Orthopedic Coding Alert

Coding and reimbursement for therapeutic injections generate as many questions as answers for orthopedic coders. Despite headway in recent years, with more HCPCS codes being introduced for injection materials and an increased acceptance among carriers of injection therapy as a reimbursable item, understanding the rules for billing injections is still a challenge.

The three most common injections administered by orthopedists are SynVisc, Hyalgan and Cortisone. SynVisc and Hyalgan are intra-articular injections used for disorders like osteoarthritis, when surgery is either not necessary, not an option or is considered a last resort. Cortisone, a mainstay of orthopedic injections, is often used at an initial visit when the patient complains of joint pain, or when x-rays reveal a heel spur or subacromial spurring.

Recent Rules for Hyalgan and SynVisc

Both SynVisc and Hyalgan are viscoelastic agents. Their base is hyaluronic acid, a naturally occurring substance that increases elasticity and viscosity of synovial fluid. With osteoarthritis or certain injuries, the cartilage and other structures of the joint (in the knee, for instance) begin to break down. That inflammation often results in decreased or absent hyaluronic acid, so the joint becomes stiff and painful. Injections of SynVisc or Hyalgan replace the lost hyaluronic acid and reduce that pain and inflammation. Neither drug will cure arthritis or restore injured cartilage, but they provide temporary relief of pain and stiffness and improved mechanical action and lubrication of the joint.

In January 1999, HCPCS released specific codes for injections of Hyalgan and SynVisc. Sodium hyaluronate, which goes by the brand name Hyalgan, is billed with J7315 (sodium hyaluronate, 20 mg, for intra-articular injection). SynVisc is the brand name for Hylan, which is billed using J7320 (Hylan G-F 20, 16 mg, for intra-articular injection).

The CPT code for injection is used with the supply code for the drugs. In the case of SynVisc of Hyalgan, 20610* (athrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) is used. 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. Using the example of SynVisc injected into the patients right knee, the coding sequence would read 20610-RT, J7320.

Because SynVisc and Hyalgan injections are virtually always planned and scheduled in advance, an evaluation and management (E/M) code cannot be billed in addition to the injection procedure code. 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 a -25 [...]