Neurology & Pain Management Coding Alert

Question: Our physician performed trigger finger injections on the middle fingers of a patient’s right and left hands. The patient was also treated for another, separate condition during the office visit. We billed the encounter this way:

99213/25

20550/RT-F7

20550/59-LT

J1040x2

The third line was denied, so we resubmitted with 20550/59-f2 and 20550/xs-lt, which were also not paid.

Can this be billed 2x and, if so, what will Medicare accept?

AAPC Forum Subscriber

Answer: Medicare denial may be due to modifier problems in the third line of this claim.

The first could be your use of modifier 59 (Distinct procedural service). Although your provider performed 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) on two different anatomic sites, modifier 59 would be more appropriate if your provider had performed different procedures or the provider performed the same procedure during different sessions. Also, per the guidelines for modifier 59 in Appendix A of CPT^®, “Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” In this case, you have other, more descriptive modifiers available to you.

The second could be your use of the RT (Right side (used to identify procedures performed on the right side of the body)) and LT (Left side …) modifiers, as these are more accurately used for paired organs or body parts other than fingers or toes, which have their own modifiers. In your case, the modifiers would be F2 (Left hand, third digit) and F7 (Right hand, third digit), which you used on the second line of the claim but not the third.

As Medicare prefers the use of Level II (HCPCS) modifiers, it is entirely possible that the F2/F7 combination is all you need on the two appropriate lines of this claim. But Medicare’s acceptance of your use of RT on line two suggest that Medicare might accept LT-F2 on the third line. Whichever is the case, it would be wise reach out to your Medicare Administrative Contractor (MAC) for a final determination on this.

Why 20550 for trigger finger injections? Even though CPT^® references plantar fascia in the code descriptor for 20550, the code is more accurate in describing a trigger finger injection than, say 20551 (Injection(s); single tendon origin/ insertion), as these injections are given in the tendon sheath and not the tendon itself.