J7325, Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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).
- Intra-articular hyaluronic acid (viscosupplementation) injections are billable for treatment of knee osteoarthritis only when the service meets the Local Coverage Determination L39260 clinical criteria and the product is used consistent with FDA‑approved dosing and frequency.
11 Active Policies
A56157, Billing and Coding: Intraarticular Knee Injections of Hyaluronan
J5
A52420, Billing and Coding: Hyaluronans Intra-articular Injections of
J6
WPS-L39529, Intraarticular Knee Injections of Hyaluronan
J8
PALMETTO-JJ-L39260, Hyaluronic Acid Injections for Knee Osteoarthritis
JJ
Related Codes
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