march 2015

Large Joint Injection Codes

As you know new codes were developed in 2015 for the different types of joint injections (small, intermediate and large) to capture the technology of using ultrasound guidance with these injections. When you look at the code description it reads “with ultrasound guidance, with permanent recording and reporting.” When the injections are performed we are receiving documentation that images or permanent recording is being done but simply stating that ultrasound guidance was used does not meet the requirement for reporting. There is an article in CPT Assistant Feb. 2015 that explains ultrasound reporting which can be seen below:

Ultrasound Intraservice Work: Perform a focused ultrasound evaluation. Obtain, label, and interpret images in multiple planes through the specific area of concern, focusing on best approach for injection. Document the normal anatomic structure and any pathologic findings.

Look at it like this. If you have ever read an arthroscopic knee or shoulder op note the physician will first insert the scope and examine the joint, documenting the structures viewed and any pathology such as rotator cuff or meniscus tears. The same thing must be done with ultrasound injections - the physician must first perform a diagnostic exam (which is dictated as a report) and then proceed with the injection procedure. Once these components are in place then your coding and claims should stand up to the scrutiny of an audit process.



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