Injections CPT - 20526, 20550, 20612, 28899 - Therapeutic Local


This policy addresses the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents and/or neurolytic agents into ganglion cysts, tendon sheaths, tendon origins/insertions, ligaments, costochondral areas, or near nerves of the feet (e.g., Morton’s neuroma) to affect therapy for a pathological condition.

Note: the term “Mortons neuroma” is used in this policy generically to refer to a swollen inflamed nerve in the ball of the foot, including the more specific conditions of Morton’s neuroma (lesion within the third intermetatarsal space), Heuter’s neuroma (first intermetatarsal space), Hauser’s neuroma (second intermetatarsal space) and Iselin’s neuroma (fourth intermetatarsal space). This policy applies to each.

Injection of a carpal tunnel is indicated for the patient with a mild case of the carpal tunnel syndrome if oral non-steroidal anti-inflammatory drugs (NSAIDs) and orthoses have failed or are contraindicated. Note that this procedure has its own CPT code, 20526. Injection of a tarsal tunnel is indicated for the patient with a mild case of tarsal tunnel syndrome if oral NSAIDs and orthoses have failed or are contraindicated. Though there are many similarities between this and carpal tunnel syndrome, there is as yet no specific CPT code for tarsal tunnel injection. Instructions below clarify that CPT 28899 is to be used until a more specific code becomes available.

Injection into tendon sheaths, ligaments, tendon origins or insertions, ganglion cysts, or neuromas may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes. Proper use of this modality with local anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause. In some circumstances after diagnosis has been confirmed, injection of a sclerosing or neurolytic agent may be appropriate for longer-term management.

The signs or symptoms that justify these treatments should be resolved after one to three injections (see reference 2 below, under “Sources of Information and Basis for Decision”). Injections beyond three must be justified by the clinical record indicating a logical reason for failure of the prior therapy and why further treatment can reasonably be expected to succeed. A recurrence may justify a second course of therapy.

Injection therapies for tarsal tunnel syndromes (which include any so-called “Baxter’s injections”) do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 28899 (Unlisted procedure, foot or toes), since there is not yet a CPT code that specifically addresses tarsal tunnel injection. Most specifically, the provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas such as a carpal tunnel, tarsal tunnel or Morton’s neuroma.
Fluoroscopic or Computed Tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by codes 64490–64495. For paravertebral spinal nerves and branches, image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of codes 64490–64495.

Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is questionable. Such injections are likely to result in a request for medical records which must evidence careful justification of necessity.

“Dry needling” of ganglion cysts, ligaments, neuromas, tendon sheaths and their origins/insertions are non-covered procedures.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 71X, 75X, 83X, 85X
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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors.
20526©
Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel
20550©
Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia’’)
20551©
Injection(s); single tendon origin/insertion
20612©
Aspiration and/or injection of ganglion cyst(s) any location
28899©
Unlisted procedure, foot or toes
Note: Use 28899 for tarsal tunnel injection.
64455©
N block inj, plantar digit
64632©
N block inj, common digit

TRIGGER POINT INJECTIONS AND INJECTIONS OF TENDON SHEATH, LIGAMENT, GANGLION CYST, CARPAL AND TARSAL TUNNELS

For trigger point injections, use code 20552 for one or two muscle groups injected, or 20553 for three or more muscle groups. The number of services for either code is one (1), regardless of the number of injections at any individual site, and regardless of the number of sites. Only 20552 or 20553 may be billed, not both. Trigger point injections must be billed on only one line, regardless of the number of sites. 

CPT code 20551 should be used when the origin or insertion of a tendon is injected, in contrast to an injection of the tendon sheath, CPT code 20550. 

CPT code 28899 (unilateral procedure, foot or toe) should be billed for the injection of the tarsal tunnel. 

Injection of separate sites (tendon sheath, ligament or ganglion cyst) during the same encounter should be reported on a separate line of coding and must have the modifier 59 appended. Multiple surgical rules will apply. Modifier 50 should not be reported with CPT codes 20551, 20552, 20553 or 20612, but may be reported, when appropriate, with CPT codes 20550 and 20526.

Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (Number of Services (NOS)001). 

Claims for prolotherapy must not be reported with the trigger point codes or other injection codes.

Pyament Policy Overview
This policy identifies circumstances in which UnitedHealthcare Community Plan will reimburse physicians or other health care professionals for injections to treat problems in the tendon/tendon sheath, ligament, ganglion cyst, carpal tunnel or tarsal tunnel.

