Denials for 20550 + 20610/20611

[cordraydevinj@my.jccmi.edu]

Hello Everyone,

We've been getting a lot of denials for 20550 and 20610/20611 being billed together, and it looks like all of these are cases where both injections were very close together.
Example: [Right Supraspinatus tendon injection w/ Right Glenohumeral Joint injection] Each procedure has its own ICD code attached [M75.91 for 20550, M19.011 for 20611].

I've read some info from AAPC that suggests that these codes sometimes can't be billed together if they're in the same "location" (if I'm reading it correctly).

Would cases like these be something we would have to try and send medical records for, or are they more likely to not be able to be billed together because the locations are too close?

Also, this is happening with multiple payers, not just one specifically.

I'm a CPC-A and I just started learning denials so any help would be appreciated. I'm trying to make a guide for our providers on certain procedure codes we're getting clusters of denials for so that we can make sure they're all being documented/coded/processed correctly.

Thank you!

 

[NRaizman]

You'd need very good documentation, and the appropriate modifiers. There's no reason they theoretically couldn't be coded together.

HOWEVER, a subacromial bursal injection ("supraspinatus tendon") is coded as a large joint injection. You never want to inject directly into the supraspinatus tendon or else you'll injure it. If this is an attempt to call a bursal injection a tendon injection for the purposes of billing, that is 100% the wrong thing to do. The subacromial space and GH joint are different spaces. If they're being injected from different approaches, you might get away with it, but would often be denied.
My practice is 40-50% shoulder. I think I've done both subacromial and glenohumeral injections in the same patient at the same sitting maybe 2-3x in my career, so color me skeptical.

You can send a procedure note if you want more clarity.

 

[amyjph]

If you are new to coding and new to the practice, is there a supervisor, lead, manager, or senior person/coder you can go to? Who do you report to as a CPC-A? How large is the group?
Are you working as a coder, A/R rep, biller, edit fixer, rejections, etc.? Are these actually going out and denying at the payer level or are they getting stuck in the clearinghouse or pre-bill in-house edits of your EMR?

Questions I would have as a supervisor or manager in an ortho group if you came to me with this:
How many instances?
When you say "a lot" what does that mean?
When you say "multiple payers" which ones?
What are the denial reason codes if they are making it all the way out to the health plan? Bundling?
How long has this been going on?
Which provider(s)? Is it only a single doctor or more? Is the doctor new? Is it the individual or is it something with the way the EMR is set up/documentation/templates, etc.?
Is a coder manually coding this and incorrect? Is it even being coded by the doctor?
Do you have a new EMR, is it something with that?
M75.9X is unspecified, also questionable.
Before you start spending time making guides or help sheets, all of this needs to be looked into.

Agree w/ Dr. Raizman, this is odd.

 

[cordraydevinj@my.jccmi.edu]

If you are new to coding and new to the practice, is there a supervisor, lead, manager, or senior person/coder you can go to? Who do you report to as a CPC-A? How large is the group?
Are you working as a coder, A/R rep, biller, edit fixer, rejections, etc.? Are these actually going out and denying at the payer level or are they getting stuck in the clearinghouse or pre-bill in-house edits of your EMR?

Questions I would have as a supervisor or manager in an ortho group if you came to me with this:
How many instances?
When you say "a lot" what does that mean?
When you say "multiple payers" which ones?
What are the denial reason codes if they are making it all the way out to the health plan? Bundling?
How long has this been going on?
Which provider(s)? Is it only a single doctor or more? Is the doctor new? Is it the individual or is it something with the way the EMR is set up/documentation/templates, etc.?
Is a coder manually coding this and incorrect? Is it even being coded by the doctor?
Do you have a new EMR, is it something with that?
M75.9X is unspecified, also questionable.
Before you start spending time making guides or help sheets, all of this needs to be looked into.

Agree w/ Dr. Raizman, this is odd.

I'm new to coding and to the practice. We have a total of 8 providers across multiple locations and there are 3 coders on our team. I report to our senior coder.
My trainer/supervisor and I have been working on these together.
I work as a coder and biller. I process outgoing claims and work denials that come back.
They are denying at the payer level and coming back.
There are at least 10 claims in our current denial pile from these codes being billed together.
"A lot" would be relative to how many times we bill these codes, which isn't terribly often since we are mainly a family practice.
The payers we have denials from currently are Hap, Aetna, BCBS, Priority Health, Medicare, and Humana.
The denial code is coming back as 97-97-PMT INCL IN PMT FOR OTHR SVC/PX.
We currently have denials going back to 2025.
All the denials are from the same provider since he is the only one who does these injections. He is not new; he is the practice owner.
The codes are dropped by the providers and are then reviewed by a coder before being processed.
We have always used the same EMR system.
My trainer/supervisor and I are working on provider education guides to help with some of the coding issues we've been seeing a lot of denials for to help with documentation.

 

[cordraydevinj@my.jccmi.edu]

You'd need very good documentation, and the appropriate modifiers. There's no reason they theoretically couldn't be coded together.

HOWEVER, a subacromial bursal injection ("supraspinatus tendon") is coded as a large joint injection. You never want to inject directly into the supraspinatus tendon or else you'll injure it. If this is an attempt to call a bursal injection a tendon injection for the purposes of billing, that is 100% the wrong thing to do. The subacromial space and GH joint are different spaces. If they're being injected from different approaches, you might get away with it, but would often be denied.
My practice is 40-50% shoulder. I think I've done both subacromial and glenohumeral injections in the same patient at the same sitting maybe 2-3x in my career, so color me skeptical.

You can send a procedure note if you want more clarity.

Thank you for the information. I appreciate the insight from someone who does these types of injections.

This is an example of a procedure note template that's used for these injections:

Right Supraspinatus Tendon Sheath
After discussing risks and benefits of the procedure with patient, an informed consent was obtained. Patient was brought to the US suite. Using US guidance and no touch technique, alcohol swab followed by Betadine swab by two was done as antiseptic followed by injection of 40mg triamcinolone with 3cc of 1% Lidocaine using 22 gauge in the supraspinatus tendon sheath under US guidance. That was tolerated well. No acute complications. That resulted in immediate relief of pain and discomfort.

Right Glenohumeral Joint Injection
After discussing risks and benefits of the procedure with patient, an informed consent was obtained. Patient was brought to the US suite. Using US guidance and no touch technique, alcohol swab followed by Betadine swab by two was done as antiseptic followed by injection of 40mg triamcinolone with 3cc of 1% Lidocaine using 22 gauge in the glenohumeral joint under US guidance. That was tolerated well. No acute complications. That resulted in immediate relief of pain and discomfort.

Most of these are formatted the same way, with small differences depending on the patient.

 

[arkolab]

We've had luck billing these two together at our facility using the 59(commercial)/XS(medicare) modifier on CPT 20550.