CPT codes: 20611-LT, 20611-RT, J7326x2 or 20611, 20611-50, J7326x2
ICD-10: M17.0
Coding Rationale
CPT Codes: 20610-LT, J7325x16
ICD-10 Code: M17.12
This claim is rejected by the insurance carrier because the injection was outside of the preauthorization window that ended on Oct. 31. Most insurance carriers enforce their preauthorization dates for procedures. In some cases, they will not reimburse a claim if it is only one day outside of the end date of the preauthorization, which can be a financial burden for practices. Do not assume a preauthorization is from January to December; that may not be the case, and it is based on the decision of the payer. There should be a review of every preauthorization to determine how many times a procedure is allowed and the allowed window of time.
Even if the preauthorization was correct, the only thing acceptable to code is the injection itself. The practice staff knew this patient was coming in for the injection. There is nothing in the patient’s history that indicates a need for an evaluation and management visit along with the injection.
The ICD-10 code is for the unilateral primary osteoarthritis of the left knee.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at mtillman@rheumatology.org or call 404-633-3777 x820.