November 2, 2017
Our orthopaedic surgeon performed and clearly documented a joint injection to the right shoulder and a trigger point injection bilaterally to the trapezius muscle. We are receiving denials when we report CPT code 20610 and 20552 on the same claim form? Are you able to assist us in understanding if we have coded correctly or how to appeal?
You are correct to question this denial! There is no clinical reason for this denial assuming your documentation and medical necessity supports reporting CPT 20610 and 20552 as defined in your scenario. If the payor is Medicare, or a payor who follows NCCI rules, the answer has to do with NCCI edits between the code combinations. Several years ago, Medicare identified coding patterns where the 2055x series of codes were reported during the same session as joint or other musculoskeletal surgical injections. In doing their due diligence, Medicare found in record review that the 2055x series was being incorrectly reported for the administration of a local anesthetic prior to the definitive injection. In the KZA orthopaedic coding workshops the surgical package and administration of local anesthesia is discussed as the rationale for the creation of this edit.
This is an example where the use of modifier 59 (distinct procedure modifier) has a role in claims reporting!
20610 linked to the shoulder diagnosis
20552-59 linked to the appropriate diagnosis to support the trigger point injection
We are confident the denial, while not identified in your question, was for a bundled or service integral to another procedure on the same day. It is not uncommon for the Center for Medicare and Medicaid Services (CMS) to implement edits when a pattern of incorrect code combinations are identified.
The following statement is found in the January 2017 NCCI Guidelines (CHAPTER IV SURGERY MUSCULOSKELETAL SYSTEM):
Injections of local anesthesia for musculoskeletal procedures (surgical or manipulative) are not separately reportable. For example, CPT codes 20526-20553 (therapeutic injection of carpal tunnel, tendon sheath, ligament, muscle trigger points) should not be reported for the administration of local anesthesia to perform another procedure. The NCCI contains many edits based on this principle. If a procedure and a separate and distinct injection service unrelated to anesthesia for the former procedure are reported, the injection service may be reported with an NCCI-associated modifier if appropriate.
*This response is based on the best information available as of 11/02/17.