20611
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.07
Facility
$50.10
Non-Facility
$104.21
Documentation Required
- The medical record must document relevant medical history, physical examination, pertinent diagnostic test/procedure results, and history of pharmacologic therapy supporting medical necessity.
- Documentation for subsequent courses must clearly establish reduction in patient symptomatology and medication usage and must be available upon request.
- Append appropriate site modifier (RT or LT) to CPT 20610/20611 for unilateral services and modifier 50 to indicate bilateral services.
- Use the EJ modifier on drug codes to indicate subsequent injections of a series; do not use EJ for the first injection of each series.
Key Coverage Criteria
- Intra-articular hyaluronan injections are covered for pain associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.
- Intra-articular hyaluronan injections may be used as a therapeutic option for osteoarthritis of the shoulder.
- Intraarticular hyaluronan is covered for treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond adequately for at least 3 months to simple analgesics and conservative nonpharmacologic therapy (exercise/physical therapy, weight loss if appropriate, use of assistive devices).
- Repeat courses are covered when the prior series produced documented significant improvement in knee pain and functional capacity and at least 6 months have elapsed since the last injection series for that knee.
- Viscosupplementation is covered only when furnished and administered by a physician or appropriately trained provider in an appropriate clinical setting and when the drug is not usually self-administered by the patient (incident-to rules may apply).
- Claims for CPT/HCPCS codes describing services on anatomic structures that can be distinguished as left or right must include the appropriate laterality modifier (-RT or -LT) on each claim line for unilateral procedures.
10 Active Policies
L39529 — Intraarticular Knee Injections of Hyaluronan
J05
A56157 — Billing and Coding: Intraarticular Knee Injections of Hyaluronan
J05
A52420 — Billing and Coding: Hyaluronans Intra-articular Injections of
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
Related Codes
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