Medicare Compliance & Reimbursement

Question: One of our Medicare patients receives knee injections for her arthritis. She's interested in trying Synvisc, but I don't see that on our Medicare fee schedule. When I called the carrier to ask about it, the representative told me that they don't publish a list of all covered J codes. She told me to send in the claim and see if it gets paid. I'd like to avoid any write-offs or denials. What's your advice?

Answer: Some Medicare carriers (such as Trailblazer) do cover the code in question, J7325 (Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg). A quick check of the local coverage determinations (LCDs) for the carrier in Louisiana (Novitas Solutions) shows that they do have one regarding J7325 use, effective August 13, 2012. That LCD indicates that J7325 is covered under certain conditions. For more information, please view the LCD online at www.novitas-solutions.com/policy/jh/l32737-r1.html

When you report the injection, submit J7325 along with the surgical code 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the actual injection. If you believe the service will not meet Medicare's coverage criteria as specified in the LCD, be sure to have the patient sign an advance beneficiary notice, so you may collect what is due you, if, in fact, Medicare denies the claim.

CMS posted FAQs on the payment window at cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/CR7502-FAQ.pdf.