Wiki Medicare replacement plan denying 20610

[grandmacora]

We have been trying to get a claim paid since January for an intra-articular cortisone injection of the shoulder through a Medicare replacement plan, Universal Health Care Insurance Company. We billed 20610 with 715.91 and 719.41. The insurance company keeps stating that per the LMRP code L18093, the diangosis does not support procedure code 20610. This policy, however, pertains to hyaluronate injections. I have appealed with this information and they continue to deny. I have spent hours on the CMS web site and for Wisconsin, the only LMRP I can find for CPT 20610, is the one relating to hyaluronate injections. Do you know where I can get LMRP that shows 20610 not related to hyaluronate injections or any other suggestions?? Thank you!!

 

[mitchellde]

try getting your physician to document either acute or chronic pain and use a 338.xx code first listed. Works for me!

 

[LLovett]

http://www.wpsmedicare.com/part_b/policy/inj033.pdf

Indications and Limitations of Coverage and/or Medical Necessity
Purified natural hyaluronates have been approved by the FDA for the treatment of osteoarthritis
of the knee in patients who have failed to respond to simple analgesics or conservative
nonpharmacologic therapy. Osteoarthritis leads to changes in hyaluronan, a natural substance
that helps provide the fluid within the joint with elasticity and viscosity. The goal of visco
supplementation is to supplement and restore the natural elastic and viscous properties of the
synovial joint fluid. Osteoarthritis (OA) is a common condition affecting the knees. OA is
characterized by deterioration and loss of the articular cartilage, subchondral sclerosis and
osteophyte formation, and is often accompanied by inflammation of the synovium. This can cause
pain and loss of function in the joint. Many treatments have a role in the management of the pain
of OA. These include symptomatic pharmacological treatment with analgesics, non-steroidal
anti-inflammatory drugs (NSAID) and intra-articular corticosteroid injections. Muscle
strengthening exercises and weight loss has also been helpful in managing osteoarthritis.

This is from the policy they are siting and it is the only reference I see regarding cortisone. I honestly don't know where they are coming from. I would keep pushing higher up the chain at medicare until they can give you a good reason or overturn it.

Good luck,

Laura, CPC, CEMC

 

[RebeccaWoodward*]

Although I'm in a different state, 719.41 is the only approved dx for my region (out of the 2 you submitted). Maybe our policy could be used as a guide....

http://www.cms.hhs.gov/mcd/results_...ent+Services+(05535)+-+Carrier&letter_range=4

 

[mitchellde]

I use the 338.xx code with the 719.x code and have had no problems with payers paying.