Knee Injections, E/M Services: Diagnosis, Intent and Modifier Determine Coding Possibilities- Published on Fri, Mar 01, 2002 Updated on Wed, Oct 01, 2014
Orthopedic coders accustomed to billing for therapeutic injection in the knee (a common in-office procedure) can bill both an injection and an E/M service on the same day, depending on the original intent of the visit, diagnosis and appropriate modifier.
Hyalgan, Synvisc and Supartz are among the most common drugs injected for therapeutic purposes. They are intra-articular injections used for osteoarthritis of the knee and are usually administered when the patient has not responded to conservative therapies, when surgery is not an option for a particular patient, or when surgery is regarded as a last resort pending the impact of the injections.
Use J7316 (Sodium hyaluronate, 5 mg for intra-articular injection
) for Hyalgan, the brand name for sodium hyaluronate.
Bill J7320 (Hylan G-F 20, 16 mg, for intra-articular injection
) for Synvisc, the brand name for Hylan. Code J7316 for Supartz, the newest form of sodium hyaluronate to be approved by the Food and Drug Administration (FDA).
When you bill for these three injections, submit the J code for the drug supply with the CPT code for the injection: Use 20610* (Athrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]
Because these drugs are injected into one side of the body or the other, use the appropriate HCPCS modifier
(-LT or -RT) to indicate the left or right side.
Unlike other injections that may occur on the day of the initial visit, Synvisc, Hyalgan or Supartz injections are almost always scheduled in advance, usually after an initial visit at which the physician has evaluated the patient and ordered x-rays. Therefore, an E/M code can rarely be billed on the same day as the preplanned injection.
The exception to this rule is when a significant, separately identifiable service was also performed. In this case, the coder would bill the appropriate E/M code (e.g., 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 on the same day of the procedure or other service
). For carriers to consider the E/M claim, the patient must have presented for the previously scheduled injection and then have had a separate complaint that was clearly unrelated to the affected joint that was being injected.
For example, a patient reporting for a regular Synvisc injection in the knee for the treatment of osteoarthritis (e.g., 715.16, Osteoarthritis, localized, primary, lower leg
) may complain of a new problem of shoulder pain. Since the patient is an avid tennis player, the physician wants to rule out a tear or strain in the shoulder before assuming that the problem is osteoarthritis. He conducts an evaluation and [...]