Primary Care Coding Alert

Question: We just got a denial on 20526 with 96372. What are we doing wrong?

Missouri Subscriber

Answer: Reporting 20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel) with 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) is unnecessary if your provider only performs one injection for the carpal tunnel (CT).

That’s because 96372 is an injection administration code for subcutaneous or intramuscular injections, and injection administration is built in to 20526’s procedure description.

Coding caution: If your provider performs two injections on the same patient on the same day, one for the CT using 20526 and another to administer a therapeutic, prophylactic, or diagnostic substance or drug for a condition entirely separate from the patient’s CT, it is possible to code both procedures.

When performed during the same service, these two procedures form an edit pair according to the National Correct Coding Initiative (NCCI), with 20526 being the primary procedure for the service and 96372 the column 2 code for 20526.

However, the edit pair has a modifier indicator of 1, so you can get paid for both by appending modifier 59 (Distinct procedural service), which is the modifier of choice when separating a code pair rather than modifier 51 (Multiple procedures), which you would use when two procedures are not an edit pair. You would apply modifier 59 to 96372, which has a lower total relative value unit (RVU) in the nonfacility setting than 20526 (0.40, compared to 2.25 for 20526).