The musculoskeletal therapeutic injection codes 20550 through 20553 have been revised to read as follows:
- 20550, Injection(s); tendon sheath, ligament;
- 20551, Tendon origin/insertion;
- 20552, Single or multiple trigger point(s), one or two muscle(s);
- 20553, Single or multiple trigger point(s), three or more muscle(s).
What are the practical implications of these changes? You should report 20552 and 20553 only once per session, regardless of the number of injections or muscles involved. You should also report 20550 and 20551 only once per tendon sheath, ligament, or tendon origin/insertion, regardless of the number of injections involved. Also note that the words “ganglion cyst” have been removed from 20550, as well as from 20600 and 20605. This is because CPT 2003 includes a new code, 20612, for “Aspiration and/or injection of ganglion cyst(s) any location.”
Colposcopy coding has also changed. In the past, there were only three codes for pelvic endoscopy: 57452, 57454 and 57460. Although these codes were listed under the vagina section of CPT, they were typically used for colposcopy involving the cervix. Accordingly, for 2003, these codes have been revised and moved to the cervix uteri section of CPT, and two new codes, 57420 and 57421, have been added to the vagina section. Two new codes for colposcopy of the vulva, 56820 and 56821, have also been added, along with three new codes for procedures done in conjunction with colposcopy of the cervix uteri. A review of all three sections of CPT may be in order if you do colposcopy in your practice.
General billing Guidelines
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.
Coverage Indications, Limitations, and/or Medical Necessity
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 “Morton’s 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, the best apparent CPT code is 64450.
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. Noncoverage for prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents is found in the CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations (Internet-only Manual).
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”) and for Morton’s neuroma (64455) 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. Tarsal Tunnel Syndrome therapy should be billed with CPT code 64450. Occasionally, injections of alcohol are used for nerve sclerosing (e.g. in heel for nerve entrapment and neuromas in the foot). The procedure involves 4-10% alcohol injected every 7-10 days to decrease pain associated with nerve entrapment. Noridian would not expect more than six consecutive procedures to be billed. CPT code 64450 is used to describe this service.
Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2. Injections for calcaneal spurs are addressed as are other tendon origin/insertions by 20551. Injections to include both the plantar fascia and the area around a calcaneal spur, are to be reported using a single 20551.
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.
Note: Nerve blocks are contraindicated and not covered for peripheral diabetic neuropathy.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
Group 1 Paragraph: N/A
Group 1 Codes:
20526 INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL
20527 INJECTION, ENZYME (EG, COLLAGENASE), PALMAR FASCIAL CORD (IE, DUPUYTREN’S CONTRACTURE)
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
26341 MANIPULATION, PALMAR FASCIAL CORD (IE, DUPUYTREN’S CORD), POST ENZYME INJECTION (EG, COLLAGENASE), SINGLE CORD
64455 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON’S NEUROMA)
Rheumatology Technical Procedures
Minor Surgical Procedures
In addition to the major global surgeries in the Surgery section of the AMA CPT®manual, there are a number of minor surgeries. These minor surgeries involve a readily identifiable surgical procedure but include variable preoperative and postoperative services (e.g., injection of a tendon sheath and manipulation of a joint under anesthesia). Because of the indefinite preoperative and postoperative services, they are not traditionally paid using a global surgery policy.
20526 Injection, therapeutic (e.g., local anesthetic corticosteroid), carpal tunnel
20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”)
20551 single tendon origin/insertion
20552 Injection(s); single or multiple trigger point(s), one or two muscle(s)
20553 single or multiple trigger point(s), three or more muscle(s)
20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (e.g., fingers, toes)
20605 intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
20610 major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa)
NOTE: When billing two joints of the same size and it is not bilateral, you may want to use modifier -59 to ensure that the carrier realizes you are performing two separate joints. In some cases, there have been denials of the second code because it was thought the practices were billing for the aspiration and the injection. This is not allowed; the joint injection is for both aspiration and/or injection.
