Ultrasonic cpt 76942 – knee injection billing

CPT CODE 76942 – Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation -average fee payment – $60 – $70


Ultrasonic Guidance for Knee Injections

Audits were recently performed by Highmark Medicare Services’ Medical Review Department for procedure code 76942, ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

In reviewing the medical records provided to support these services, it was determined that providers were using ultrasound guidance for knee joint injections. The documentation did not provide any information which would support the medical necessity for using ultrasound guidance for knee injections.

Medical necessity is defined as the need for an item(s) or service(s), to be reasonable and necessary for the diagnosis or treatment of disease, injury or defect. The need for the item or service must be clearly documented in the patient’s medical record.

To report the use of ultrasound to guide injections or aspirations, the suggested code is 76942 – Ultrasonic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), imaging supervision and interpretation. Report 76942 in addition to the code for the underlying procedure.

Under the National Correct Coding Initiative, NCCI, which sets CMS payment policy as well as many private payers, one unit of service is allowed for CPT code 76942 in a single patient encounter regardless of the number of needle placements performed. Per NCCI, “The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

Medically necessary services or items are:

• Appropriate for the symptoms and diagnosis or treatment of the patient’s condition, illness, disease or injury; and
• Provided for the diagnosis or the direct care of the patient’s condition, illness, disease or injury; and
• In accordance with current standards of good medical practice; and
• Not primarily for the convenience of the patient or provider; and
• The most appropriate supply or level of service that can be safely provided to the patient.
The use of ultrasound guidance for knee joint injections may be considered medically reasonable and necessary by Highmark Medicare Services if the documentation supports one of the following:
• The failure of the initial attempt at the knee joint injection where the provider is unable to aspirate any fluid.
• The size of the patient’s knee(s), due to morbid obesity or disease process, inhibits the provider’s ability to inject the knee(s) without ultrasound guidance.
• The provider is planning to drain a popliteal (Baker’s) cyst.

Although there is data to support that ultrasound guidance improves the accuracy of knee joint injections and reduces procedural pain in some cases, the data does not support improved clinical outcomes to support the coverage of ultrasound guidance for all knee joint injections. In addition, package inserts for drugs used for knee joint injections do not indicate the necessity of the use of ultrasound guidance for safe and effective usage.

Therefore, unless there is documentation provided to support the medical necessity for the ultrasound guidance for knee joint injections, the ultrasound guidance may be denied as coverage and reimbursement of healthcare services provided to Medicare beneficiaries requires that services be medically necessary in order to be eligible for reimbursement.

Billing and coding procedure code 76942

Based upon further input, First Coast Service Options Inc. (First Coast), the Medicare administrative contractor (MAC) for jurisdiction 9 (J9) is retracting previous articles titled Ultrasound guidance for needle placement in the office setting and Minimum criteria for reimbursement of diagnostic ultrasound tests. In the 2014 proposed rule for Revisions to Payment Policies under the Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) proposes a reduction in the relative value units (RVUs) based on equipment inputs and procedure time assumptions for Current Procedural Terminology (CPT®) code 76942 (Ultrasound guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation). First Coast’s prior guidance and recoding of 76942 to an unlisted procedure code has been rescinded and claim adjustments will be performed. However, services that were previously denied as not reasonable and necessary for an ultrasound guidance service will remain denied.

Based upon clinical literature and input from practicing physicians in several specialties, MAC J9 maintains that ultrasound guidance may not be reasonable and necessary and is not the established standard of care for all needle placement procedures. Therefore, billing and coding the ultrasound guidance procedure code 76942 with an associated procedure must be clearly supported in the medical record as meeting the reasonable and necessary threshold for coverage for the given beneficiary or it should not be coded and submitted with the claim. On audit, if the documentation does not support that the ultrasound guidance provided clinical value, the claim will be denied. Providers should also be aware of MAC J9 local coverage determinations (LCDs) which specifically non-cover or limit coverage of ultrasound guidance for specific injection procedures. For example, LCD L29298 (Florida) and LCD L29403 (Puerto Rico and U.S. Virgin Islands) – Treatment of varicose veins of the lower extremity, specifically state under Limitations “Intraoperative ultrasound guidance is not separately reimbursable,” and in the Coding Guidelines the LCD states “Procedure code 76942 represents a service that is not covered by Medicare for the purposes of this LCD.” Another LCD providers should be aware of is L29307 (Florida) / L29408 (Puerto Rico and U.S. Virgin Islands) – Viscosupplementation therapy for knee. This LCD specifically states under Limitations that “Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.”

