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. 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.