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
G56.03 Carpal tunnel syndrome, bilateral upper limbs
G57.51 Tarsal tunnel syndrome, right lower limb
G57.52 Tarsal tunnel syndrome, left lower limb
G57.53 Tarsal tunnel syndrome, bilateral lower limbs
G57.61* Lesion of plantar nerve, right lower limb
G57.62* Lesion of plantar nerve, left lower limb
G57.63* Lesion of plantar nerve, bilateral lower limbs
M08.1 Juvenile ankylosing spondylitis
M24.211 Disorder of ligament, right shoulder
M24.212 Disorder of ligament, left shoulder
M24.221 Disorder of ligament, right elbow
M24.222 Disorder of ligament, left elbow
M24.231 Disorder of ligament, right wrist
M24.232 Disorder of ligament, left wrist
M24.241 Disorder of ligament, right hand
M24.242 Disorder of ligament, left hand
M24.251 Disorder of ligament, right hip
M24.252 Disorder of ligament, left hip
M24.271 Disorder of ligament, right ankle
M24.272 Disorder of ligament, left ankle
M24.274 Disorder of ligament, right foot
M24.275 Disorder of ligament, left foot
M24.28 Disorder of ligament, vertebrae
M25.711 Osteophyte, right shoulder
M25.712 Osteophyte, left shoulder
M25.721 Osteophyte, right elbow
M25.722 Osteophyte, left elbow
M25.731 Osteophyte, right wrist
M25.732 Osteophyte, left wrist
M25.741 Osteophyte, right hand
M25.742 Osteophyte, left hand
M25.751 Osteophyte, right hip
M25.752 Osteophyte, left hip
M25.761 Osteophyte, right knee
M25.762 Osteophyte, left knee
M25.771 Osteophyte, right ankle
M25.772 Osteophyte, left ankle
M25.774 Osteophyte, right foot
M25.775 Osteophyte, left foot
M35.7 Hypermobility syndrome
M45.0 Ankylosing spondylitis of multiple sites in spine
M45.1 Ankylosing spondylitis of occipito-atlanto-axial region
M45.2 Ankylosing spondylitis of cervical region
M45.3 Ankylosing spondylitis of cervicothoracic region
M45.4 Ankylosing spondylitis of thoracic region
M45.5 Ankylosing spondylitis of thoracolumbar region
M45.6 Ankylosing spondylitis lumbar region
M45.7 Ankylosing spondylitis of lumbosacral region
M45.8 Ankylosing spondylitis sacral and sacrococcygeal region
M46.01 Spinal enthesopathy, occipito-atlanto-axial region
M46.02 Spinal enthesopathy, cervical region
M46.03 Spinal enthesopathy, cervicothoracic region
M46.04 Spinal enthesopathy, thoracic region
M46.05 Spinal enthesopathy, thoracolumbar region
M46.06 Spinal enthesopathy, lumbar region
M46.07 Spinal enthesopathy, lumbosacral region
M46.08 Spinal enthesopathy, sacral and sacrococcygeal region
M46.09 Spinal enthesopathy, multiple sites in spine
M46.1 Sacroiliitis, not elsewhere classified
M46.81 Other specified inflammatory spondylopathies, occipito-atlanto-axial region
M46.82 Other specified inflammatory spondylopathies, cervical region
M46.83 Other specified inflammatory spondylopathies, cervicothoracic region
M46.84 Other specified inflammatory spondylopathies, thoracic region
M46.85 Other specified inflammatory spondylopathies, thoracolumbar region
M46.86 Other specified inflammatory spondylopathies, lumbar region
M46.87 Other specified inflammatory spondylopathies, lumbosacral region
M46.88 Other specified inflammatory spondylopathies, sacral and sacrococcygeal region
M46.89 Other specified inflammatory spondylopathies, multiple sites in spine
M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region
M48.8X2 Other specified spondylopathies, cervical region
M48.8X3 Other specified spondylopathies, cervicothoracic region
M48.8X4 Other specified spondylopathies, thoracic region
M48.8X5 Other specified spondylopathies, thoracolumbar region
M48.8X6 Other specified spondylopathies, lumbar region
M48.8X7 Other specified spondylopathies, lumbosacral region
M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region
M49.81 Spondylopathy in diseases classified elsewhere, occipito-atlanto-axial region
M49.82 Spondylopathy in diseases classified elsewhere, cervical region
M49.83 Spondylopathy in diseases classified elsewhere, cervicothoracic region
M49.84 Spondylopathy in diseases classified elsewhere, thoracic region
M49.85 Spondylopathy in diseases classified elsewhere, thoracolumbar region
M49.86 Spondylopathy in diseases classified elsewhere, lumbar region
M49.87 Spondylopathy in diseases classified elsewhere, lumbosacral region
M49.88 Spondylopathy in diseases classified elsewhere, sacral and sacrococcygeal region
M49.89 Spondylopathy in diseases classified elsewhere, multiple sites in spine
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M53.3 Sacrococcygeal disorders, not elsewhere classified
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.861 Other myositis, right lower leg