It is not expected that a non-physician practitioner (NPP) would perform procedures utilizing 76942 as they are not qualified to “interpret” diagnostic ultrasounds. Note that this code includes “imaging supervision and interpretation.” An interpretation of the ultrasound guidance must be documented in the patient’s medical record in order to separately bill this procedure code

• For ultrasound guidance of nerve block procedures, the recommended CPT code is 76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation. Report CPT code 76942 in addition to the code for the nerve block itself Medicare Correct Coding Initiative (CCI) edits do not, at present, bundle the nerve block and ultrasound guidance of the nerve block specific to the procedures listed in this guide. It is recommended to check with each private payer regarding their policies on this service. In addition CPT has in recent years changed specific procedure codes to reflect to requirement of image guidance for several types of injections commonly performed by pain specialists. It is recommended to review CPT code descriptions carefully and adhere to the correct coding conventions

• Under the National Correct Coding Initiative, NCCI, which sets CMS payment policy as well as many private payers, one unit of service is allowed for CPT code 76942 in a single patient encounter regardless of the number of needle placements performed. Per NCCI, “The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

Added section for Allergen Immunotherapy. Added to the section Ultrasonic Guidance for Needle Biopsy – “Separate reimbursement is allowed for 76942 (Ultrasonic Guidance for Needle Biopsy) when submitted with 76645 (Ultrasound, Breast(s) (unilateral or bilateral), B-scan and or real time with image documentation). Removed the bundling guidelines for Hot or Cold Packs. Removed the bundling guidelines for Introduction of Needle or Intracatheter. Section contained information for CPT codes effective January 1, 2006. Removed the bundling guidelines under Casting Application and Strapping – “A4580, ‘cast supplies (e.g., plaster),’ will be considered incidental to casting/strapping codes 29000- 29799. The cost of the cast or splint is included in the basic value of the application and its corresponding code and does not provide separate reimbursement.”

 CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

Limitations

** Dry needle trigger point injections are not considered medically necessary, as there is insufficient evidence of therapeutic value.

** Injections used on a routine basis (e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes) are not considered medically necessary.

** Only injections of local anesthetics and corticosteroids are covered.

** Injections consisting of only saline and/or botanical substances are not supported in the peer-reviewed literature and are not considered medically necessary.

Note: The services represented by CPT codes 76942 and 77022 are considered incidental to injection procedure codes 20550, 20552 and 20553, and will not be separately reimbursed when submitted with these procedure codes. Modifier 59 will not override this bundling edit. Any combination of trigger point injections (20552, 20553) when billed > 3 times in 90-day period will be denied.

Q: To report code 76942 correctly, is it required that the ultrasound guide the actual ultrasound guide the actual “needle puncture needle puncture”?

A: Yes. Code 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation, requires that the ultrasound is used to guide the needle such as for that the ultrasound is used to guide the needle such as for a needle biopsy or fine needle aspiration (FNA) of an organ or body area.

It is not required that the ultrasound guidance be used specifically for the insertion of the needle through the skin but the imaging must be used to guide the needle placement in order to report the code.

Q: Would it be appropriate to report code 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation twice when there is more supervision and interpretation, twice when there is more than one lesion in the breast?

A: From a CPT coding perspective code From a CPT coding perspective, code 76942 should be should be reported per distinct lesion that requires separate needle p ,p lacement. Therefore, if several passes are made into two separate lesions in the same organ (ie, two lesions in same breast), then code 76942 would be reported twice.

