Coding for peri-articular injections into knee

Q.

We have a report that the hospital sent over as a “trigger point injection,” but it was documented as four periarticular injections around the left knee. The doctor called it prolotherapy. One of the coders wants to assign CPT^® code 20610, but I wonder if we should report it as a trigger point as that is what the hospital indicated.

A.

First, check with the patient’s payor to see if they cover prolotherapy. Most don’t. If they do, find out how they want it billed.

There is a HCPCS code for prolotherapy that you should use unless a payor tells you otherwise.

The code and full description are:

M0076  Prolotherapy

The Centers for Medicare and Medicaid Services (CMS) has a National Coverage Determination (NCD) for Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents (150.7), Indications and Limitations of Coverage.

The medical effectiveness of the above therapies has not been verified by scientifically controlled studies. Accordingly, reimbursement for these modalities should be denied on the ground that they are not reasonable and necessary as required by §1862(a)(1) of the Act.

In addition, the Noridian LCD for trigger point injections specifically says “Prolotherapy, the injection into a damaged tissue of an irritant to induce inflammation, is not covered by Medicare. Billing this under the trigger point injection codes is misrepresentation.”  Based upon our research, there are other LCDs that say it’s not covered as well.

As such, we would not recommend assigning CPT code 20610 nor coding as a trigger point injection.