Wiki Denied Joint Injections from Medicaid

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I work for an orthopedic office and I just found out Medicaid Amerigroup is denying 20610, 20605 when billed for chronic conditions like OA (M17.11, M19.072). They said that they will only pay for acute conditions.
Is anyone seeing the same thing?
How are you handling this?
Can I code knee pain on the injection after the physician already diagnosed OA?

We are just going to submit notes that include (pain).But the injection has the OA diagnosis.
 
Dr. Marks (Karen Zupko & Associates) presented an on site seminar for our office last month. The information provided on this topic was that the encounter was for pain control as opposed to treating the underlying condition (OA). According to the guidance from the seminar, we were instructed to sequence pain first followed by the underlying condition. Reminder: this can never be assumed based on the number of visits for pain management and it must be clearly documented in the note.

Personally, I break it down by thinking that the Kenalog, celestone, or whatever medication isn't used to treat OA but used to alleviate the symptoms related to the OA. It was hard for me to wrap my brain around this at first because we are not permitted to report signs and symptoms if we have a definitive dx, but that specific procedure was for the symptom specifically. (I hope that makes sense)

If you haven't been on the Karen Zupko website, it is a great resource! They have the option of submitting coding questions as well.
 
We haven't been having these issues with medicaid - perhaps it's that particular plan that doesn't cover chronic diagnoses?
 
Ckonen512 said:
Does anyone know how you would bill a Sacroiliac Injection? Would that still fall under the 20610 or is it a whole other code?
Click to expand...
Our providers bill 20552, trigger point injection. If you bill for 20552, LCD does not cover M53.3 or M46.1. It only covers M54.5 low back pain. M53.3 is covered for 20550 if given in tendon sheath or ligament.
I would be interested to know also, how other people are coding these.
 
meg2017 said:
I work for an orthopedic office and I just found out Medicaid Amerigroup is denying 20610, 20605 when billed for chronic conditions like OA (M17.11, M19.072). They said that they will only pay for acute conditions.
Is anyone seeing the same thing?
How are you handling this?
Can I code knee pain on the injection after the physician already diagnosed OA?

We are just going to submit notes that include (pain).But the injection has the OA diagnosis.
Click to expand...
meg2017 said:
I work for an orthopedic office and I just found out Medicaid Amerigroup is denying 20610, 20605 when billed for chronic conditions like OA (M17.11, M19.072). They said that they will only pay for acute conditions.
Is anyone seeing the same thing?
How are you handling this?
Can I code knee pain on the injection after the physician already diagnosed OA?

We are just going to submit notes that include (pain).But the injection has the OA diagnosis.
Click to expand...
Our Texas Medicaid manual says that KX modifier is required for injections to indicate "Injection is necessary into joints, bursae, tendon sheaths, or trigger points to treat an acute condition or the acute flare up of a chronic condition". Are you using a modifier on your injections?
 
Sorry to just be getting back to you. I've attached a copy of the Medicaid manual. Page 26 has the info about the modifiers. Hope this helps!
 

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  • Medicaid Claims Filing.pdf
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