2013  CPT Code  CPT Code Descriptor    Global Payment  Professional Payment   Technical Payment    

76942  Ultrasonic guidance for needle placement (e.g., biopsy, aspiration injection, localization device), imaging supervision and interpretation

$61.22

$34.01

$27.21

Example  Column 1 Code/Column 2 Code 47370/76942

CPT Code 47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency

CPT Code 76942 – Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT code 76942 should not be reported and modifier 59 should not be used if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure. Code 76942 may be reported with modifier 59 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ

Arthrocentesis

20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting  (Do not report 20600, 20604 in conjunction with 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)

20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (Do not report 20610, 20611 in conjunction with 27370, 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)

CMS proposed CPT code 76942 (Ultrasonic guidance for needle placement (for example, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) as a potentially misvalued code because of the high frequency with which it is billed with CPT code 20610 Arthrocentesis aspiration and/or injection; major joint or bursa (for example, shoulder, hip, knee joint, subacromial bursa). One CMD suggests that the payment for CPT code 76942 and CPT code 20610 should be combined to reduce the incentive for providers to always provide and bill separately for ultrasound guidance.

CMS notes that they are making a proposal regarding the direct PE inputs for CPT code 76942 as described above. Claims data show that the procedure time assumption for CPT code 76942 is longer than the typical procedure with which the code is billed (for example, CPT code 20610). CMS believes that the discrepancy in procedure times and the resulting potentially inaccurate payment raises a fundamental concern regarding the incentive to furnish ultrasound guidance. CMS believes this concern spans more than just an individual code for ultrasound guidance. Accordingly, they have proposed additional ultrasound guidance codes as potentially misvalued   in Table 12 (below). CMS sought public comment on including these codes as potentially misvalued codes.

CMS decided in the final rule to move forward with evaluating CPT code 76942 as a potentially misvalued code. This action is consistent with a comment received recommending that CMS delay action until the AMA RUC acts because CMS routinely considers AMA RUC recommendations through the usual review of potentially misvalued codes. Thus, CMS would seek the AMA RUC recommendation before re-valuing.

Payment Information

The following chart provides payment information that is based on the national unadjusted Medicare physician fee schedule for the ultrasound services discussed in this guide. Payment will vary by geographic region. Use the “Professional Payment” column to estimate reimbursement  to the physician for services provided in facility settings.

Ambulatory Payment Classification (APC) codes and payments are used by Medicare to reimburse Outpatient Hospitals and ASCs under the Hospital Outpatient Prospective Payment System (OPPS). Payment is based on the national unadjusted OPPS amounts. The actual payment will vary by location.

CPT Code       CPT Code Descriptor   Global Payment      Professional Payment  Technical Payment  APC Code  APC Payment

76942

Ultrasonic guidance for needle placement (e.g., biopsy, aspiration injection, localization device), imaging supervision and interpretation

$61.22

$34.01

$27.21

 Packaged Service

No Payment


Reimbursement changes for CPT code 76942 

In the December 2013 issue of Network Update, you were notified of the following: For claims with dates of service on or after March 17, 2014, Anthem Blue Cross and Blue Shield (Anthem) in Indiana, Kentucky, Missouri, Ohio and Wisconsin (individually referred to herein as the Health Plan), will no longer reimburse CPT® code 76942 (Ultrasonic guidance for needle placement) when it is reported with 27096, 32554, 32555, 32556, 32557, 37760, 37761, 43232, 43237, 43242, 45341, 45342, 64479-64484, 64490-64495, 76975, 0213T-0218T, 0228T-0213T, 0232T, 0249T, and 0301T.

After our December 2013 issue published, the Current Procedural Terminology (CPT) parenthetical guideline was updated to include three additional CPT codes: 10030, 19083 and 19285.

As a result, we are notifying you of the following:

• Effective March 17, 2014, the Health Plan will no longer reimburse CPT code 76942 when it is reported with 10030, 19083, 19285.

• Effective May 19, 2014, the Health Plan will no longer override the edit when Modifier 59 is appended to either 76942 and 10030, 19083 and 19285. If you have questions, please contact your local Network Relations consultant.