Orthopedic Coding Alert

Coding and reimbursement for therapeutic injections generate as many questions as answers for orthopedic coders. Despite headway in recent years, with more HCPCS codes being introduced for injection materials and an increased acceptance among carriers of injection therapy as a reimbursable item, understanding the rules for billing injections is still a challenge.

The three most common injections administered by orthopedists are SynVisc, Hyalgan and Cortisone. SynVisc and Hyalgan are intra-articular injections used for disorders like osteoarthritis, when surgery is either not necessary, not an option or is considered a last resort. Cortisone, a mainstay of orthopedic injections, is often used at an initial visit when the patient complains of joint pain, or when x-rays reveal a heel spur or subacromial spurring.

Recent Rules for Hyalgan and SynVisc

Both SynVisc and Hyalgan are viscoelastic agents. Their base is hyaluronic acid, a naturally occurring substance that increases elasticity and viscosity of synovial fluid. With osteoarthritis or certain injuries, the cartilage and other structures of the joint (in the knee, for instance) begin to break down. That inflammation often results in decreased or absent hyaluronic acid, so the joint becomes stiff and painful. Injections of SynVisc or Hyalgan replace the lost hyaluronic acid and reduce that pain and inflammation. Neither drug will cure arthritis or restore injured cartilage, but they provide temporary relief of pain and stiffness and improved mechanical action and lubrication of the joint.

In January 1999, HCPCS released specific codes for injections of Hyalgan and SynVisc. Sodium hyaluronate, which goes by the brand name Hyalgan, is billed with J7315 (sodium hyaluronate, 20 mg, for intra-articular injection). SynVisc is the brand name for Hylan, which is billed using J7320 (Hylan G-F 20, 16 mg, for intra-articular injection).

The CPT code for injection is used with the supply code for the drugs. In the case of SynVisc of Hyalgan, 20610* (athrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) is used. Because these drugs are injected into one side of the body or the other, use the appropriate HCPCS modifier (-LT or -RT) to indicate the left or right side. Using the example of SynVisc injected into the patients right knee, the coding sequence would read 20610-RT, J7320.

Because SynVisc and Hyalgan injections are virtually always planned and scheduled in advance, an evaluation and management (E/M) code cannot be billed in addition to the injection procedure code. The exception to this rule is when a significant, separately identifiable service was also performed. In this case, the coder would bill the appropriate E/M code (e.g., 99213, office or other outpatient visit for the evaluation and management of an established patient ...) with a -25 modifier indicating that the E/M service was a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. For the E/M claim to pass carriers scrutiny, the patient must have presented for the injection and then had a complaint separate from the affected joint (with a separate diagnosis) that necessitated a separate E/M service from the same physician.

Because both drugs are injected in a series of treatments that usually cover several weeks, orthopedic coders may be submitting identical claims from week to week, which can lead to confusion and rejection by carriers who perceive that the orthopedist is submitting duplicate bills. The Documentation Guidelines section of Medicare Policy YPF #183, which covers hyaluronase polymers, provides that it is suggested that the entire series of injections be billed on the same claim form. But when working with private carriers, coders should confirm in advance how they want the series billed. An appropriate diagnosis code should be submitted on the claim, and the patients record should indicate the signs and symptoms that support the diagnosis.

The approved diagnosis codes for SynVisc and Hyalgan are for osteoarthritis and include 715.16 (osteoarthritis, localized, primary; lower leg), 715.26 (osteoarthritis, localized, secondary; lower leg), 715.36 (osteoarthritis, localized, not specified whether primary or secondary; lower leg) and 715.96 (osteoarthritis, unspecified whether generalized or localized; lower leg). Osteoarthritis is the only disease for which the Food and Drug Administration (FDA) has approved these drugs.

Although both drugs have become a more common alternative to expensive, painful surgery to the knee(s), check with the carrier to make sure it accepts claims for these relatively new therapies. Documentation indicating that other avenues of care were explored before the shots were administered is helpful as well. But many HMOs will not reimburse physicians for the cost of SynVisc and Hyalgan. Therefore, patients must obtain these agents via their pharmacy benefit from an approved supplier and bring the three- or five-dose kit to the physicians office. In that situation, the provider can bill for the administration of the injection, but not for the supply.

Coding for Cortisone

Cortisone is a glucocorticoid, a steroid-like substance that has an anti-inflammatory effect when injected into the human body. Unlike hyaluronate, cortisone does not naturally occur in humans. In injection form, cortisone can encourage growth of connective tissues and effectively mask pain from an injured joint.

Because Cortisone is used for injection into both large and small joints of the body, injection codes 20550*-20610* may be used depending on the location of the injection. As with other injectables, the -LT or -RT modifier should be appended to indicate the side of the body treated. The supply code for cortisone is J0810 (injection, cortisone, up to 50 mg). Celestone (J0702, injection, betamethasone sodium phosphate, per 3 mg) and Depomedrol (J1030, injection, methylprednisolone acetate, 40 mg) are two additional commonly used cortisone preparations.

Like SynVisc and Hyalgan, cortisone injections often are done in a series over several weeks. Unlike the other injections, cortisone often is given at a patients initial appearance before the orthopedist with a complaint of joint pain or heel spur. Because of the immediacy of injection, many coders are unsure if they can bill for the injection procedure, injection supply and office visit.

Generally, if the cortisone is injected at the initial office visit for a new patient, the office visit (99202-99205) is billable separately from the injection code. The office visit is billable (using 99212-99215) for an established patient if the patient presents with a new complaint and the injection is done at the same visit. But if the cortisone injection is done at a follow-up to an initial visit or as a scheduled procedure, most carriers will not pay for both an evaluation and management (E/M) visit and an injection procedure.

As with SynVisc and Hyalgan, circumstances (other than initial visits) in which an E/M visit will be reimbursed along with the cortisone injection service are rare. Although the injection codes for these visits are starred surgical procedures, meaning they are exclusive of other global surgical services, the CPT rules for starred procedures are written to allow liberal variance in payment rules from carrier to carrier. The rationale of carriers is that because starred procedures dont have predetermined global surgery packages, the carriers can determine what is included in the global package for an injection. Most often, the office visit is considered part of the injection code and not paid separately. As with the other injections, the exception to this carrier rule occurs when the patient has a complaint in addition to the problem at the injection site. This almost always requires a separate diagnosis code.