Auditors – Accelerate Your Knowledge of Anatomy to Choose Between Codes

Auditors –  Accelerate Your Knowledge of Anatomy to Choose Between Codes

Recently, a provider asked me the difference between CPT© 20605 and 20551. He had already asked others the same question, and was confused that they gave him different answers. As we talked and reviewed the particular case he was coding, I came to understand that the level of knowledge of the anatomy made the difference in this case, and explained the conflicting answers he was getting.
Here’s the description of the service he provided to his patient suffering with lateral epicondylitis.

Patent verbally consented to risks and benefits of corticosteroid injection. A time out was done confirming the patient’s name, date of birth, location of injection, and that the proper materials and meds are available and present.  Prepped with iodine and alcohol. Left elbow injected at lateral epicondyle in a sterile fashion with 1.5 ml. Xylocaine, 20 mg. of Kenalog, and 2 mg. of Dexamethoasone. No significant bleeding. Patient tolerated the procedure well. From the time of the decision to provide the injection to the time of the procedure, the provider did not leave the room.  The patient was conscious throughout the procedure.

These are the three answers and rationale the provider received. (All agreed on the HCPCS Level II coding)

  1. Cannot code the injection at all – I can’t tell if the bursa or a tendon was injected.
  2. Report 20605 – You injected the elbow.
  3. Report 20551 – You injected at the insertion point.

As I analyzed his question, and of the three reported responses I found that I agreed that 20551 was the correct code to report. Below are the steps to reaching that conclusion.
First, understand the condition. Lateral epicondylitis is a tendonitis also known as tennis elbow although the majority of people with lateral epicondylitis have never played tennis. The condition causes pain on the outside portion of the elbow over a bony prominence termed the lateral epicondyle. Pain occurs with activities such as grasping, pushing, pulling and lifting. As the process progresses the pain may occur with limited activities or even at rest.[1]
Secondly, understand how the procedure is done. Often the best way to do this is to have a conversation with the provider and let him/her tell you all the steps.  This is a particularly effective method for helping them to understand what must be included in the documentation. Also, online research will also teach you, and in some cases, show you the procedure. The following instruction was found by web research. Note in the following description, we see that the needle does not enter the joint space nor the tendon sheath.
The most tender point of the epicondyle is identified by gentle palpation. The needle is inserted at 90 degrees down to the level of the bone and then pulled back 1 to 2 mm (Figures 2 and 3). The pharmaceutical solution is injected evenly and slowly.[2]
And finally, understand the code description. There are many tools that provide additional descriptions in easy to understand language. I use AAPC Coder and this is excerpted from the information surrounding CPT© code 20551.
The provider injects a drug into the origin or insertion site of a tendon to relieve pain, inflammation, and swelling from a diseased or damaged tendon.[3]
My coding conclusion is that CPT©20551 is the correct code because we know the needle was inserted at the lateral epicondyle and by definition, this is the site of the origin of the wrist extensor supinator muscle group. The procedure described by CPT© 20551 is an injection at the point of tendon insertion/origin.    The medication is injected in the tissue surrounding the area where the tendons attach to the bone, between the subcutaneous fat and the tendon, not in the tendon sheath.

Charla Prillaman
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Charla Prillaman, CPC, CPCO, CPMA, CPC-I, CCC, CEMC, has more than 30 years’ experience in coding, compliance, and billing for physician practices. She has experience in an academic setting as well as private practice. Prillaman’s compliance experience includes auditing, IRO work, development and implementation of practice compliance plan, and writing policy and procedure. She provides post audit support at Audit Services Group.

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