Primary Care Coding Alert

Question: We billed a private payer 99213-25; 20610; J7328-RT; J7328-LT for Gelsyn-3 injections into the left and right knees of a patient with osteoarthritis in both knees. The payer rejected the claim, stating that “the procedure code is inconsistent with the modifier used or a required modifier is missing.” What are we doing wrong?

Codify Subscriber

Answer: The issue here is the choice and placement of the modifiers. Billing 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is correct assuming that the evaluation and management (E/M) service was significant and separately identifiable from the work associated with the injections the provider administered at the encounter.

However, appending the RT (Right side) and LT (Left side) modifiers to J7328 (Hyaluronan or derivative, Gel-Syn, for intra-articular injection, 0.1 mg) is incorrect, as it is the procedure, and not the medication, that receives any laterality modifiers. For medications, the only information required other than the correct HCPCS or CPT^® code is the number of units that your provider administered.

The laterality modifier needs to be applied to the procedure itself, which you correctly give as 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance). But even here you cannot use the RT or LT modifiers. As the procedure was performed in both knees, you would instead append modifier 50 (Bilateral procedure), which is the missing modifier mentioned in the payer’s denial.

So, you should resubmit the claim using 99213-25; 20610-50; and J7328, specifying the exact amount of Gelsyn-3 your provider injected.