Draft Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (DA52863)

CMS National Coverage PolicyN/AArticle TextThis article containscoding and other guidelinesthat 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 MACHCPCS DRUG CODESA 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.Forinjections 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.