Billing and Coding: Pain Management - injection of tendon sheaths, ligaments,
ganglion cysts, carpal and tarsal tunnels

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Pain Management.  
  
 **  Coding Information:**  
  
Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.  
  
All procedures related to pain management procedures performed by the
physician/provider performed on the same day must be billed on the same claim.  
  
Acupuncture, a non-covered service, prior to January 21, 2020, is reported
with CPT codes 97810 - 97814\. Effective January 21, 2020, Medicare will cover
all types of acupuncture including dry needling for chronic low back pain
within specific guidelines in accordance with NCD 30.3.3.  
  
Injection of separate sites (tendon sheath, ligament or ganglion cyst) during
the same encounter as trigger point injections should be reported on a
separate line of coding and must have the modifier 59 appended. Multiple
surgical rules will apply. Modifier 50 should not be reported with CPT codes
20551 or 20612, but may be reported, when appropriate, with CPT codes 20550
and 20526. For an Ambulatory Surgical Center (ASC), the appropriate site
modifier (RT and/or LT) should be appended to indicate if the service was
performed unilaterally or bilaterally. Bilateral services must be reported on
separate lines using an RT and LT modifier (50 modifier should not be used).  
  
Multiple injections per day, at the same site, are considered one injection
and should be coded with one unit of service (NOS 001).  
  
 **For claims submitted to the Part B MAC**  
  
 **HCPCS DRUG CODES**  
A claim for services rendered in the off-campus-outpatient hospital (19),
inpatient hospital (21), on campus-outpatient hospital (22) or emergency room,
hospital (23), ambulatory surgery center (24), skilled nursing facility for
patients in a part A stay (31), comprehensive inpatient rehabilitation
facility (61), and comprehensive outpatient rehabilitation facility (62) must
indicate the name of the drug and dosage in item 19 or the electronic
equivalent. The HCPCS drug code and dose is not required when CPT 20612 is
reported for aspiration and not for injection or when the ICD-10-CM codes
reported are M77.11 or M77.12 and there is no injection.  
  
The medication being injected, designated by an appropriate HCPCS drug code
must be submitted on the same claim, same day of service as the claim for the
procedure. Claims for local anesthetic should not be reported. The exceptions
to this guideline are:

  * When services are rendered in places of services 19, 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.

  
A claim for services rendered in the office or independent clinic, when the
physician does not bill for the injectables, must include the name of the drug
and dosage in item 19 or the electronic equivalent.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.

A procedure note must be legible and include sufficient detail to allow
reconstruction of the procedure. Required elements of the note include a
description of the techniques employed, and sites(s) of injections, drugs and
doses with volumes and concentrations as well as pre- and post-procedural pain
assessments.

For **injections of tendon sheaths, ligaments, ganglion cysts, carpal and
tarsal tunnels** , the medical record must include a procedural note
documenting the reason for the injection at any particular site. If multiple
sites are injected, documentation to substantiate that all the injections are
reasonable and necessary must be present.

**Utilization Guidelines:**

**Injection Tendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal
Tunnel:**

  * Most conditions that require injections into the tendon sheaths, ligaments or ganglion cysts should be resolved with one to three injections.

Frequency and Number of Injections or Interventions:

  * In the diagnostic phase, a patient may receive injections at intervals of no sooner than one week or preferably, two weeks. 
  * The number of injections in the diagnostic phase should be limited to no more than two times. 
  * Once a structure is proven to be negative, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure. 
  * The effect of injected corticosteroids may remain for several weeks. The benefit is attributed to a decrease of local inflammation and perhaps some local anesthetic effect. It is usually not necessary to repeat an injection if there has been a satisfactory response to the first injection. Patients who relapse after a satisfactory response may be candidates for another trial after an appropriate interval. Consideration should be given to the cumulative dose injected and limitations made to avoid steroid complications. 
  * In the therapeutic phase (after the diagnostic phase is completed), the frequency should be two months or longer between each injection, provided that there is initial pain relief with diagnostic injections of greater than or equal to (>/=) 75% - 100% with the ability to perform previously painful maneuvers, and a persistent pain relief of greater than or equal to (>/=) 50% with the continued ability to perform previously painful maneuvers is maintained for at least six weeks. The therapeutic frequency must remain at least two months or longer. 
  * In the treatment or therapeutic phase, the injections should be repeated only as medically necessary. No more than four per patient per year are anticipated for the majority of patients.