Counting the Number and Complexity of Problems Addressed

Question:

Would cervical and lumbar radiculopathy count as one or two problems, and are they considered acute, chronic, stable, or not stable on the table of risk?

Answer:

Good questions! First, the number of problems would be two since these are different body parts, and each will require its own diagnosis and treatment recommendation.

The next is issue is, are the presenting problems acute or chronic, and that will require a good history of present illness, detailing how the problem presented. Was it an injury? Is it degenerative, so by the very nature of degenerative disease it is chronic. An accurate selection of where the problems “fit’ within the problem element cannot be determined without a good history.

*This response is based on the best information available as of 12/19/24.

Risk of Patient Management

Question:

Is a decision to NOT perform an injection with risk factors discussed “moderate” risk?

Ex: The patient has done 6 weeks of physical therapy for their spinal stenosis, which has provided some relief, but he is not at the treatment goal. We discussed performing a lumbar epidural steroid injection with the risks of the procedure, including bleeding, infection, and nerve damage. The patient is a diabetic, and we discussed the risks of the corticosteroid injection elevating blood glucose levels. After this discussion, he elected to continue PT and avoid injection at this time.

Answer:

Yes, a decision for treatment, in this case, an epidural injection, is a medical decision made by the physician. Even if the patient defers this recommendation, it still constitutes a medical decision and one with documented patient and procedure risks.

Per CPT Guidelines:

For the purposes of MDM, the level of risk is based upon the consequences of the problem (s) addressed at the encounter when appropriately treated. Risk also includes MDM for initiating further testing, treatment, and/or hospitalization.

1) The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified healthcare professional during the reported encounter.

2) Includes the possible management options selected and those considered but not selected after sharing MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care.

*This response is based on the best information available as of 12/5/24.

Number and Complexity of Problems Addressed

Question:

I see a lot of patients with chronic pain and other issues. What defines “stable” vs. “exacerbation or progression”?

Answer:

Number and Complexity of Problems Addressed

Per the CPT guidelines, ‘stable’ for the purposes of categorizing medical decision-making is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

A chronic illness with exacerbation, progression, or side effects of treatment is a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control the progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.

For all E/M codes, while it doesn’t contribute to code selection, documenting the history of the present illness (HPI) is crucial documentation. The provider must document each problem addressed and indicate stable, acute, chronic, exacerbation, etc., for each problem. Incorporate the terms exacerbation (getting worse) and severe exacerbation (getting significantly worse, requiring significant treatment changes) in your assessment when applicable. Be sure to document a recommendation (plan of care) for each problem addressed (i.e., stable, make changes, order additional testing).

*This response is based on the best information available as of 11/17/24.

Risk of Patient Management

Question:

I am a Pain Management Physician. I have a patient with lumbar spinal stenosis who has completed two months of physical therapy and 2 epidural steroid injections, but significant pain still persists. Since extensive conservative management has failed to provide adequate relief, I now recommend a surgical consultation with a spine physician. I document, “We discussed risks of surgery including bleeding, infection, nerve damage as well as patient-specific risks including hypertension. After discussing the risks and benefits of surgery, the patient elects to continue conservative management”. Does this count as a decision for surgery (moderate risk)? I am not clear on if I can make a “decision for surgery” as a non-surgical physician.

Answer:

Thank you for your inquiry. In answer to your question, no, this would not be a decision for surgery on the MDM table of risk. You are not the surgeon; you are considering a surgical consultation. The surgeon is the provider who makes the decision for surgery.

*This response is based on the best information available as of 10/17/24.

Sphenopalatine Ganglion Block with Medication Delivery

Question:

One of our physicians is using a device to deliver medication through the nose when a sphenopalatine ganglion block is performed under fluoroscopic guidance for patients with migraine headaches.  Can we report 64505 for this service?  If not, what is the best code to report?

Answer:

 There is no specific CPT code that accurately describes the service.  The code set includes CPT code 64505, which describes the injection of the sphenopalatine ganglion; however, it is inappropriate to report this code since an injection is not performed. Therefore, the unlisted code 64999, Unlisted procedure, nervous system, should be reported. 

Another variation on blocking the sphenopalatine ganglion is using a Q-tip to apply anesthetic topically through the nose. There is no specific CPT code for this procedure, which is best reported as part of the E/M service. 

*This response is based on the best information available as of 10/17/24.

Paraspinal Intramuscular Injections

Question:

The type of injections our physicians perform are best described as paraspinal intramuscular injections or paraspinal nerve blocks without radiographic guidance. We are unsure how to code this procedure. What is the best code to use?

Answer:

Any injection around the spine without imaging guidance is best described as a trigger point injection.  The number of muscles injected determines whether CPT code 20552 (1 or 2 muscles) or CPT code 20553 (3 or more muscles) is billed.  If one muscle is injected multiple times, it should be coded with the lower code 20552.

*This response is based on the best information available as of 9/16/24.