This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35427 Hyaluronan Acid Therapies for Osteoarthritis of the Knee. Please refer to the LCD for reasonable and necessary requirements.
Coding Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Billing the drug code
When reporting C, J or Q HCPCS codes for hyaluronan acid therapy, it should be noted that some codes are “per dose” and some are “per mg” as specified in the code descriptor. When reporting a “per mg” drug code, report the appropriate number of units that reflect the dosage given. Units of service are to be billed in multiples of the dosage specified in the full HCPCS descriptor. This descriptor does not always match the dose given. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient.
Hyaluronan Drug Dosing Tables
1.The following HCPCS codes are per dose codes:
| HCPCS Code |
Billing Unit |
Drug Name(s) |
Dosing frequency per series (per knee)* |
Dose (per knee)* |
Units per dose (per knee) |
| J7321 |
per dose |
Hyalgan |
3 to 5 weekly injections |
20 mg once weekly |
1 unit |
| J7321 |
per dose |
Supartz |
3 to 5 weekly injections |
25 mg once weekly |
1 unit |
| J7321 |
per dose |
Visco-3 |
3 weekly injections |
25 mg once weekly |
1 unit |
| J7323 |
per dose |
Euflexxa |
3 weekly injections |
20 mg once weekly |
1 unit |
| J7324 |
per dose |
Orthovisc |
3 to 4 weekly injections |
30 mg once weekly |
1 unit |
| J7326 |
per dose |
Gel-One |
Single injection** |
30 mg x 1 dose |
1 unit |
| J7327 |
per dose |
Monovisc |
Single injection** |
88 mg x 1 dose |
1 unit |
*Note: Dose frequency and dose listed is from package insert or is FDA approved dosing.
**Note: Gel-One and Monovisc are administered through a single intra-articular injection.
2.The following HCPCS codes are per mg codes (not per dose):
| HCPCS Code |
Billing Unit |
Drug Name(s) |
Dosing frequency per series (per knee)* |
Dose (per knee)* |
Units per dose (per knee) |
| J7328 |
per 0.1 mg |
Gelsyn-3 |
3 weekly injections |
16.8 mg once weekly |
168 units |
| J7329 |
per 1 mg |
TriVisc |
3 weekly injections |
25 mg once weekly |
25 units |
| J7318 |
per 1 mg |
Durolane |
Single Injection** |
60 mg x 1 dose |
60 units |
| J7320 |
per 1 mg |
Genvisc 850 |
3 to 5 weekly injections |
25 mg once weekly |
25 units |
| J7325 |
per 1 mg |
Synvisc |
3 weekly injections |
16 mg once weekly |
16 units |
| J7325 |
per 1 mg |
Synvisc-One |
Single injection** |
48 mg x 1 dose |
48 units |
| J7322 |
per 1 mg |
Hymovis |
2 weekly injections |
24 mg once weekly |
24 units |
| J7331 |
per 1 mg |
Synojoynt |
3 weekly injections |
20 mg once weekly |
20 units |
| J7332 |
per 1 mg |
Triluron |
3 weekly injections |
20 mg once weekly |
20 units |
*Note: Dose frequency and dose listed is from package insert or is FDA approved dosing.
**Note: Synvisc-One and Durolane are administered through a single intra-articular injection.
Billing subsequent injections in a series (EJ modifier)
A series is defined as a set of injections for each joint and each treatment. The EJ modifier must be used with the HCPCS code for the drug administered to indicate subsequent injections of a series. The modifier is not to be used with the first injection of each series.
Drug Wastage
When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.
JW Modifier Requirement:
Effective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under CAP), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient’s medical record.
Billing the injection procedure (with or without ultrasound guidance):
- The procedure code (CPT code) 20610 or 20611 (with ultrasound guidance) may be billed for the intra-articular injection in addition to the drug.
- If an aspiration and an injection procedure are performed at the same session, bill only one unit for CPT code 20610 or 20611 (if applicable).
- When additional substances are concomitantly administered (e.g. cortisone, anesthetics) with viscosupplementation, only one injection service is allowed per knee.
- The appropriate site modifier (RT or LT) must be appended to CPT code 20610 or 20611 (if applicable) to indicate if the service was performed unilaterally and modifier (-50) must be appended to indicate if the service was performed bilaterally.
Billing for imaging guidance using fluoroscopy, ultrasound, computed tomography (CT), or magnetic resonance (MR) imaging to provide guidance for needle placement with viscosupplementation of the knee:
- If fluoroscopic guidance is performed for needle placement, the add-on CPT code 77002 would be listed separately in addition to the intra-articular injection procedure CPT code 20610.
Note: It would not be appropriate to report arthrography (e.g., CPT code 27369 or 73580) if the intent is to inject contrast only to confirm needle position within the joint (Reference AMA CPT Assistant, June 2012, Volume 22, Issue 6).
- If ultrasound guidance is used for needle placement, the CPT code 20611 would be reported instead of CPT code 20610. This code includes the intra-articular injection of the knee with ultrasound guidance, with permanent recording and reporting.
Note: It would not be appropriate to report any other ultrasound CPT code separately for viscosupplementation with ultrasound guidance.
- If CT or MRI guidance is performed for needle placement, the CPT codes 77012 (CT guidance for needle placement) or 77021 (MRI guidance for needle placement) as applicable, would be reported in addition to the injection procedure CPT code 20610. These services are not covered when performed for the purpose of needle guidance. For reasonable and necessary information on the use of imaging with viscosupplementation of the knee, please refer to LCD L35427, Hyaluronan Acid Therapies for Osteoarthritis of the Knee.
Evaluation and Management service
Please refer to Medicare’s criteria for billing an E&M service on the same day of service as a drug administration which is located in the Internet-Only Manuals (IOMs) published on the CMS Web site: Medicare Claims Processing Manual – Pub. 100-04, Chapter 12, Section 30.6.7 (D).
- 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.
- An E&M service should not be reported for subsequent injections unless there was a separately identifiable problem for which the E&M service was required and rendered.
