Wiki 20611 -injection w/ultrasound

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scooter1

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Just a general question. . . .
Physician is doing the knee injection with Ultrasound, and a Hyaluronate.
We coded 20611 and J7325.
We are getting denials . . . . ? So I am wondering if anyone else is receiving denials from insurance companies and/or Medicare ? I know it is a new code for this year. . . .
Would appreciate any input. Thank you
 
What diagnosis are you using? Hyalurinates are only covered for OA, specifically of knee tho Medicare (NGS) recently stated will cover for shoulder OA as well. Also, depending on payer, the brand may not be covered.

We do these w & w/o US and have had no denials.
 
I dont' believe we are getting denials either. Our MAC requires RT/LT modifiers for the drug and also EJ for subsequent injections when given in a series based on NGS MAC policy for WI.
 
When you get denials are you appealing them with the notes to show exactly what the doctor did and why the ultrasound was a necessary part of the procedure? Some would argue that the knee is a big joint that has been injected for years without benefit of ultrasound and some payers are not covering the extra charges. Check your payers rules and see if they mention this.
 
Are you getting denials across the board or from a specific carrier? So far, one of our physicians who performs these types of procedures has not seen issues except for one insurance that I suspect has not updated this new code as of this year within their system! We're still having discussions with that particular carrier and the policy we pulled up that they quote for reason for denial is about as clear as mud! Other carriers including Medicare are processing these without issues (so far).

As one of the responders stated concerning the necessity of the US for large joints, perhaps the reason for its creation was to scale down the generous amount paid for these type of procedures when 76942 was used? Please take note that this is only my opinion.
 
We have been seeing a lot of denials from Aetna, but after appeals we have been able to get some of them covered.
Note: You should be submitting a clean claim to the insurance and they can deny the claim in whole on the fact that you are billing 20611 with 76942. The 2015 CPT book clearly states to not bill the two together because US reimbursement is already built into 20611. I would suggest only billing 20611, but also meeting one of the following criteria:
BMI >30
Systemic Disease
Severe osteoarthrosis(this one particular criteria may not be enough)

It must be documented thorougly in the notes, such as a paragraph of the procedure along with an explanation as to why US guidance was needed.

I hope this helps!
 
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