Neurology & Pain Management Coding Alert

Question: A new physician in our office wants to administer Synvisc knee injections for our mostly-Medicare patient population. A Medicare representative told me that national and local coverage determinations (NCDs/ LCDs) are nonexistent and that we simply have to prove medical necessity. What diagnoses work or don't work?

New Jersey Subscriber

Answer: Currently, Synvisc (hyaluronan) injections are only approved by the FDA to treat osteoarthritis of the knee. You report diagnosis 715.16 (Osteoarthrosis, localized, primary; lower leg).

The Medicare representative you spoke to is correct in saying Medicare does not have an NCD addressing the hyaluronan articular biologics. Many LCDs on the subject exist, however, and many commercial payers also have coverage policies addressing the treatment. Some have guidelines regarding conservative therapies the physician should document before administering hyaluronon injections. Check each payer's coverage policy before beginning treatments.

Tip: Some non-Medicare payers might require you to order Synvisc from a specialty pharmacy. Research this before ordering the medication for your non-Medicare patients.