Internal Medicine Coding Alert

Question: How should I code for a joint aspiration injection of lidocaine? Should I bill for the injection as well as the drug?

Vermont Subscriber

Answer: For the injection, you should report 20600* (Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]), 20605* (... intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) or 20610* (... major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). Normally, you would also report the medication with the appropriate HCPCS level-two supply code. The National Correct Coding Initiative, however, bundles lidocaine (J2000, Injection, lidocaine HCl, 50 cc) with injection codes 20526-20610. Therefore, many payers that follow the edits will not separately reimburse for lidocaine (J2000) when billed with a pain management injection, such as 20610.
  
Medicare bases this bundle on the dose specified in J2000. Because J2000 refers to 50 cc of lidocaine, Medicare covers the code only with ICD-9 codes that relate to cardiac arrhythmias, such as 427.9 (Cardiac dysrhythmia, unspecified) and emergencies.
 
For example, Georgia Medicare's local policy for lidocaine states, "The dosage indicated by the code description is specific to the treatment of cardiac arrhythmias and emergencies only. The billing of J2000 is not appropriate for the 1-2 cc usually required for a local anesthetic." The policy concludes that when your physician uses lidocaine as a local anesthetic, the payer will consider the drug part of the materials included in the procedure and will not separately reimburse it.
 
Regardless of payment, you should still report J2000. If you do not include the name of the drug with the injection procedure (20610), some insurers will deny the claim. This confuses some coders who believe that you should not list a nonreimbursable drug on the claim form. But you should add the drug's name and HCPCS code even if you do not expect reimbursement. Consequently, you should list J2000 on your injection claims, but expect Medicare to deny additional reimbursement for the drug by bundling the cost of the lidocaine into the injection payment.

  - Answers for You Be the Coder and Reader Questions were provided by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.