Primary Care Coding Alert

Coders have reported an increase in the use of a new therapy called Synvisc (hyaluronic acid or Hylan G-F 20) to treat pain as a result of osteoarthritis (OA) of the knee. Because it is an emerging treatment protocol, many coders have questioned how to code the service to ensure they are reimbursed properly. If approved for reimbursement by your carrier, it could be reimbursed at 95 percent of the average wholesale price.

According to Sue Foster, business office manager for Buffalo Clinic, a 31-physician multispecialty practice in Buffalo, Minn., doctors there have been using Synvisc for approximately a year, and many of their patients have responded well over the short term. And, she reports, the practice also has been successful in getting reimbursed.

Were seeing Synvisc used more and more to treat osteoarthritis in the knee (715.16, osteoarthrosis, localized, primary; lower leg), she says. Its a substance that acts as a lubricant on the cartilage within the joint. The material is delivered during arthrocentesis (20610, arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) and is coded J7320 (Hylan G-F 20, 16 mg, for intra-articular injection). Foster notes that the in-office treatment includes a series of three injections, spaced approximately one week apart.

Coding Must Comply With Payer Restrictions

Although reimbursement for Synvisc has been consistent, Foster adds that there are a number of restrictions by Medicare and other insurers.

To begin with, this therapy has been approved only for treatment of OA in the knee. Many family physicians also treat osteoarthritis of other joints like the shoulder or hip, but the injection of Synvisc wont be reimbursed in these cases. In fact, the only four diagnosis codes that support the use of Synvisc are 715.16, 715.26 (osteoarthrosis, localized, secondary; lower leg), 715.36 (osteoarthrosis, localized, not specified whether primary or secondary; lower leg) and 715.96 (osteoarthrosis, unspecified whether generalized or localized; lower leg).

Tom Mayberger, MPH, BS, area business consultant for Biomatrix, the manufacturer of Synvisc, confirms that this is the current situation. All of the clinical trials were done on patients with OA of the knee, so this is the area where Synvisc was initially approved. It is anticipated that Synvisc eventually will be used in other joints.

In addition, family physicians must attempt more conventional treatment therapies before turning to Synvisc, Foster says. Here in Minnesota, we must support our treatment plan with x-ray (73560-73565), and the physician must have tried established therapies. In many areas around the country, Synvisc injections require advanced carrier authorization.

Mayberger points out that in many states, the patient must have failed some nonpharmacological approaches, such as physical therapy, weight loss regimens, and use of cane or walker, as well as routine analgesic therapies like acetaminophen. Some insurers additionally may require that steroid injections be tried.

In some instances, physicians also may administer steroids or anesthetics when Synvisc is injected, Foster says. These may include lidocaine (J2000), bupivicaine (J3490, unclassified drugs) or Depo-Medrol (J1020 for 20 mg, J1030 for 40 mg or J1040 for 80 mg), and may be coded in addition to J7320.

Mayberger notes that in many cases these medications are not needed. Although it is assigned a J code, Synvisc is not a drug, but actually a medical device or prosthesis. As such, it acts as a lubricant and shock absorber.

The effects may last for a number of months, Mayberger adds. If the patients have a favorable response to treatment, insurers allow the procedure to be repeated. In most states this may be done six months after completion of the previous series of injections.