Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76881, 76942, 99214, J2001, and J7325 
rendered on April 11, 2023. 
 
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 the records do not support the services billed. 
 
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 76881: 
 
Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation 
 
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
Healthcare Common Procedure Coding System (HCPCS) J2001: 
 
Injection, lidocaine hcl for intravenous infusion, 10 mg 
 
HCPCS J7325: 
 
Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg 
 
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 not supported by the medical records. Our reviewer found that in terms of CPT 76881, the 
medical record does not include a radiology report for complete joint (ie, joint space and peri-articular soft-
tissue structures), real-time with image ultrasound. 
 
In terms of CPT 76942, the procedure report describes an injection given. However, the medications and 
radiology services reported cannot be verified as correctly billed, and therefore this procedure would not be 
covered. 
 
In terms of CPT 99214, the procedure report does not include sufficient documentation to support the service 
reported, to include an appropriate examination as well as medical decision making.  The records do not 
include documentation of time; therefore this procedure code cannot be verified. 
 
In terms of J2001, the procedure report does not include documentation to indicate that intravenous lidocaine 
hcl infusion was performed. Therefore, this code cannot be verified. 
 
In terms of J7325, the National Drug Code (NDC) number reported for Synvisc 2 mg injection 58468009003 
does not match the medication documented. The number for Synvisc is 58468-0090-01, and the number for 
Synvisc-One is 58468-0090-03. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 76881, 76942, 99214, J2001, and J7325 rendered on April 11, 2023.