Wiki Durolane Injection coding

[mgarcia400]

Hello all, I work for a Family practice and we recently started giving Durolane injections in the knee. We had patient recently have the injection in both knees in one office visit.
My question is am I coding this correctly? I recently submitted a claim to Medicare Plus Blue (MI) as follows.

1. M17.12 (Osteoarthritis of Left knee)
2. M17.11 (Osteoarthritis of Right knee)

99213- 25 linked 1,2
20610- LT linked 1
J73.18 linked 1 60units
20610- RT linked 2
J73.18 linked 2 60units

The office visit 99213 was not paid at all stating "Diagnoses inappropriately coded" Advance Clinical Edits
20610- RT unpaid stating "Bundled service not separately payable, but 20610 LT was paid.

Are we not allowed to do both knees in one visit?
Why wouldn't office visit be paid or apply towards deductible.?

Any information is appreciated!

 

[sls314]

Hello all, I work for a Family practice and we recently started giving Durolane injections in the knee. We had patient recently have the injection in both knees in one office visit.
My question is am I coding this correctly? I recently submitted a claim to Medicare Plus Blue (MI) as follows.

1. M17.12 (Osteoarthritis of Left knee)
2. M17.11 (Osteoarthritis of Right knee)

99213- 25 linked 1,2
20610- LT linked 1
J73.18 linked 1 60units
20610- RT linked 2
J73.18 linked 2 60units

The office visit 99213 was not paid at all stating "Diagnoses inappropriately coded" Advance Clinical Edits
20610- RT unpaid stating "Bundled service not separately payable, but 20610 LT was paid.

Are we not allowed to do both knees in one visit?
Why wouldn't office visit be paid or apply towards deductible.?

Any information is appreciated!

Was there a significant & separately identifiable office visit? If the patient just came in for the injections, an office visit isn't separately payable. If another condition was evaluated on the office visit, you may want to add the additional diagnosis code for that and appeal with records showing that there was an evaluation distinct from the injections.

Depending on the payer, they may want the 20610 billed in one of 3 ways:

1) Billed as a bilateral procedure 20610-50

2) Payer may want one of the X modifiers - XS (separate structure) would be appropriate.

3) Payer may prefer Modifier 59 over the X modifiers. (X modifiers are more specific than Modifier 59, but some payers still prefer 59 for some reason.)

 

[mgarcia400]

Was there a significant & separately identifiable office visit? If the patient just came in for the injections, an office visit isn't separately payable. If another condition was evaluated on the office visit, you may want to add the additional diagnosis code for that and appeal with records showing that there was an evaluation distinct from the injections.

Depending on the payer, they may want the 20610 billed in one of 3 ways:

1) Billed as a bilateral procedure 20610-50

2) Payer may want one of the X modifiers - XS (separate structure) would be appropriate.

3) Payer may prefer Modifier 59 over the X modifiers. (X modifiers are more specific than Modifier 59, but some payers still prefer 59 for some reason.)

Thank you for the info. So office visit wouldn't be separately payable if though it was the provider who saw the patient and gave the injections?

 

[sls314]

Thank you for the info. So office visit wouldn't be separately payable if though it was the provider who saw the patient and gave the injections?

Not if the only purpose of the visit was to receive the injections.

 

[wongs84]

Hi @mgarcia400

So did you end up receiving payments on the J7318 and 20610,RT?

 

[dlb0426]

Hello all, I work for a Family practice and we recently started giving Durolane injections in the knee. We had patient recently have the injection in both knees in one office visit.
My question is am I coding this correctly? I recently submitted a claim to Medicare Plus Blue (MI) as follows.

1. M17.12 (Osteoarthritis of Left knee)
2. M17.11 (Osteoarthritis of Right knee)

99213- 25 linked 1,2
20610- LT linked 1
J73.18 linked 1 60units
20610- RT linked 2
J73.18 linked 2 60units

The office visit 99213 was not paid at all stating "Diagnoses inappropriately coded" Advance Clinical Edits
20610- RT unpaid stating "Bundled service not separately payable, but 20610 LT was paid.

Are we not allowed to do both knees in one visit?
Why wouldn't office visit be paid or apply towards deductible.?

Any information is appreciated!

If it is a planned Visco Supplementation OV are not payable. You would bill the 20610-LT and then the 20610-59,RT and the J7318-120 units. We just had a huge audit for viscosupplementation billing from Florida Medicare. Look at your LCD for your Medicare. BUT CMS retired the LCD in May or June of this year. I would still follow their guidelines most MCA Advantage plans will follow Medicare LCD but can have some variances. Make sure you have current xrays, documented procedural note and they have had conservative treatment for at least 3 months prior to injection. Again the LCD in FL is retired but you can always check the Insurance carriers policies.