Reimbursement Guidelines
UnitedHealthcare Community Plan reimburses for injections into the tendon/tendon sheath, or ligament (CPT codes 20550, 20551) ganglion cyst (CPT code 20612), carpal tunnel or tarsal tunnel (CPT code 20526) when one of the diagnosis codes are listed on a claim denoting problems with one of these regions. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the (ICD-9-CM and ICD-10-CM) diagnostic codes being included on the claim accurately reflecting the member's condition. 

CPT code section
20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar fascia)


Coding Information  General

Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma

1. Though there are many similarities between tarsal tunnel syndrome and carpal tunnel syndrome, there is as yet no specific CPT code for tarsal tunnel injection. Tarsal tunnel injections should be billed with  CPT code 28899 (unlisted procedure, foot or toes).

2. When billing for the injection of tarsal tunnel syndrome with CPT code 28899, please place "tarsal tunnel syndrome," in Item 19 on the CMS-1500 claim form or the electronic equivalent.

3. When injection therapies for tarsal tunnel syndromes include "Baxter's injections" and/or injections for Morton’s neuroma use CPT codes 64455 or 64632. 

4. Morton's neuromas injections do not involve the structures described by CPT codes 20550 and 20551 or direct injection into other peripheral nerves but rather the injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using CPT codes 20550, 20551, 64450, or 64640. Most specifically, the provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas. 

5. Injections for plantar fasciitis are billed with CPT code 20550 and ICD-9-CM 728.71. Injections for calcaneal spurs are billed as other tendon origin/insertions with CPT code 20551. 

6. Injections that include both the plantar fascia and the area around a calcaneal spur are to be reported using a single CPT code 20551.

7. Billing for Xiaflex™ (collagenase clostridium histolyticum) Xiaflex 

TM is only indicated for Dupuytren’s contractures, ICD-9 code 728.6 (Contracture of palmar fascia).

Use CPT code 20527 for Injection, enzyme (eg, collagenase), palmar fascial cord (i.e., dupuytren's contracture)

Use CPT code 26341 for Manipulation, palmar fascial cord (i.e., dupuytren's cord), post enzyme injection (e.g., collagenase), single cord and CPT 29130 for the splint application. 


Issue: Payment for 20550/20551
I have received several inquires regarding Medicare (FCSO) policies (LCD) on injection codes 20550, 20551.

History: Recently, I argued a case with an ALJ (Administrative Law Judge) regarding apparent confusion with the LCD that was referenced for injections. To avoid belaboring the issue, I indicated that the policy under certain circumstances was inappropriately applied to adjudicate claims for 20550 and 20551 resulting in denials to providers. After lengthy discussion and substantiation of the argument, the judge agreed. I then took the argument to Medicare (FCSO) and they agreed to honor my request and make appropriate changes. 

My argument was that criteria for trigger point injections were erroneously being applied to 20550/51.

Resolution: Rather than writing a new policy on these codes, they were to modify the existing LCD to avoid the confusion of applying trigger point injection criteria to these non-trigger point CPT codes.

Conclusion: This change is the result of my request to remove the restrictions from these codes.

This modified LCD should result in reimbursement of 20550/51 under appropriate circumstances, eliminating denials that in the past resulted in non-payment for these services. By removing these codes from the LCD, it eliminates the issues encountered (denials as stated). The exclusion of these codes from the LCD is extremely favorable and in no way implies that these codes are not billable. (An LCD is written when there are issues with provider utilization, i.e., abuse, over utilization etc. Therefore, one will note that many codes do not have an LCD. This is a good thing. It is a bad thing when an LCD is written for a CPT code. That implies a problem has been encountered and the payer is applying strict guidelines/parameters for payment.)  

ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 20526, 20550, 20551 and 20612:
Covered for:
354.0
Carpal tunnel syndrome
355.5
Tarsal tunnel syndrome
355.6
Lesion of plantar nerve
720.0-720.2
Ankylosing spondylopathies and other inflammatory spondylopathies
720.81
Inflammatory spondylopathies in diseases classified elsewhere
720.89
Other inflammatory spondylopathies
720.9
Unspecified inflammatory spondylopathy
723.7
Ossification of posterior longitudinal ligament in cervical region
724.71
Hypermobility of coccyx
724.79
Other disorders of coccyx
726.0
Adhesive capsulitis of shoulder
726.10-726.12
Rotator cuff syndrome of shoulder and allied disorders
726.19
Other specified disorders of bursae and tendons in shoulder region
726.2
Other affections of shoulder region not elsewhere classified
726.30-726.33
Enthesopathy of elbow region
726.39
Other enthesopathy of elbow region
726.4
Enthesopathy of wrist and carpus
726.5
Enthesopathy of hip region
726.60-726.65
Enthesopathy of knee
726.69
Other enthesopathy of knee
726.70-726.73
Enthesopathy of ankle and tarus
726.79
Other enthesopathy of ankle and tarsus
726.8
Other peripheral enthesopathies
726.90-726.91
Unspecified enthesopathy
727.00-727.06
Synovium and tenosynovitis
727.09
Other synovium and tenosynovitis
727.1 - 727.3
Other disorders of synovium, tendon and bursa
727.40-727.43
Ganglion and cyst of synovium, tendon and bursa
727.49
Other ganglion and cyst of synovium, tendon and bursa
727.50 -727.51
Rpture of synovium
727.59
Other rupture of synovium
727.60-727.69
Rupture of tendon, nontraumatic
727.81-727.83
Other disorders of synovium, tendon and bursa
727.89
Other disorders of synovium tendon and bursa
727.9
Unspecified disorder of synovium tendon and bursa
728.4-728.6
Disorders of muscle, ligament and fascia
728.71
Plantar fascial fibromatosis
728.79
Other fibromatoses of muscle ligament and fascia
729.0-729.1
Other disorders of soft tissues
729.4
Fasciitis unspecified
733.6
Tietzes disease
733.99
Other disorders of bone and cartilage
840.0-840.9
Sprains and strains of shoulder and upper arm
841.0-841.3
Sprains and strains of elbow and forearm
841.8-841.9
Sprains and strains of elbow and forearm
842.00-842.02
Sprains and strains of wrist
842.09
Other wrist sprain
842.10-842.13
Sprains and strains of hand
842.19
Other hand sprain
843.0-843.1
Sprains and strains of hip and thigh
843.8-843.9
Sprains and strains of hip and thigh
844.0-844.3
Sprains and strains of knee and leg
844.8-844.9
Sprains and strains of knee and leg
845.00-845.03
Sprains and strains of ankle
845.09
Other sprains and strains of ankle
845.10 - 845.13
Sprains and strains of foot
845.19
Other foot sprain
846.0-846.3
Sprains and strains of sacroiliac region
846.8-846.9
Sprains and strains of sacroiliac region
847.0-847.4
Sprains and strains of other and unspecified parts of back
847.9
Sprain of unspecified site of back
848.0-848.3
Other and ill-defined sprains and strains
848.40-848.42
Other and ill-defined sprains and strains of sternum
848.49
Other sprain of sternum
848.5
Pelvic sprain
848.8-848.9
Other and ill-defined sprains and strains
Medicare is establishing the following limited coverage for CPT/HCPCS codes 64455 and 64632:
Covered for:
355.6*
Lesion of plantar nerve
Note: Use 355.6 for Morton’s metatarsalgia, neuralgia or neuroma
355.8
Mononeuritis of lower limb, unspecified
355.9
Mononeuritis of unspecified site
729.2
Neuralgia, neuritis and radiculitis, unspecified
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
The clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use injection. If the number of injections exceeds three, the record must justify these added injections since the presumed need for further injections should raise the issues of correct diagnosis or correct choice of therapy as well as concerns for adverse side effects. Records must be made available upon request.
When billing for the injection of tarsal tunnel syndrome with CPT code 28899, place the appropriate descriptor, “tarsal tunnel syndrome,” on the claim form or the electronic equivalent.

Submission of injection codes 64490–64495 (injection, paravertebral facet joint or facet joint nerve) or joint space injection codes (20600, 20605 and cpt code 20610) in addition to 20550 and/or 20551 must be supported by documentation in the medical record of the medical necessity of the separate procedure(s).

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

1 comment:

kevin smith said...

The most common symptom of Morton's neuroma is localized pain in the interspace between the third and fourth toes. It can be sharp or dull, and is worsened by wearing shoes and by walking. Pain usually is less severe when the foot is not bearing weight. 
Neuroma Surgery Winston Salem NC

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