Wiki Splitting Injections Between Payors

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Hello - We are a large orthopedic and sports medicine practice and we have been having the same conversation regarding the billing of off-label use of HA injections into non-FDA approved joints. The doctors want to split up the codes and bill the administration code, 20610, to the private payors and then bill the J-code to the patient. They want to do this in order to keep costs down for the patient. I've tried to explain that the administration code into the non-knee joint remains with the medication as they are a part and parcel of the off-label procedure they are performing. I've been asked to obtain any documentation to support not splitting up the codes, but would also welcome being told I'm incorrect and there is something out there to support the doctors' position. Could anyone point me in the right direction?

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Looking for Direction in a Cold, Cruel World
 
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The performance of the injection is being done to adminster what the payers deem as an "experimental" or " not medically necessary" drug. It doesn't make sense to bill the 20610, 20611, 20605 (for example) to the payer. Let's say the payer requests medical records in the course of an audit, when they see the drug documented which was injected into a non-covered joint they are going to deny the admin. In the large ortho practice I worked in we had a cash pay rate for these which included the performance of the injection. You could present it to them this way: Let's say the payer runs data analytics and sees a bunch of 20610 with no J code on the claim. Even though 20610 can be done for aspiration this is more rare than for injection. The payer will most likley request records since 20610 in ortho is such a high frequency CPT. You are making yourself an audit target/risk by doing this. I didn't find any documentation in a quick search but you could look up experimental policies, off label policy, check CPT Assistant, or possible AAOS or Zupko has info about it. It seems to be a common occurrence. I have seen denials of injection admin when there is no J code on the claim or it even rejects at the clearinghouse level (which doesn't always make sense because these codes are for aspiration too but it happens).

I know you are talking about private payers but this is what CMS says. I know it's in the knee injection article but the idea is the same in my opinion.
Billing the injection procedure
  • The procedure code (CPT code) 20610 or 20611 may be billed for the intraarticular injection. The charge, if any, for the drug or biological must be included in the physician’s bill and the cost of the drug or biological must represent an expense to the physician.
  • If an aspiration and an injection procedure are performed at the same session, bill only one unit for CPT code 20610 or 20611.
  • When additional substances are concomitantly administered (e.g. cortisone, anesthetics) with viscosupplementation, only one injection service is allowed per knee.
  • The appropriate site modifier (RT or LT) must be appended to CPT code 20610 or CPT code 20611 to indicate if the service was performed unilaterally and modifier (-50) must be appended to indicate if the service was performed bilaterally.
  • If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.
  • Please refer to the WPS GHA Guides and Resources – Modifier 50, LT, RT Fact Sheets.
 
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