Orthopedic Coding Alert

As of Jan. 1, 1999, there are finally specific level II HCPCS codes for both Hyalgan and SynVisc. And although orthopedic practices dont have to worry as much about claims being denied for these injections given to patients in 1999, many offices have numerous outstanding claims from 1998 that they are still tying to get paid.

Many orthopedic practices have been having difficulty receiving reimbursement for these injections. The reason for these problems, according to Jeri Harris, CPC, CPC, H, member, National Advisory Board for the American Academy of Professional Coders, and coding specialist and staff compliance officer of Orthopedic Specialists, Charleston, SC, has been the lack of specific codes. There is also confusion about which CPT codes to use, whether Hyalgan and SynVisc are drugs or medical devices, and about the correct supporting diagnosis codes. By considering how this treatment is used, the coder can improve reimbursement for this important orthopedic therapy.

HCPCS and CPT Unlisted Codes

If your practice is having trouble getting reimbursed for injections of Hyalgan and SynVisc given prior to Jan. 1, 1999, you should code for these injections as unlisted drugs, Harris says. This can be a real hassle, she adds, because of the lack of carrier understanding and the amount of paperwork involved. But she also suggests that coding for unlisted drugs is something the orthopedic coder must understand, because orthopedic therapies continue to develop faster than the codes that describe them. Harris recommends a couple of different ways of coding for unlisted drugs.

One approach is to use the HCPCS book codes. The HCPCS manual is based on the Health Care Financing Administrations (HCFA) Common Procedure Coding System. The book contains Medicares National Level II Codes, such as injection drugs, durable medical equipment, etc.

The HCPCS book gives several separate unlisted drug codes, each of which signifies a specific description to the insurance carrier. Some examples are as follows:

J3490 - unclassified drug that is administered by a method other than orally (i.e., intramuscularly, subcutaneous or intravenously).

J7599 - immunosuppressive drug that is not otherwise specified.

J8999 - chemotherapeutic prescription drug given orally that is not otherwise specified.

J9999 - antineoplastic drug given by infusion for oncology therapy.

For each of the above unclassified or unlisted drug codes, regional Medicare carriers have ideas as to what they will pay and how they want the items to be billed. If a regional Medicare carrier has its own HCPCS Level III code, that code must be used. Many regional Medicare carriers require companion information when you submit your claim. They may require that you give them the national drug code number and the dosage (units) on line 19 of the HCFA 1500 claim form.

Note: National drug code numbers are published annually and utilized by pharmacies, the FDA, drug manufacturers and distributors, and by insurance carriers nationwide -- call your local carrier for a list.

Another approach for unlisted injections is to use an injection code from the Medicine section of the CPT. The only code from that section that would apply is the 90799 (unlisted therapeutic or diagnostic injection).

Additional Coding For Hyalgan and SynVisc Treatments Prior to 1999

In addition to using the unlisted HCPCS or CPT codes, you can bill for these treatments using the appropriate Evaluation and Management (E/M) codes to reflect the services provided.

If you are using the HCPCS codes, the injection of the knee should be coded first, with the CPT 20610 (injection of major joint) following. Be sure to include the appropriate -RT (right) or -LT (left) modifiers to indicate on which leg the procedure was performed. Then the Hyalgan or SynVisc is listed individually using J3490 with a unit service of 1 for each injection, or all injections may be billed together with the total units of service. The units of service for SynVisc would be three, since a course of treatment is three intra-articular injections, administered one week apart. And the units for Hyalgan would be five, since it is administered as five intra-articular injections, each one week apart.

The other option is to use the CPT code 90799 for unlisted injections with the name of the drug/device and dosage in the description field. The ICD-9-CM code that supports medical necessity in this case would be 715.16 (osteoarthritis of the knee).

Tip: A reason for denial would be to use these devices for injection to any other joint or any for any purpose other than treating osteoarthritis, because the carrier does not have the discretion to approve off-label use of medical devices.

When using the HCPCS J3490, the initial claim must be billed in hard copy, must include medical records to support medical necessity and be sent to the attention of the carriers medical director. Examples of documentation for the first dose of the series should include the following:

An active quadriceps strengthening regimen

Does not have severe osteoarthritis

Has significant pain or functional limitation despite:

1. Acetaminophen, 1000 mg, four times per day, or

2. Multiple trials of systemic NSAIDs, intra-articular corticosteroid or contraindications to these therapies.

Mark Jordan, professional network contractor from Blue Cross/Blue Shield of South Carolina, says that the medical documentation for carriers other than Medicare must also include the following:

Degenerative joint disease (DJD or arthritis) of the knee

Conservative treatment from 4-6 months
(documented evidence)

Combination of: Acetaminophen, NSAIDs or evidence that the patient is found to be intolerant of NSAID therapy

Diagnostic test results from either or both an
x-ray or MRI

Height and weight

Therapy and rehabilitation, with documentation of length of time, type recommended and number of times or visits

Any previous treatments from any other doctor for same problem

Tip: All Hyalgan or SynVisc claims should be sent with surgical notes attached, written in bold on the top of the HCFA 1500 form.

Coding For Injections Given in 1999

Thankfully, you do not have to worry about much of the above for injections of Hyalgan and SynVisc in 1999. As of Jan.1, there are specific HCPCS codes for both Hyalgan and SynVisc. The codes are:

J7315 -Sodium hyaluronate, 20mg for intra-articular injection (Hyalgan)

J7320 - Hylan G-F 20, 16 mg for intra-articular injection (SynVisc)

When using these codes, you still use the CPT injection code (20610) with the appropriate modifier (ie. LT or RT) and then the HCPCS code (J7315 or J7320). Harris still recommends checking with your carrier to assure that they are familiar with these new therapies. Jordan echoes this advice stating that Blue Cross/Blue Shield of South Carolina will still be looking for strong documentation to support Hyalgan and SynVisc claims in 1999.

Hyalgan and SynVisc: Medical Devices or Drugs? In October last year, HCFA approved Hyalgan and SynVisc as medical devices for the treatment of osteoarthritis (not severe arthritis), explains Jeri Harris, CPC, CPC-H, member, National Advisory Board for the American Academy of Professional Coders, and coding specialist and staff compliance officer of Orthopedic Specialists, Charleston, SC. Prior to that, the FDA approved both drugs as a therapeutic, conservative treatment for patients with arthritis. This treatment is for those patients that would not require total joint surgery, or could not (by choice or for health reasons) have total joint surgery. Blurring the lines between medical device and drug, this injection, referred to as visco-supplementation, is the first of its kind to be approved in America. According to the Arthritis Foundation, hyaluronic acid is naturally produced by the body and lubricates cartilage within the joint. With osteoarthritis (OA), the cartilage and other structures of the joint begin to break down. In some patients, a small amount of inflammation breaks down the hyaluronic acid so that lubrication is lost. Joints become stiff and movement is painful. Hyaluronic acid injections replace or supplement the bodys natural hyaluronic acid that is broken down by the inflammation. Hyaluronan is destroyed by stomach enzymes and cannot be absorbed through the skin. But in the form of the two approved brands, Hyalgan and SynVisc, it can be injected directly into the knee joint. Hyaluronan does not cure osteoarthritis or heal worn-out cartilage, but it does provide relief of pain and temporary stiffness. Exactly how it works is not known, but it may have some short-term anti-inflammatory effects and lubricating similar to those that occur after changing the oil in a car. SynVisc is injected into the osteoarthritic knee once a week for a total of three consecutive weeks. Hyalgan is injected weekly for a total of five consecutive weeks. Up to 80 percent of patients receiving treatment report improvement.