Anesthesia Coding Alert

Payers allow additional reimbursement when you report multiple units of 20550-20551

Anesthesia coders whose heads are still spinning from the myriad changes that CPT made to the trigger point injection (TPI) codes can finally relax. After two years of tinkering with the TPI codes, CPT Codes 2004 has moved on, and this time tendon and ligament codes got a facelift. Collect the approximately $60 that Medicare allots for 20550-20551 every time by following our expert coding tips.

CPT altered the ligament and tendon injection code descriptors this year:
 

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

20551 -- ... single tendon origin/insertion.

This year, CPT added "aponeurosis" to 20550's descriptor to make it more specific. In addition, the codes now distinguish between injections to the tendon itself rather than  the tendon sheath. You can also report the codes multiple times when appropriate to collect additional reimbursement.

Report 20550 Multiple Times for Additional Injections

Old way: Many anesthesiology coders remember when 20550 represented trigger point injections, says Scott Groudine, MD, an Albany, N.Y., anesthesiologist.

New way: CPT 2002 introduced new TPI codes (20552-20553), leaving 20550 to represent tendon sheath and ligament injections.

Anesthesiologists occasionally perform multiple tendon or tendon sheath injections during one session, but it doesn't happen frequently, says Mark Hines, MD, a pain management specialist in North Carolina. "I sometimes administer double injections, but don't go crazy with it."

Strategy: When the physician administers multiple injections, append either modifier -51 (Multiple procedures) or modifier -59 (Distinct procedural service) to the injection code. Hines says either of these modifiers is appropriate, but he is more comfortable with modifier -59 and generally doesn't face reimbursement problems.

Don't miss: Remember, the physician must inject separate sites before you can report multiple injections. Check your local carrier's policy for applicable guidelines.

CIGNA Medicare in Tennessee, for example, says, "Codes 20550 and 20551 should be reported one time for multiple or single injections to a tendon sheath, ligament, tendon origin or tendon insertion performed. Thus, multiple injections to the same tendon sheaths, tendon origins, tendon insertion, or ligaments would be reported one time only, while injections to multiple tendon sheaths, tendon origins, tendon insertion, or ligaments are reported one time for each injection."

Physicians treat plantar fasciitis more often than ever before, which might help explain why CPT changed 20550 to include the example of "aponeurosis (e.g., plantar 'fascia')."

Result: "This detail is important if you were unsure which code to use in the past," Hines says. "This simplifies which code to use so reporting is consistent instead of having coders report different codes for the same procedure."

When you're coding for these injections, also pay attention to the drug that the physician administers. Although physicians don't inject crystalloid steroids to tendons, Hines says, they do inject noncrystalloid steroids such as dexamethasone.

Report the Correct Supporting Diagnosis

Anesthesiologists might not report 20550 and 20551 regularly because these injections are more complicated to administer and they have fewer supporting diagnoses (especially when compared to trigger point injections), Groudine says.

Empire Medicare of New York, for example, lists only the following conditions as acceptable diagnoses for reporting code 20550:
 

 Morton's neuroma -- 355.6, Lesion of plantar nerve

Inflamed tendon sheaths/ligaments -- 726.0-726.69 (various locations for Peripheral enthesopathies and allied syndromes) and 727.00-727.3 (types of Synovitis and tenosynovitis, Bunion, Specific bursitides often of occupational origin and Other bursitis)

Synovial cyst, unspecified -- 727.40

Ganglion of joint -- 727.41

Ganglion of tendon sheath -- 727.42.

Remember: The patient's medical record must also include the reason for the injection and the site that the physician injects, Groudine says. You should also include the appropriate J code that represents the medication and report it to your insurer with the injection claim. Hines also includes a diagram in his documentation, which illustrates where he administers the injection.

Increase Payments and Improve Accuracy

"These code changes can be helpful, but it depends on the physician's treatment style," Hines says. "Anesthesiologists who don't focus on pain management don't see the change as a big deal; they won't see much change in reimbursement because they don't perform the injections very often. But the change can be helpful to pain therapists who do them more frequently -- both in terms of reimbursement and more accurate reporting."