Orthopedic Coding Alert

Policy will drive whether to report dry needling.

Patients that report to the orthopedist for treatment of certain painful conditions will often undergo a therapeutic procedure using a needle. These can be injections or aspirations, and they’ll often include some tricky coding decisions.

Such as? Some payers might not cover certain aspiration procedures, while others will. Choosing the correct code depending on anatomy and other factors is also a concern, as is making sure you’re coding everything you should with every encounter.

During her HEALTHCON 2022 session, Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor, ran attendees through some of the more pressing questions surrounding these needle procedures. Check out what she had to say.

Code for Dry Needling … Maybe

One service that your provider could be performing on a patient is dry needling. “This is a technique in which a needle is going to be used to penetrate the skin and stimulate underlying myofascial trigger points, muscles, or connective tissue. This technique is going to be used to treat dysfunctions in skeletal muscle fascia and connective tissue,” explained Clements.

You should report dry needling with one of these codes, depending on encounter specifics:

• 20560 (Needle insertion(s) without injection(s); 1 or 2 muscle(s))
• 20561 (… 3 or more muscles)

“These codes were added a couple years ago, and they described services that are typically referred to is dry needling or trigger point acupuncture,” said Clements. “These services are services that neither are traditional acupuncture and they’re not injections; they kind of fall in between the two.”

Watch Policies for Dry Needling

You should be checking each of your payer contracts for their specifics on 20560 or 20561. Since the codes are relatively new, not all policies are completely set. For example, Clements pointed out that Noridian states dry needling is not a covered procedure in LCD L34218, effective date Oct. 1, 2019, with no revision date.

National Government Services (NGS), however, states “Effective January 21, 2020, Medicare will cover all types of acupuncture including dry needling for chronic low back pain within specific guidelines in accordance with NCD 30.3.3.”

“UHC [UnitedHealthcare] has a policy, but [it] really states that they follow Medicare guidelines,” says Jennifer McNamara, CPC, CRC, CPC-I, CGSC, COPC, AAPC approved instructor and professional recruiter at Ozark Coding Alliance LLC in Bentonville, Arkansas. “For BCBS [Blue Cross Blue Shield], it depends on the state.”

Takeaway: Be sure you review payer policies if you have any doubt about coding dry needling. Carriers will certainly vary as to whether they cover 20560/20561, and the conditions they’ll reimburse the codes under will also vary.

Remember Separate Codes for Ganglion Cyst, Morton’s Neuroma Shots

Another pair of needle procedures your provider might perform are injections for ganglion cysts or Morton’s neuroma treatment. Clements said you should code those shots with the following codes:

• 20612 (Aspiration and/or injection of ganglion cyst(s) any location)
• 64455 (Injection(s), anesthetic agent(s) and/or steroid; plantar common digital nerve(s) (eg, Morton’s neuroma))

“Ganglion cyst are noncancerous lumps that most commonly develop along a tendon or a joint in your wrist or hand. You’ll notice in code 20612, it’s kind of like our joint [injection] codes; it’s for an aspiration and/or injection,” explained Clements. “So if the provider aspirates the cyst and then decides to inject it, we still only have one code.”

You also have to remember that Morton’s neuroma injections are coded with a 60000 series code, not a 20000 series code like many other injections. “But there is a parenthetical note within our injection section that tells us for Martin’s aroma injection, see code 64455,” stated Clements.

During these procedures, providers will typically inject steroids along with an anesthetic agent, Clements said. Some of the medication you might code for with the above injection codes include:

• J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) aka Kenalog
• J7323 (Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose)
• J7325 (Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg)
• J7326 (Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose)
• J7329 (Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg)

Note: This is just a sampling of the drug codes you might need to use when your provider performs one of the above injection services. Always code to the notes, and check with your provider and payer if you have any questions on coding these services.

“As you see, you’ll have some codes that are per dose and some are for 1 mg; make sure you’re watching to see how much is injected in the number of joints that are being injected in order to support your proper billing and proper reimbursement,” Clements stressed.

Remember These Modifiers on Injections

For 20612 and 64455, you might need help from a few modifiers. First, you would use modifier JW (Drug amount discarded/not administered to any patient) to identify unused drugs or biologicals from single-use vials or single-use packages that are appropriately discarded. Clements reminded coders of these conventions when using modifier JW:

• Report the discarded amount on a separate claim line using the JW modifier.
• Document the discarded drug or biological in the patient’s medical record.

You’ll also need a modifier that indicates laterality for either 20612 or 64455. If it is a bilateral procedure, report modifier 50 (Bilateral procedure) along with the injection code. If the injection is one-sided, report modifiers RT (Right side) or LT (Left side), as appropriate.