Orthopedic Coding Alert

Here’s what you should do when your orthopedist treats both knees.

Physicians administer hyaluronate or hyaluronic acid injections (commonly known by brand names Synvisc, Synvisc-One, Hyalgan, Supartz, and others) for osteoarthritis of the knee, but you need to look beyond a simple code when reporting the procedures.

Code confusion: Hyaluronate injections have had its own J code for some time, but it has been changed from “unspecified” to its own assigned code, back to “unspecified,” and then back to an assigned HCPCS code. 

Now, all hyaluronate injections fall under the same code, here are three checkpoints to keep in mind and help you calculate correctly.

Verify the Type of Medication

Physicians use hyaluronate injections to help alleviate the patient’s pain due to osteoarthritis of the knee. The medications achieve the same purpose, and you report both types of injections with J7325 (Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg). Correct coding depends on the medication used and the number of units you report. Synvisc-One is a one-shot injection equaling 6 cc of the medication. The patient sees your physician once for the full injection, which you report as 48 units of J7325 (2 cc = 16 g, so 6 cc = 48 mg). Physicians administer the other forms of hyaluronate as a series of injections instead of one shot at a single patient visit. Watch the dosage amounts closely so you’ll report the correct number of J7325 units for each administration.

Chart note: Because of the difference in calculations and unit reporting, the physician must clearly document the medication used and number of units administered. Medication reimbursement can be low, so incorrect or unclear documentation could mean the difference between of payment versus virtually none. Some providers give patients a prescription for hyaluronate (depending on the insurer) and ask them to get the medication and return to the physician’s office for the injection.

Injection: Code J7325 represents only the medication, so you still need to report the injection procedure. Submit 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). 

Check the Diagnosis Code

Medicare will only reimburse for hyaluronate injections to treat osteoarthritis of the knee, experts say. You have several diagnosis options, so be sure one of these applies to help smooth your claims processing:

• 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)
• 715.96 (Osteoarthritis, unspecified whether generalized or localized; lower leg).

Anatomy note: Your “additional digit” choices for the 715.xx code family don’t include a specific choice for knee. When selecting the best anatomic choice, consider the knee part of the lower leg instead of “pelvic region and thigh.”

ICD-10: When your diagnosis system changes, you’ll look to the M17 (Osteoarthritis of knee) category. You will choose your code based on the following information:

1. the anatomical location (such as knee, hip, etc.)
2. status (primary, secondary, post-traumatic, or unspecified)
3. whether the osteoarthrosis is right, left, or bilateral, or unspecified

Determine Whether E/M and Modifiers Apply

Some visits for hyaluronate injections qualify for an E/M code or modifiers, but others don’t. If the patient comes to your office specifically for a scheduled Synvisc-One injection, you’ll only report the injection code. If, however, the physician completes another service during the visit, an E/M code might apply.

Example: The orthopedist completes and documents a thorough examination. He advises the patient to go through a series of hyaluronate injections and the patient agrees. You can report an E/M code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) in addition to 20610 and J7325. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

You won’t submit an E/M code for follow-up visits for the additional hyaluronate injections unless the physician completes an additional service during the visit.

Global watch: Code 20610 has a 10-day global period, but practitioners often schedule the follow-up Synvisc injections within that timeframe. If the patient returns within the 10-day global period, append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 20610. You turn to modifier 58 because the physician knows he’ll administer the additional injections as part of the normal course of treatment; in other words, consider the follow-up visits part of a planned (or staged) procedure.

Many patients receive hyaluronate injections to only one knee, but your physician might treat both knees at times. In that case, explain the situation by appending modifier 50 (Bilateral procedure) to 20610. List J7325 on the claim twice, with modifiers LT (Left side) and RT (Right side) appended.