Local Coverage Article Billing and Coding

Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis

A59030

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Contractor Information

Article Information

General Information

Article ID
A59030
Article Title
Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis
Article Type
Billing and Coding
Original Effective Date
08/21/2022
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.7(D) Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201-99215) - Drug Administration Services and E/M Visits Billed on Same Day of Service

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, §40 Discarded Drugs and Biologicals and §90.2 Drugs, Biologicals, and Radiopharmaceuticals

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hyaluronic Acid Injections for Knee Osteoarthritis L39260.

*Note: The prescribing information for the dose and frequency of administration should be consistent with the United States (U.S.) Food and Drug Administration (FDA) approved labeling.

Billing subsequent injections in a series (EJ modifier):

Use EJ modifier with the HCPCS code for the drug administered to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as a set of injections for each joint and each treatment.

JW Modifier Requirement:

Effective January 1, 2017, the Centers for Medicare and Medicaid Services (CMS) issued CR 9603, regarding the use of the JW modifier for discarded Part B drugs and biologicals. Providers are required to use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the CAP for Part B drugs and biologicals). Document the discarded drug or biological in the patient’s medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded.

Billing the injection procedure:

  • The CPT® code (procedure 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 1 unit for CPT® code 20610 or 20611.
  • When additional substances simultaneously administer (e.g., cortisone, anesthetics) with viscosupplementation, only 1 injection service is allowed per knee.
  • The appropriate site modifier (RT or LT) must be appended to CPT® code 20610 or CPT® code 20611 to indicate if the service was performed unilaterally and modifier (50) must be appended to indicate if the service was performed bilaterally.
  • An Evaluation and Management (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.

Coding Information

CPT/HCPCS Codes

Group 1

(13 Codes)
Group 1 Paragraph

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

Group 1 Codes
CodeDescription
J7318 HYALURONAN OR DERIVATIVE, DUROLANE, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7320 HYALURONAN OR DERIVITIVE, GENVISC 850, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7321 HYALURONAN OR DERIVATIVE, HYALGAN, SUPARTZ OR VISCO-3, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7322 HYALURONAN OR DERIVATIVE, HYMOVIS, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7323 HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7324 HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7325 HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7326 HYALURONAN OR DERIVATIVE, GEL-ONE, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7327 HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7328 HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG
J7329 HYALURONAN OR DERIVATIVE, TRIVISC, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7331 HYALURONAN OR DERIVATIVE, SYNOJOYNT, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7332 HYALURONAN OR DERIVATIVE, TRILURON, FOR INTRA-ARTICULAR INJECTION, 1 MG

Group 2

(2 Codes)
Group 2 Paragraph

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

Group 2 Codes
CodeDescription
20610 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE
20611 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING

CPT/HCPCS Modifiers

Group 1

(7 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
25 SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE: THE PHYSICIAN MAY NEED TO INDICATE THAT ON THE DAY A PROCEDURE OR SERVICE IDENTIFIED BY A CPTCODE WAS PERFORMED, THE PATIENT'S CONDITION REQUIRED A SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE ABOVE AND BEYOND THE OTHER SERVICE PROVIDED OR BEYOND THE USUAL PREOPERATIVE AND POSTOPERATIVE CARE ASSOCIATED WITH THE PROCEDURE THAT WAS PERFORMED. THE E/M SERVICE MAY BE PROMPTED BY THE SYMPTOM OR CONDITION FOR WHICH THE PROCEDURE AND/OR SERVICE WAS PROVIDED. AS SUCH, DIFFERENT DIAGNOSES ARE NOT REQUIRED FOR REPORTING OF THE E/M SERVICES ON THE SAME DATE. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -25 TO THE APPROPRIATE LEVEL OF E/M SERVICE, OR THE SEPARATE FIVE DIGIT MODIFIER 09925 MAY BE USED. NOTE: THIS MODIFIER IS NOT USED TO REPORT AN E/M SERVICE THAT RESULTED IN A DECISION TO PERFORM SURGERY. SEE MODIFIER -57.
50 BILATERAL PROCEDURE: UNLESS OTHERWISE IDENTIFIED IN THE LISTINGS, BILATERAL PROCEDURES THAT ARE PERFORMED AT THE SAME OPERATIVE SESSION SHOULD BE IDENTIFIED BY ADDING THE MODIFIER -50 TO THE APPROPRIATE FIVE DIGIT CODE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09950
EJ SUBSEQUENT CLAIMS FOR A DEFINED COURSE OF THERAPY, E.G., EPO, SODIUM HYALURONATE, INFLIXIMAB
JW DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
JZ ZERO DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
LT LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
RT RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)

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.

Group 1 Codes
CodeDescription
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

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

N/A

ICD-10-PCS Codes

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.

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.

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.


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Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2023 R1

Under CPT/HCPCS Modifiers Group 1: Codes added JZ. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/10/2023 01/01/2023 - N/A Currently in Effect You are here
07/01/2022 08/21/2022 - 12/31/2022 Superseded View

Keywords

  • Hyaluronic Acid
  • Hyaluronic Acid Injections
  • Knee Osteoarthritis