateral injections, remember to append modifier 50 to the injection code(s).
Certain factors (age, gender, and pre-existing conditions like arthritis) can influence the severity and prognosis of whiplash injuries. When the patient does not respond to more conservative treatments or if her symptoms worsen, your physician may re-evaluate her for other disorders.
In these instances, code the additional diagnoses along with whiplash.
Your pain specialist might determine that the patient’s presenting symptoms and/or test results indicate occipital neuralgia (723.8, Other syndromes affecting cervical region), spondylosis (721.0, Cervical spondylosis without myelopathy) or herniated disc (722.0, Displacement of cervical intervertebral disc without myelopathy). These diagnoses can help justify greater pain management intervention (such as cervical epidurals, facet blocks, or even referral to surgery).
If nerve blocks fails to bring the patient long-lasting relief, your pain specialist may consider paravertebral facet joint denervation. CPT includes two codes for denervation in these cases:
- 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].
As with nerve blocks, physicians often perform the therapeutic destructive procedures as unilateral procedures. If your specialist performs a bilateral procedure, append modifier 50 and document which joint levels he treated.
With the prevalence of whiplash injury and the range of treatment options for whiplash and related disorders, physicians and coders need to know what payers cover — and what they don’t.