ICD9 Code more detailed?
I am thinking the issue lies with the diagnosis code too. 715.95 is very generalized and not more specific. It usually raises flags if you cannot be more detailed on a claim form. Depending on the chart, try to use either 715.15, 715.25, or 715.35.
Did you bill Supartz as J7321?
J7321 -
Hyaluronan or Derivative, Hyalgan or Supartz, For Intra-Articular Injection, Per Dose
Also, if you do an appeal, print the following and attach with your appeal. Most insurance companies follow Medicare Guidelines on coverage and I have won some appeals on this same issue when a managed care carrier didn't cover a service, but Medicare did, they overturned my denial and issued payment. I copy and pasted the below from the Medicare website. I am sure you could find it by putting in the below in search to pull it up. Good luck. PS. I would appeal, and maybe find a more detailed diagnosis as well.
Per Medicare Guidelines:
Intra-articular Injections of Hyaluronan (INJ-033) Billing and Coding Guidelines
Coding Guidelines
1. HCPCS code J7321, J7323, and J7324 are per dose codes. When the injections are administered bilaterally, list J7321, J7323 or J7324 in item 24 (FAO-09 electronically) with a 2 in the unit's field.
J7321
Hyaluronan or Derivative, Hyalgan or Supartz, For Intra-Articular Injection, Per Dose
J7323
Hyaluronan or Derivative, Euflexxa, For Intra-Articular Injection, Per Dose
J7324
Hyaluronan or Derivative, Orthovisc, For Intra-Articular Injection, Per Dose
2. HCPC's code J7325 is defined as 1 mg
J7325
Hyaluronan or Derivative, Synvisc or Synvisc-One, For Intra-Articular Injection, 1mg
When this injection is administered either unilaterally or bilaterally the injections would be billed by placing J7325 in item 24 (FAO-09 electronically) and listing the total number of mg's administered in the units field.
There are 2 different products that are billed using this code.
Synvisc® - (16mg/2ml) – injection is given once a week (i.e., at seven-day intervals) for a total of three injections.
Synvisc-One™- (48mg/6ml) - single dose injection
3. The aspiration and/or injection procedure code may be billed in addition to the drug. Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT 20610). Place the CPT code 20610 in item 24D. If the drug was administered bilaterally, a -50 modifier should be used with 20610.
4. When this drug is administered in the hospital (inpatient or outpatient) setting, the drug/visco supplementation would not be covered by Part B. It would be covered under the Part A benefit.
5. Evaluation and management service:
a. An E&M service may be appropriate if the decision to start the series of injections is made after an evaluation during the same visit. Indicate this by using an E&M code with modifier -25.
b. After the first injection, during the visits for subsequent injections, an E&M service will not be covered unless there was a separately identifiable problem for which the E&M service was required and rendered.
6. When additional substances are concomitantly administered (e.g. cortisone, anesthetics) with viscosupplementation, only one injection service is allowed per knee.
7. If the drug is denied as not reasonable and necessary, the associated injection code is also not covered.
8. We suggest that the entire series of injections be billed on the same claim form.
Revision Effective Date: 01/01/10
Published: Article 02/01/2010; Article 01/01/10; Article 10/01/09; 09/01/09
Revision History:
02/01/2010- Removed code J7325 from coding instruction #1 and added #2, renumbered document.
Annual code updates-Added J7325, Deleted J7322; Added Per JSM 09414 08-13-09 new instructions for hospital billing of Synvisc-One: For services provided between February 26, 2009, through December 31, 2009, contractors shall instruct hospitals to bill for Synvisc-One using three (3) units of the Healthcare Common Procedure Coding System (HCPCS) Code J7322 (Hyaluronan or derivative, Synvisc, for intraarticular injection, per dose). The instructions for billing NOC codes (J3490 and C9399) have been removed. All settings should bill Synvisc-One as 3 units of code J7322.