Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for injection services provided to the enrollee on August 16, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that payment is not allowed for this multi-use vial because it was billed with an inappropriate or invalid modifier for the procedure.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is:  CPT 01402:  Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty  CPT 64447:  Injection(s), anesthetic agent(s) and/or steroid; femoral nerve  CPT 76942:  Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found the anesthesiologist billed CPT code CPT 01402, which is for anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty. In addition, the anesthesiologist billed CPT code 64447-59 for the femoral nerve block to be used for post-operative analgesia. The anesthesiologist performed a femoral nerve block after the induction of general anesthesia. Post-operative pain procedures performed primarily for post-operative analgesia may be separately reported whether they are administered pre-operatively, intra-operatively or post-operatively. A post-operative pain procedure may be reported as a service separate from the anesthetic if the post-operative pain procedure is employed primarily for post-operative analgesia and if the anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique.    When modifier -59 is appended to a CPT code, it indicates that the service is separate and distinct from another service with which it would usually be bundled. CPT Code 76942-26, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection and localization device), imaging supervision and interpretation, is an appropriate code for certain procedures when performed. In these cases, the primary injection code is billed in addition to 76942 for ultrasound guidance.  Modifier -26 is appended to a procedure code to indicate that the service provided was the reading and interpreting of the results of a diagnostic and/or laboratory service. The billing codes for this enrollee's total knee arthroplasty, under general anesthesia, along with the femoral nerve block, to be used for post-operative analgesia, were billed appropriately for this case. The records support the billing codes.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for injection services provided to the enrollee on August 16, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.