By Daniel Nagle, MD
Chair, CPT/RUC Committee
INJECTION CODES
History
The AMA CPT Editorial Panel accepted five new/revised injection codes for CPT2002. These codes were the result of discussions dating back to 1999. Clarification of the injection nomenclature was requested by the AMA CPT Editorial Panel because of the number of questions coming to the AMA about these codes. The AMA Relative Value Update Committee (RUC), during its November 2001 meeting, recommended that all of the new/revised codes retain the same Medicare physician work value as the "root" code (20550) until frequency distribution data could be accumulated. The Center for Medicare and Medicaid Services (CMS, formerly HCFA) agreed with this rationale. Once adequate data were available, adjustment of the relative value were to be made to maintain family budget neutrality (ie, the total that CMS would spend for all the revised/new codes would be the same as if there were still only one code).
Early in 2002, the ASSH, as well as nine other specialty societies (see list below), participated in a RUC survey to establish a relative payment relation between the new/revised codes. (I would like to thank all of our members who participated in the survey process. Your effort is greatly appreciated!) New relative values were reviewed by the RUC for the five injection codes during the April 2002 AMA RUC meeting. [In addition, a sixth code is being considered for CPT2003 for the injection/aspiration of a ganglion. It is proposed that any references to ganglions should be removed from the other injection codes. The new code for aspiration/injection of a ganglion is not yet an official part of the AMA CPT nomenclature.]
Until January 1, 2003 the term “ganglion” will remain in the descriptors of the following codes:
20550 Injection; tendon sheath, ligament, ganglion cyst
20600 Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion
cyst (eg, fingers, toes)
20605 Arthrocentesis, intermediate joint, bursa or ganglion cyst…
The CPT 2002 New/Revised Injection Codes
2002 CPT 2002 CPT Descriptor Global Period
20526 Injection, therapeutic (eg, local anesthetic, corticosteroid); carpal tunnel
(If imaging guidance is performed, see 76003,76393,76942) 000
20550 Injection; tendon sheath, ligament, ganglion cyst 000
20551 tendon origin/insertion 000
20552 single or multiple trigger point(s), one or two muscle group(s) 000
20553 single or multiple trigger point(s), three or more muscle group(s) 000
Highlights:
The “root” code for these injection codes is 20550. This code was thought to be too inclusive and was expanded into five codes. In CPT2001, code 20550 read as follows: Injection, tendon sheath, ligament, trigger points or ganglion cyst. As you can see, code 20550 has remained relatively intact except that “trigger point” injections are now reported with 20552 and 20553. In addition, separate codes were created for carpal tunnel injection (20526) and for injections into tendon origins/insertions (20551) (eg, lateral epicondylitis).
How to use these codes with E&M services
These codes can be used in addition to the appropriate E&M code without a modifier, if the decision to perform an injection is made at the time of an initial office visit or consultation. If a subsequent visit is scheduled specifically for a repeat injection, no E&M code is billable. However, if a “significant, separately identifiable evaluation and management service is provided,” at the time of the followup visit, both the injection and E&M service can be billed by appending a modifier -25 to the E&M code.
Example:
Scenario #1: Mr. Jones, a new patient, undergoes a carpal tunnel injection at his initial visit and is told to return as needed. This encounter could be coded:
E&M 9920x (depending on the complexity of the history and exam for this new patient)
Injection of carpal tunnel 20526
Mr Jones returns three months later for re-evaluation. It is determined that another injection is indicated after taking an interval history and completing a physical exam. This encounter could be coded:
E&M 9921x (depending on the complexity of the history and exam of this established patient) -25
Injection 20526
Scenario #2: Mr. Jones, a new patient, undergoes a carpal tunnel injection at his initial visit and is told to return in two months for a repeat injection. This encounter could be coded:
E&M 9920x (depending on the complexity of the history and exam of this new patient)
Injection of carpal tunnel 20526
Mr Jones returns two months later. A cursory exam is performed. The injection is given. This encounter could be coded:
Injection 20526
These scenarios seem simple enough. Unfortunately, the interpretation of the Medicare rule vary from state to state. In some states, the Medicare carriers steadfastly refuse to accept any E&M code attached to an injection code at a subsequent visit. In other states, the only way the -25 modifier is acceptable is if a new diagnosis, in addition to carpal tunnel syndrome, is made at the time of the followup visit. The representatives of CMS who attended the April 2002 AMA RUC meeting indicated that neither of these practices is supported by the current Medicare rules.
How to code multiple injections performed during one visit
The usual rules apply to multiple injections. The modifiers -51 (Multiple Procedures) and/or -59 (Distinct Procedural Service) should be used. Again, the whim of the local Medicare carrier often determines how to use these modifiers. Medicare carriers in some states refuse to pay for multiple injections given during one encounter. Some third party payers require both -51 and -59. In addition, the HCPCS anatomy modifiers are required for Medicare (i.e. F5 = right thumb, FA = left thumb).
Examples:
Mr. Jones, a new patient, is given an injection into a trigger thumb on the right hand and a left index trigger finger. These injections would be coded as follows:
E&M 9920x (depending on the complexity of the history and exam for this new patient)
Injection right trigger thumb 20550
Injection left index trigger finger 20550-59 or 20550-51-59
Or
E&M 9920x (depending on the complexity of the history and exam for this new patient)
Injection right trigger thumb 20550 F5
Injection left index trigger finger 20550-59F1 or 20550-59-51F1
The Relative Values
The relative values for physician work for these codes will remain at 0.86 and the total RVU will remain at 1.77 (non-facility) until December 31, 2002. On January 1, 2003, interim RVU values, based on the RUC recommendations (and your surveys), will be implemented by CMS. After that, there will be a comment period if any changes need to be made, and then the values will be made final. The ASSH Coding and Reimbursement Committee will follow this issue and keep you informed. Look for an update in the Fall 2002 Coding Corner, after the CPT has published its 2003 manual and CMS has published it's Medicare fee schedule for 2003.
Notes
Ray Janevicius MD has written a Coding Corner for the ASPS which also reviews the new injection codes.
Please note that there will be a Hand Surgery Coding Course given during the afternoon of October 3, 2002 in conjunction with the ASSH Annual Meeting. The course is going to be run by Karen Zupko Associates, the leader in this field.
A useful coding reference is the 2002 Coding Companion for Orthopaedics: Upper Spine & Above first edition, published by Medicode an Ingenix company a division of the St. Anthony Publishing company. Their address is 2525 Lake Park Blvd., Salt Lake City, Utah 84120. The telephone number is 8800 999-4600.
--------------------------------------------------------------------------------
Specialty Societies Participating in the RUC Process
American Academy of Neurology
American Academy of Orthopaedic Surgeons
American Academy of Physical Medicine and Rehabilitation
American College of Rheumatology
American Orthopaedic Foot and Ankle Society
American Podiatric Medical Association
American Society of Anesthesiologists
American Society of Plastic Surgeons
American Society for Surgery of the Hand
North American Spine Society