Many physicians who are NOT properly advised on viscosupplementation issues are trying to short course their way to injections by just obtaining radiologic evidence and bypassing the required documentation that justifies the injections.  We remind clinicians that one of the prerequisites for injections is that the patient must be symptomatic.  Since cartilage is aneural, Medicare and other carriers note that significant radiographic findings are often noted in asymptomatic patients who are imaged for other reasons.

To substantiate your protocols, you MUST document the prerequisites.

• The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness.
• The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts.
• The diagnosis is confirmed as OA and other diagnoses have been excluded. ( We are reasonably confident that the pain and functional disability is not likely to be due to a diagnosis other than OA of the knee.)
• The patient has failed at least three months of conservative therapy (weight loss, HEP, PT, analgesics, NSAIDS and when inflammation is a significant component, intra-articular corticosteroid injection therapy.  The medical record must include documentation that supports that conservative therapy was attempted prior to viscosupplementation therapy.

 Please note: Several Medicare carriers have also published "non-coverage" on guidance procedures such as the following one on 2/1/2011 by First Coast.

"Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient's affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.  Arthrography to provide needle guidance for knee injections will not be covered."

We therefore recommend you check your local carrier's decision policies and include a statement of necessity for the guidance in your operative notes.

Many of the large carriers are systematically changing their policy provisions so that payment for out-of-network services will be reimbursed at Medicare rates rather than usual, customary and reasonable (UCR).   In one report we received, the comments were;

Chicago-based Health Care Service Corp., parent company of Blues plans in Texas, Illinois, New Mexico and Oklahoma, is moving to a fee schedule equal to what Medicare pays. Company spokeswoman Mary Ann Schultz said the implementation dates would vary depending on the state and individual products, but the switch is ongoing.

Practices should be forewarned that patients who have out of network provisions in their policies may also need to pay higher out of pocket costs to the practice.

Medicare contractors that process both institutional and professional claims have discretion to automatically deny claims billed with the GZ HCPCS modifier. The GZ HCPCS modifier indicates that an Advance Beneficiary Notice (ABN) was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy.

Beginning July 1, 2011, Medicare contractors will automatically deny claim line(s) items submitted with a GZ HCPCS modifier. 

The use of the GZ modifier will typically result in a denial that is considered a "contractual obligation" denial (CO) which assigns the financial responsibility to the "provider" and not the "patient".   Staff should be educated to obtain a signed ABN from the patient whenever it is reasonable to expect a denial based on medical necessity.   The "purpose" of the ABN is to give the beneficiary advanced notice of their personal responsibility for payment and also permit them to make an informed decision to receive the service at their own expense.  Once the ABN has been given and signed, the service should be billed with the "GA" modifier. 

Tell Your Staff NOT TO PANIC;