Local Coverage Article: Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma (A57079) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information CONTRACTOR NAME CONTRACT TYPE CONTRACT JURISDICTION STATE(S) NUMBER Noridian Healthcare Solutions, A and B MAC 01111 - MAC A J - E California - Entire State LLC Noridian Healthcare Solutions, A and B MAC 01112 - MAC B J - E California - Northern LLC Noridian Healthcare Solutions, A and B MAC 01182 - MAC B J - E California - Southern LLC Noridian Healthcare Solutions, A and B MAC 01211 - MAC A J - E American Samoa LLC Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, A and B MAC 01212 - MAC B J - E American Samoa LLC Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, A and B MAC 01311 - MAC A J - E Nevada LLC Noridian Healthcare Solutions, A and B MAC 01312 - MAC B J - E Nevada LLC Noridian Healthcare Solutions, A and B MAC 01911 - MAC A J - E American Samoa LLC California - Entire State Guam Hawaii Nevada Northern Mariana Created on 09/28/2019. Page 1 of 33 CONTRACTOR NAME CONTRACT TYPE CONTRACT JURISDICTION STATE(S) NUMBER Islands Article Information General Information Original Effective Date 10/01/2019 Article ID Revision Effective Date A57079 N/A Article Title Revision Ending Date Billing and Coding: Injections - Tendon, Ligament, N/A Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma Retirement Date N/A Article Type Billing and Coding AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT codes, descriptions and other data only are copyright 2018 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Current Dental Terminology © 2018 American Dental Association. All rights reserved. Copyright © 2019, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or Created on 09/28/2019. Page 2 of 33 codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at [email protected]. CMS National Coverage Policy Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.7. Article Guidance Article Text: The following billing and coding guidance is to be used with its associated Local Coverage Determination. Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 64455 or 64632 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma) as the correct CPT code for the service. Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2. Injections for other tendon origin/insertions by 20551. Injections to include both the plantar fascia and the area around a calcaneal spur are to be reported using a single 20551. The clinical record should include the elements leading to the diagnosis and treatment decision to use injection. If the number of injections exceeds three to the same site or local area in a six month period, the record must justify these added injections since the presumed need for further injections should raise the issues of correct diagnosis or correct choice of therapy as well as concerns for adverse side effects. Records must be made available upon request. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act. Created on 09/28/2019. Page 3 of 33 The Section titled "Does the 'CPT 30% Rule' apply" needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of the CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual. This policy is subject to the reasonable and necessary guidelines and the limitation of liability provision. This medical policy consolidates and replaces all previous policies and publications on this subject by Noridian and its predecessors for Medicare A/B. Coding Information CPT/HCPCS Codes Group 1 Paragraph: Use CPT 28899 for injection for Tarsal Tunnel Syndrome Group 1 Codes: CODE DESCRIPTION 20526 INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL 20527 INJECTION, ENZYME (EG, COLLAGENASE), PALMAR FASCIAL CORD (IE, DUPUYTREN'S CONTRACTURE) 20550 INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR "FASCIA") 20551 INJECTION(S); SINGLE TENDON ORIGIN/INSERTION 20612 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 26341 MANIPULATION, PALMAR FASCIAL CORD (IE, DUPUYTREN'S CORD), POST ENZYME INJECTION (EG, COLLAGENASE), SINGLE CORD 28899 UNLISTED PROCEDURE, FOOT OR TOES 64455 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA) 64632 DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE CPT/HCPCS Modifiers Created on 09/28/2019. Page 4 of 33 N/A ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Diagnosis codes are based on the current ICD-10-CM codes that are effective at the time of LCD publication. Any updates to ICD-10-CM codes will be reviewed by Noridian; and coverage should not be presumed until the results of such review have been published/posted. These are the only covered ICD-10-CM codes That support medical necessity: Group 1 Codes: ICD-10 CODE DESCRIPTION G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G56.03 Carpal tunnel syndrome, bilateral upper limbs G57.51* Tarsal tunnel syndrome, right lower limb G57.52* Tarsal tunnel syndrome, left lower limb G57.53* Tarsal tunnel syndrome, bilateral lower limbs G57.61* Lesion of plantar nerve, right lower limb G57.62* Lesion of plantar nerve, left lower limb G57.63* Lesion of plantar nerve, bilateral lower limbs M24.211 Disorder of ligament, right shoulder M24.212 Disorder of ligament, left shoulder M24.221 Disorder of ligament, right elbow M24.222 Disorder of ligament, left elbow M24.231 Disorder of ligament, right wrist M24.232 Disorder of ligament, left wrist M24.241 Disorder of ligament, right hand M24.242 Disorder of ligament, left hand M24.251 Disorder of ligament, right hip M24.252 Disorder of ligament, left hip M24.271 Disorder of ligament, right ankle M24.272 Disorder of ligament, left ankle M24.274 Disorder of ligament, right foot Created on 09/28/2019. Page 5 of 33 ICD-10 CODE DESCRIPTION M24.275 Disorder of ligament, left foot M53.3 Sacrococcygeal disorders, not elsewhere classified M65.221 Calcific tendinitis, right upper arm M65.222 Calcific tendinitis, left upper arm M65.231 Calcific tendinitis, right forearm M65.232 Calcific tendinitis, left forearm M65.241 Calcific tendinitis, right hand M65.242 Calcific tendinitis, left hand M65.251 Calcific tendinitis, right thigh M65.252 Calcific tendinitis, left thigh M65.261 Calcific tendinitis, right lower leg M65.262 Calcific tendinitis, left lower leg M65.271 Calcific tendinitis, right ankle and foot M65.272 Calcific tendinitis, left ankle and foot M65.28 Calcific tendinitis, other site M65.29 Calcific tendinitis, multiple sites M65.311 Trigger thumb, right thumb M65.312 Trigger thumb, left thumb M65.321 Trigger finger, right index finger M65.322 Trigger finger, left index finger M65.331 Trigger finger, right middle finger M65.332 Trigger finger, left middle finger M65.341 Trigger finger, right ring finger M65.342 Trigger finger, left ring finger M65.351 Trigger finger, right little finger M65.352 Trigger finger, left little finger M65.4 Radial styloid tenosynovitis [de Quervain] M65.811 Other synovitis and tenosynovitis, right shoulder M65.812 Other synovitis and tenosynovitis, left shoulder M65.821 Other synovitis and tenosynovitis, right upper arm M65.822 Other synovitis and tenosynovitis, left upper arm M65.831 Other synovitis and tenosynovitis, right forearm Created on 09/28/2019.