Primary Care Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer. Question: My family physician performed an office visit and procedure for a female patient who has Medicare and Medicaid. He diagnosed her with myalgia, shoulder pain and hip pain. In addition, he gave her two injections. He coded:
99213-25 linked to 729.1, 719.41 and 719.45
20551 linked to 719.41
J1030 linked to 719.41
20552 linked to 719.45
J1030 linked to 719.45. Medicare denied the claim. How should he report it? North Carolina Subscriber

Answer: The problem is that the diagnosis codes you submitted do not match the procedure codes. The diagnosis code (719.41, Other and unspecified disorders of joint; pain in joint; shoulder region; 719.45, pelvic region and thigh)tied to each injection code is for joint pain, but the CPT injection codes (20551, Injection[s]; tendon origin/insertion; 20552, single or multiple trigger point[s], one or two muscle[s]) are for tendon or muscle injections, not joint injections. The CPT code for an injection of the shoulder or hip joint, which would be consistent with a diagnosis of shoulder joint or hip joint pain, is 20610* (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). Therefore, if the diagnoses are correct, you should report 20610 for the shoulder joint injection and 20610 appended with the carrier's preferred modifier for the hip joint injection. Most carriers require that you append modifier -59 (Distinct procedural service) to the second joint injection, rather than reporting two units of 20610, but some providers prefer modifier -51 (Multiple procedures). So check with the Medicare carrier for specific instructions.

Your example points out a common problem in injection reporting:The FP failed to provide enough detail to guide you to the correct CPT code.Encourage your doctor to identify the injection location, such as joint bursa, trigger point or tendon.

When you refile, you should also change how you reported the Depo-Medrol (J1030, Injection, methylpred-nisolone acetate, 40 mg). Most carriers want J1030 billed in units. So rather than listing J1030 twice, you should report J1030 x 2. Check your Medicare carrier's guidelines. Some payers instead require J1020 (Injection, methylprednisolone acetate, 20 mg) billed with the number of units. If North Carolina requires this type of reporting, you would code J1020 x 4 (80 mg of Depo-Medrol/20 mg = 4 units).