SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee

A55036

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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General Information

Source Article ID
N/A
Article ID
A55036
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee
Article Type
Billing and Coding
Original Effective Date
04/01/2016
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

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):

  1. The procedure code (CPT code) 20610 or 20611 (with ultrasound guidance) may be billed for the intra-articular injection in addition to the drug.
  2. 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).
  3. When additional substances are concomitantly administered (e.g. cortisone, anesthetics) with viscosupplementation, only one injection service is allowed per knee.
  4. 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:

  1. 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).
  2. 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.
  3. 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).

  1. 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.
  2. 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.

 

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
025X Pharmacy - General Classification
036X Operating Room Services - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0636 Pharmacy - Drugs Requiring Detailed Coding
N/A

CPT/HCPCS Codes

Group 1

(13 Codes)
Group 1 Paragraph

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

The following CPT/HCPCS codes associated with the services outlined in this policy will not have diagnosis limitations applied at this time: 20610, 20611, and 77002.

Group 1 Codes
Code Description
J7318 Inj, durolane 1 mg
J7320 Genvisc 850, inj, 1mg
J7321 Hyalgan supartz visco-3 dose
J7322 Hymovis injection 1 mg
J7323 Euflexxa inj per dose
J7324 Orthovisc inj per dose
J7325 Synvisc or synvisc-one
J7326 Gel-one
J7327 Monovisc inj per dose
J7328 Gelsyn-3 injection 0.1 mg
J7329 Inj, trivisc 1 mg
J7331 Synojoynt, inj., 1 mg
J7332 Inj., triluron, 1 mg

Group 2

(7 Codes)
Group 2 Paragraph

Note: The following CPT codes for imaging of the knee are noncovered when reported at the same anatomic site with any of the HCPCS codes in Group 1.

For additional information regarding coverage guidance for CPT codes 76881 and 76882, please refer to LCD L35409, Non-Vascular Extremity Ultrasound.

Group 2 Codes
Code Description
27369 Njx cntrst kne arthg/ct/mri
73580 Contrast x-ray of knee joint
76881 Us compl joint r-t w/img
76882 Us lmtd jt/fcl evl nvasc xtr
76942 Echo guide for biopsy
77012 Ct scan for needle biopsy
77021 Mri guidance ndl plmt rs&i
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(8 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for HCPCS codes J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, and J7332:

Note: For frequency limitations, please refer to LCD L35427, Hyaluronan Acid Therapies for Osteoarthritis of the Knee.

Group 1 Codes
Code Description
M17.0 Bilateral primary osteoarthritis of knee
M17.11 Unilateral primary osteoarthritis, right knee
M17.12 Unilateral primary osteoarthritis, left knee
M17.2 Bilateral post-traumatic osteoarthritis of knee
M17.31 Unilateral post-traumatic osteoarthritis, right knee
M17.32 Unilateral post-traumatic osteoarthritis, left knee
M17.4 Other bilateral secondary osteoarthritis of knee
M17.5 Other unilateral secondary osteoarthritis of knee
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity" section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this Article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Medicare Claims Processing Manual for further guidance.


Code Description
025X Pharmacy - General Classification
036X Operating Room Services - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0636 Pharmacy - Drugs Requiring Detailed Coding
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R8

Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 76882 in Group 2 Codes. 

04/01/2021 R7

Article revised and published on 04/22/2021 effective for dates of service on and after 04/01/2021 to reflect the April 2021 CPT/HCPCS Code Update. The following HCPCS code has been deleted and therefore has been removed from the article: J7333 in the first (#1) ‘Hyaluronan Drug Dosing Table’, in the ‘CPT/HCPCS Codes’ section in the ‘Group 1 Codes’, and in the ‘ICD-10 Codes that Support Medical Necessity’ section in the ‘Group 1 Paragraph’. For the following HCPCS code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: J7321 in the first (#1) ‘Hyaluronan Drug Dosing Table’ (3rd row), in the ‘CPT/HCPCS Codes’ section in the ‘Group 1 Codes’. Minor formatting changes have been made throughout the coding section.

07/01/2020 R6

Article revised and published on 07/30/2020 effective for dates of service on or after 07/01/2020. In response to July CPT/HCPCS code updates, J7321 has a descriptor change. J7321 was changed to J7333 for Visco-3 in the per dose table. J7333 has been added to the CPT code group 1 and ICD-10 group 1 paragraph.

10/01/2019 R5

Article revised and published on 10/31/2019 effective for dates of service on or after 10/01/2019. In response to CR11422 quarterly updates, CPT/HCPCS codes J7331 and J7332 have been added to table 2 for codes that are per mg dose, to the Group 1 CPT/HCPCS Codes and to the ICD-10 Code Group 1 paragraph. Due to system changes, the order of the Coding Section has been revised and new sections for CPT/HCPCS Modifiers and other Coding Information have been added.

05/20/2019 R4

Article revised and published on 04/04/2019 to become effective for dates of service on and after 05/20/2019. Coding information from LCD L35427 Hyaluronan Acid Therapies for Osteoarthritis of the Knee has been added to this article (reference TN854, CR 10901), the title was changed to “Billing and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee”, and the article has been updated to include CPT code 20611 as well as information on reporting image guidance methods used for needle placement with viscosupplementation of the knee.

The 2019 annual CPT/HCPCS code updates were incorporated into the final LCD and then moved to this article. HCPCS codes J7318 and J7329 have been added to the Group 1 CPT codes and to the Hyaluronan Drug Dosing Table #2 in the article text. Group 2 CPT code 27370 has been deleted and therefore removed. CPT code 27369 has been added to the Group 2 noncovered CPT codes replacing 27370. Group 2 CPT code 77021 has been revised, either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays in the document.

01/01/2019 R3

Article revised and published on 02/14/2019 effective for dates of service on and after 01/01/2019 to reflect the annual CPT/HCPCS code updates. HCPCS codes J7318 and J7329 have been added to the Group 1 CPT/HCPCS codes and to the Hyaluronan Drug Dosing Table #2 in the article text. The note beneath the Drug Dosing Table #2 was updated to include Durolane.

01/01/2018 R2

Article revised and published on 01/25/2018 effective for dates of service on and after 01/01/2018 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS codes have been revised: J7321and J7328. Information for Visco-3 (J7321) has been added to the Hyaluronan Drug Dosing Table #1 for “per dose” codes.

01/01/2017 R1 Article revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS code(s) have been deleted and therefore removed from the Article, Group 1 codes: C9471 and Q9980. The following CPT/HCPCS code(s) have been added to the Article, Group 1 codes: J7320 and J7322. Information on drug wastage and reporting the JW modifier has been revised per CR 9603 effective 01/01/2017.
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