Prior Authorization, Precertification & Billing Process - Hyaluronan Acid & Visco Therapies for Osteoarthritis of the knee - Prior Authorization Services, Patient Access Services & RCM

Prior Authorization, Precertification & Billing Process for Hyaluronan Acid & Visco Therapies for Osteoarthritis of the knee

9/27/2022

Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, "wear-and-tear" type of arthritis that occurs most often in people 50 years of age and older, although it may occur in younger people, too.

In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.

Osteoarthritis usually develops slowly and the pain it causes worsens over time.

I know it can be hard to determine if your patient's injection would need a prior authorization or precertificaton. It is always best that we verify our patients' coverage, benefits and eligibility.

Blog Post: PRIOR AUTHORIZATION, PRECERTIFICATION & BILLING PROCESS FOR HYALURONAN ACID & VISCO THERAPIES FOR OSTEOARTHRITIS OF THE KNEE

PRIOR AUTHORIZATION, PRECERTIFICATION & BILLING PROCESS - HYALURONAN ACID & VISCO THERAPIES FOR OSTEOARTHRITIS OF THE KNEE

CPT CODES: 20605, 20606, 20610, 20611
HCPCS CODES: J7318, J7323, J7328, J3490, J7320, J7321, J7322, J7324, J7325, J7326, J7327, J7329, J7331, J7332

Let's look at a commonly published clinical policy and guideline for these visco and hyaluronan acid therapies. Pay attention to everything on this post because these can all be very helpful for your billing and in order to maximize reimbursement.

Conservative Treatment:

Physical therapy or pharmacotherapy/NSAIDs (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], acetaminophen and/or topical capsaicin cream)

Understanding Indications and Dosing:

Intra-articular injections of sodium hyaluronate are proven and medically necessary when all of the following are met:
1. Diagnosis of knee osteoarthritis
2. Member has not responded adequately to conservative therapy which may include physical therapy or pharmacotherapy or injection of intra-articular steroids or member is unable to tolerate conservative therapy because of adverse side effects
3. The member reports pain which interferes with functional activities.
--- ambulation, prolonged standing
4. The pain is attributed to degenerative joint disease/primary osteoarthritis of the knee.
5. There are no contraindications to the injections
--- active joint infection, bleeding disorder
6. Dosing is in accordance with the US FDA approved labeling as follows.
--- Durolane: Approved as a single injection
--- Euflexxa: Approved for 3 injections
--- Gel-One: Approved as a single injection
--- Gelsyn-3: Approved for 3 injections
--- GenVisc 850: Approved for 3-5 injections
--- Hyalgan: Approved for 5 injections
--- Hymovis: Approved for 2 injections
--- Monovisc: Approved as a single injection
--- Orthovisc: Approved for 3-4 injections
--- Supartz: Approved for 3-5 injections
--- Synojoynt: Approved for 3 injections
--- Synvisc One: Approved as a single injection
--- Synvisc: Approved for 3 injections
--- Triluron: Approved for 3 injections
--- TriVisc: Approved for 3 injections
--- Visco-3: Approved for 3 injections

Learn how to properly bill and report these HCPCS codes for maximized reimbursement. READ HERE!

Prior Authorization Services for Pain Management

Common Criteria and Utilization Limitations:

Initial Determination:
--- therapy has not resulted in functional improvement after at least 3 months

Reauthorization/Continuation
--- At least 6 months have passed since the prior course of treatment for the respective joint

Intra-articular injections of sodium hyaluronate are unproven and not medically necessary for treating any other indication due to insufficient evidence of efficacy including, but not limited to the following:
----- Hip osteoarthritis
----- Temporomandibular joint osteoarthritis
----- Temporomandibular joint disc displacement

Hyaluronic acid gel preparations to improve the skin's appearance, contour and/or reduce depressions due to acne, scars, injury or wrinkles are considered cosmetic and are not covered.

Contraindications:
1. Do not administer to patients with known hypersensitivity (allergy) to hyaluronate preparations or allergies to avian or avian-derived products (including eggs, feathers, or poultry). This contraindication does not apply to Orthovisc.
1. Do not administer to patients with known hypersensitivity (allergy) to gram positive bacterial proteins. This contraindication applies to Orthovisc only.
1. Do not inject sodium hyaluronate into the knees of patients with infections or skin diseases in the area of the injection site or joint.

Imaging Requirements: (MRI, CT, XRAY, U/S):X-ray, CT, or MRI reports), Color Doppler ultrasound (CDUS) and synovitis scores
Pain Relief:  Knee Osteoarthritis (OA)
--- single 6 ml IA injection of hylan G-F 20 provided better pain relief over 26 weeks

Sodium Hyaluronate Product Therapy Using Preferred Products (Durolane, Euflexxa, and Gelsyn-3)
>>Medical notes documenting all of the following:
        --- Current prescription
        --- diagnosis of OA of the knee
        --- Conservative treatment tried for at least 3 months including response
        --- Signs and symptoms
        --- Current functional limitations
        --- Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports)
        --- Previous sodium hyaluronate treatment provided including the brand name of the drug, course of treatment, and response
        --- Dose, frequency, interval since previous sodium hyaluronate treatment
        --- Physician treatment plan

Medical Necessity Cross-over:

M17.0 -- Bilateral primary osteoarthritis of knee
M17.10 -- Unilateral primary osteoarthritis, unspecified knee
M17.11 -- Unilateral primary osteoarthritis, right knee
M17.12 -- Unilateral primary osteoarthritis, left knee
M17.2 -- Bilateral post-traumatic osteoarthritis of knee
M17.30 -- Unilateral post-traumatic osteoarthritis, unspecified knee
M17.31 -- Unilateral post-traumatic osteoarthritis, right knee
M17.32 -- Unilateral post-traumatic osteoarthritis, left knee
M17.4 -- Other bilateral secondary osteoarthritis of knee
M17.5 -- Other unilateral secondary osteoarthritis of knee
M17.9 -- Osteoarthritis of knee, unspecified

Learn how to Bill for HYALURONAN ACID & VISCO THERAPIES FOR OSTEOARTHRITIS OF THE KNEE

References: Clinical Policies of Commercial Payers and Medicare from published in the public domains. CPT Codes are a trademark and owned by the American Medical Association. ICD-10 Code book of 2022.