Wiki Orthopedic gel injections

[ams_smithfarms@yahoo.com]

I am a new coder, and the previous coder was not able to get Arkansas blue cross blue shield to cover orthopedic gel injections for patients. Some of the patients have said these were being covered by their insurance when seen at different doctors where they lived at before. I am assuming they were in Arkansas but not %100 on that. so, my question is does anyone else bill for these through Arkansas blue cross blue shield and get them covered by the insurance or does Arkansas BCBS not cover orthopedic gel injections? If the insurance is covering these, how are they being coded for them to be covered?

 

[amyjph]

https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=1998119

It depends on the drug and the type of plan they are covered under. It would never be covered for any joint other than the knee currently. In some plans it is possibly never covered at all. Some plans require the specialty pharmacy to fill the drug in a delivery scenario. Others allow "buy and bill". Many only cover or allow one or two of the drugs. There are so many different types/names: Supartz, Gel-One, Orthovisc, Monovisc, Synvisc, Synvisc-One, Eufelxxa, etc. I know at one point Anthem found them not medically necessary, but I am not sure if that has changed or not.

Here are some Medicare examples of policy, none are in AR under Novitas though.

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52420&ver=60&keywordtype=starts&keyword=hya&bc=0

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39260&ver=5

The manufacturers usually have medical professional links too for assistance. Just always take their "coding" advice with a grain of salt and caution.
Example: https://monovisc.ca/en/resources#brochures

https://www.oakneepainrelief.com/supartz_fx/hcp_resources/

If the practice has a busy total joint service line, you need a policy and procedure for the whole life cycle of doing these types of procedures for all health plans. Also, just because a patient says, "they were covered before" doesn't necessarily mean they are now.

As far as coding, if they are covered, and you meet all the pre-reqs and other requirements, it is 20610 or 20611 for the knee (major joint) depending on if US was used or not. Then, the drug (J code) if it is a buy and bill.