Joint Injection during the Global Period

Question:

Our physicians want to report 20610-79 when they perform a joint injection for pain following arthroscopic knee surgery.  Is that acceptable?

Answer:

Thanks for your inquiry. Pain management is inclusive to the global surgical package and is not separately reportable.  To append a modifier 79 to a surgical procedure, the procedure is typically at a different anatomic location to support the unrelated component.

*This response is based on the best information available as of 05/03/18.

Diagnostic Ultrasound and Ultrasound Guided Injections

Question:

Our sports medicine physicians are reporting diagnostic ultrasounds (76881) and ultrasound guided injections at the same session, same joint. We are receiving denials as inclusive and are not understanding why they are being denied.

Answer:

Thanks for your inquiry. The ultrasound guided injections (20604, 20606 and 20611) include ultrasound image guidance in the definition of the code.  These injections codes include the work associated with assessing the anatomic structures of the joint and the documentation of a separate report.   Trying to report CPT code 76881 (Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation)is inclusive to the work valued into the joint injection codes, hence the denial as inclusive.

This is also true of the use of ultrasound guidance with any other injection codes; the diagnostic component is inclusive to CPT code 76942 when this code may be reported with an appropriate injection code.

Medicare also considers the service to be inclusive..  The first reference is from the Medicare NCCI guidelines; the second notation is the introduction of new NCCI PTP edits effective April 1, 2018

Medicare NCCI guidelines also contain the following reference:

Section IX-H, Radiology Services – note: 2018 text revision highlighted in red

9. Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions.  For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement…) when performed in different anatomic regions on the same date of service.  Physician should not avoid edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.

Additionally, effective April 1, 2018 , CMS NCCI implemented PTP edits  between CPT codes 20604, 20606 and 20611 and 76881.  CPT code 76881 is now identified a Column 2 PTP edit.

*This response is based on the best information available as of 04/19/18.

My patient’s fallen on the ice and smashed their elbow. Help me select the proper code.

Question:

We received an inquiry from a client where the surgeon wanted to report the repair of the elbow lateral collateral ligament (CPT 24343) along with radial head replacement surgery (CPT 24666) when used for addressing radial head fracture. Can we use this code combination?

Answer:

According to AAOS – Global Service Data GSD) – CPT 24666 (Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed with radial head prosthetic replacement) is the primary code to address this problem.  When reviewing the GSD, it clearly states that CPT 24343 is included with this procedure. As such, it is inappropriate to bill for second code. This gets to the issue that troubles many surgeons.  They would like to be paid for tissues that are divided during the approach used to perform the procedure.  In this particular case, the annular ligament and lateral collateral ligament complex must be incised to perform the radial head insertion, and even if it was torn by the injury (fracture), its surgical repair is still included with the CPT code 24666.

*This response is based on the best information available as of 03/01/18.

Splint Application and L-codes

Question:

We are having a discussion in our office about how to report the application of off-the-shelf braces that are dispensed in our office. The nurses are adding splint application codes to the encounter forms, such as 29125 and 29515, but the coder only wants to report the HCPCS supply code. Which method is correct?

Answer:

The coder is correct in this case. The splint application CPT codes are used when a physician or provider such as a PT or OT creates a splint from “raw materials”, such as plaster, fiberglass, padding, and ace bandages. Examples include sugar tong splints and thumb spica splints, among others. The HCPCS codes used for reporting off-the-shelf braces, also called prefabricated orthotics, include the fitting of the item, so a splint application code would not be separately reportable. Even orthotics that do require custom fitting would not support separate reporting of a splint application, as the HCPCS definitions for those codes include the language “includes fitting and adjustment.”

*This response is based on the best information available as of 01/18/18.

Bone Marrow Aspirate Harvesting for Platelet Rich Plasma

Question:

Our physicians are asking us to report 38220 and 0232T when they harvest bone marrow aspirate from the iliac crest for platelet rich plasma and inject it during another procedure.  Is this correct?  If not, can we report 0232T?  What if the only service performed is a PRP injection using bone marrow aspirate?

Answer:

You’ve asked two Question:s, so we’ve provided two parts to our answer:

CPT Category III code 0232T was introduced in 2010 for reporting injection of platelet rich plasma to a targeted site; the code definition includes all harvesting, preparation, and image guidance for the service.  In August 2010 the AAOS published guidance inAAOSNowwhich explained “The new code is to be used only when PRP is performed in a complete separate patient encounter from a surgical procedure.”

Based on this direction, when PRP is injected during another procedure, whether using drawn blood or bone marrow aspirate, it is not separately reportable with the primary surgical service.

If PRP injection is the only service performed, then 0232T is the correct code.  In recent years some physicians have begun using bone marrow aspirate harvested from the iliac crest instead of drawn blood for PRP preparation, and reporting the harvesting using CPT code 38220.  The May 2012 edition ofCPTAssistantclarified that 0232T is the only code reportable for PRP injection, whether performed using drawn blood or harvested bone marrow aspirate.  In 2018 the definition of 38220 was changed to reflect that it should be used only for diagnostic bone marrow aspiration.  New code 20939 should be used when bone marrow aspiration is performed for bone grafting, for spine surgery only, via a separate incision.

*This response is based on the best information available as of 01/04/18.

Why am I Receiving a Denial When I Report a Joint Injection and a Trigger Point Injection on the Same Date of Service?

Question:

Our orthopaedic surgeon performed and clearly documented a joint injection to the right shoulder and a trigger point injection bilaterally to the trapezius muscle. We are receiving denials when we report CPT code 20610 and 20552 on the same claim form? Are you able to assist us in understanding if we have coded correctly or how to appeal?

Answer:

You are correct to question this denial!  There is no clinical reason for this denial assuming your documentation and medical necessity supports reporting CPT 20610 and 20552 as defined in your scenario.  If the payor is Medicare, or a payor who follows NCCI rules, the answer has to do with NCCI edits between the code combinations.    Several years ago, Medicare identified coding patterns where the 2055x series of codes were reported during the same session as joint or other musculoskeletal surgical injections.  In doing their due diligence, Medicare found in record review that the 2055x series was being incorrectly reported for the administration of a local anesthetic prior to the definitive injection.   In the KZA orthopaedic coding workshops the surgical package and administration of local anesthesia is discussed as the rationale for the creation of this edit.

This is an example where the use of modifier 59 (distinct procedure modifier) has a role in claims reporting!

Report:

20610 linked to the shoulder diagnosis

20552-59linked to the appropriate diagnosis to support the trigger point injection

We are confident the denial, while not identified in your Question:, was for a bundled or service integral to another procedure on the same day. It is not uncommon for the Center for Medicare and Medicaid Services (CMS) to implement edits when a pattern of incorrect code combinations are identified.

The following statement is found in the January 2017 NCCI Guidelines (CHAPTER IV SURGERY MUSCULOSKELETAL SYSTEM):

Injections of local anesthesia for musculoskeletal procedures (surgical or manipulative) are not separately reportable. For example, CPT codes 20526-20553 (therapeutic injection of carpal tunnel, tendon sheath, ligament, muscle trigger points) should not be reported for the administration of local anesthesia to perform another procedure. The NCCI contains many edits based on this principle. If a procedure and a separate and distinct injection service unrelated to anesthesia for the former procedure are reported, the injection service may be reported with an NCCI-associated modifier if appropriate.

*This response is based on the best information available as of 11/02/17.