Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive

January 9th, 2018 - Find-A-Code
Categories:   HCPCS Coding   Anesthesia|Pain Management   Documentation Guidelines  
0 Votes - Sign in to vote or comment.

According to Palmetto GBA, Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria:

  • Knee pain associated with radiographic evidence of osteophytes in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing.
  • Morning stiffness of less than 30 minutes in duration or crepitus on motion of the knee. 
  • The pain cannot be attributed to other forms of joint disease.
  • There are no contraindications to the injections.
  • The prosthetic device is approved by the Food and Drug Administration (FDA) for intra-articular injection.
  • Pain that interferes with functional activities (e.g., ambulation, prolonged standing, ability to sleep).
  • Lack of functional improvement following a trial of at least three months of conservative therapy, or the patient is unable to tolerate Non-Steroidal Anti-inflammatory Drug (NSAID) therapy because of adverse side effects.
  • Bilateral injections may be allowed if both knees meet the criteria.

The frequency of injections is:

An initial series of three to five weekly injections per knee. Note: Synvisc-One® and Gel-One® are administered through a single intra-articular injection.

A repeat series of injections for patients who have responded to the first series may be given individual consideration by Medicare for coverage under the following circumstances:

  • The medical record objectively documents significant improvement in pain and functional capacity using a standardized assessment tool; OR
  • The medical record documents significant reduction in the doses of non-steroidal anti-inflammatory medications taken or reduction in the number of intra-articular steroid injections to the knees during the six-month period following the injection; and
  • At least six months have elapsed since the prior series of injections.
  • 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.
  • The appropriate records documenting the improvement must be maintained in the medical record and made available to Medicare upon request.
  • If the series of injections using sodium hyaluronate did not prove to be beneficial to the patient, it would not be reasonable to repeat the therapy again using any of these products. Thus, a repeat series of injections would not be covered.
  • Topical application is not covered.

Drug Wastage

Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient's condition. If the physician has made good faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored, and used the drug, and made good faith efforts to minimize the unused portion of the drug in how it is supplied, the program will cover the amount of drug discarded along with the amount administered.

Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP).

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
April 12th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K
April 12th, 2021 - Wyn Staheli, Director of Research
Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.
Properly Reporting Imaging Overreads (Including X-Rays)
April 8th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
March 31st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
Understanding Skin Biopsy Codes
March 23rd, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...
How Reporting E/M Based on Time May Lose Money
March 18th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
COVID-19 Vaccines
March 10th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
To accommodate the new COVID-19 immunizations the CPT editorial panel has approved 11 Category I codes. Watch for new and revised guidelines and parenthetical notes with these codes. For example; which administration codes should be used with the vaccine codes and the NCD codes applicable to the dose being administered. These ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association