Anesthesia Coding Alert

Carrier Update:

BC/BS Montana Adds Payable Diagnoses to Tendon Injections

Published on Thu Sep 09, 2004

Check your carriers' diagnosis code listings to ensure accuracy

You're coding for accuracy, not for dollars, but it's frustrating when a carrier doesn't include particular diagnoses in its list of medically necessary circumstances for procedures. Now some coders have some good news regarding acceptable diagnoses: Blue Cross/Blue Shield of Montana recently updated its LMRP on trigger point and tendon, ligament and ganglion cyst injections to expand your coding choices.

The policy doesn't change anything related to trigger point injections, but it adds two diagnosis codes that support medical necessity for tendon, ligament and ganglion cyst injections:

724.1 - Pain in thoracic spine

724.2 - Lumbago.

These diagnoses now support medical necessity for:

20526 - Injection, therapeutic (e.g., local anesthetic, corticosteroid), carpal tunnel

20550 - Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar "fascia")

20551 - ... single tendon origin/insertion.

The additional diagnosis codes will help providers achieve more appropriate reimbursement in some situations, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. "Both of the new diagnoses could possibly be used to report 20550 for spinal ligament injections. Some tendon origins and insertions are located along the spinal vertebrae, so the new diagnoses could also apply to 20551. The challenge is that the provider's documentation often doesn't specifically indicate the origin/insertion as the anatomic structure they are injecting so you know to report 20551."

Obviously, physicians will rarely use lumbago or thoracic spine pain as diagnoses in conjunction with a carpal tunnel injection (20526). Hammer's theory is that Aetna might group the three injection codes together for LMRP purposes because they are similar procedures. That would mean the ICD-9 codes get linked with all three injection codes even if they don't support a carpal tunnel injection.

Expect These Injections for Common Injuries

Physicians often perform tendon or ligament injections to treat rheumatism, fibromyalgia and other chronic conditions, says Cindy Clark, CPC, anesthesia coding supervisor with Anesthesiology Consultants in Savannah, Ga. Other common diagnoses that support these injections include 726.39 (Enthesopathy of elbow region; other), 726.71 (Achilles bursitis or tendonitis) and 726.90 (Enthesopathy of unspecified site).

"We see tendon injections more frequently in sports-related or 'weekend warrior' type injuries," Hammer adds. "Physicians frequently use them to treat tendonitis (727.00-727.9), tennis elbow (726.32, Lateral epicondylitis) or golfer's elbow (726.32)."

Hammer's physicians perform a "moderate amount" of ligament injections. Physicians use them to help accident-type injuries and sprains or strains of knees, ankles, low back or other joints (840.0-848.9). Patients receive ganglion cyst injections least often, primarily for problems in their fingers or wrists.

Patients May Have Single or Multiple Injections

Some patients have relief after only one injection, but others need a series of injections. "Patients typically have a one-time procedure for ganglion cyst injections," Hammer says. "The physician can treat the patient with a series of tendon and ligament injections, but one-time injections are more common."

How long the patient has relief from an injection depends on the patient and the medication injected:

Anesthetic: If the physician administers an anesthetic injection, pain relief lasts for the duration of the medication. For example, Lidocaine (J2001, Injection, lidocaine HCl for intravenous infusion, 10 mg) lasts one to two hours, and Marcaine (S0020, Injection, bupivicaine HCl, 30 ml) lasts two to four hours.

Anti-inflammatory steroid: The physician injects these medications for longer-lasting pain relief, but they take one to two days to begin working. The steroid reaches maximum effectiveness in five to seven days. The duration of relief depends on a variety of factors including the severity and reversibility of the patient's condition.

Stay Up-to-Speed With NCCI Edits

None of these injections has global periods associated with them, which means you can bill for each treatment session. But always check the latest round of quarterly National Correct Coding Initiative edits before coding because many edits include these codes.

"Tendon injection codes 20550 and 20551 and trigger point injection codes 20552 and 20553 have mutually exclusive bundling issues to consider," Hammer says, "but you can override these by using modifier -59 (Distinct procedural service) if it applies and if you have appropriate documentation of the procedures."

These injection codes are also component codes of many orthopedic procedures (20000 series) and most spinal injection procedures (64xxx series). Again, you can append modifier -59 in appropriate situations to receive separate reimbursement.

Example: The physician performs an occipital nerve block (64405, Injection, anesthetic agent; greater occipital nerve) with a plantar fascia injection (20550). Code 20550 is a component code of the occipital nerve block, but Hammer says you can override this with modifier -59 with documentation supporting it as two distinct procedures.

Train Providers to Document 5 Key Facts

Whatever type of injection the physician performs, Clark and Hammer agree that obtaining clear documentation of the procedure is a challenge for many coders. Ask your practitioners to include documentation about:

The specific anatomic location of the injection: Writing "tendon injection" doesn't help your coding. Ask the physician to specify if he injected the tendon origin, tendon sheath, ligament, muscle, etc.

The number of separate injections: "Some providers inject in a fan-like method that truly is a single injection," Hammer says. Know exactly how many injections he administered before coding.

A clear understanding of CPT descriptors: Multiple injections into a single tendon or ligament equals a single injection. However, single injections to different and separate tendons or ligaments equals multiple units of the applicable codes. "Getting the physician to properly document the number of muscles injected is the biggest challenge for many coders," Clark says.

The specific medication injected: Carefully read the documentation to bill the correct medication and the correct quantity of units.

Medical necessity: If the physician injects multiple locations or performs multiple procedures, he needs to include documentation that supports medical necessity. If he performs more than three injections, he should also include documentation of the patient's response to these types of therapy.

Final advice: Help train your physicians to thoroughly document their services so you can correctly code injection procedures. If you code for services covered by BC/BS Montana, update your records regarding acceptable diagnoses for tendon injections - and refile your claims, because the change is retroactive to Sept. 1, 2002. Even if you're not affected by this particular LMRP, check with your local carriers to see if others have followed suit.