HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-31-029
Topic:
Arthrocentesis or Needling of Bursa
Section:
Surgery
Effective Date:
October 9, 2017
Issued Date:
February 18, 2019
Last Revision Date:
February 2019
Annual Review:
February 2019
 
 

Arthrocentesis or aspiration is the removal of fluid from a joint or bursa.  Bursas are saclike structures between skin and bone or between tendons, ligaments, and bone. The bursa are lined by synovial tissue, which produces fluid that lubricates and reduces friction between these structures.

Policy Position

Arthrocentesis or needling of a bursa may be considered medically necessary when ALL of the following criteria are met:

  • *Conservative therapy (rest area and avoid activity, cryotherapy, compression dressings, elevation of affected area above heart, other modalities like electrical stimulation/ultrasonography/phonophoresis, NSAIDs, or corticosteroid injections) to control pain and inflammation has failed; and
  • Affected area continues with symptoms of severe pain along with swelling and inflammation; and
  • Movement of joint remains limited due to pain; and
  • The response to therapy must be documented for medical review prior to additional therapy authorizations.

*Conservative therapy is considered a failure of treatment if no improvement or resolution of pain within 6 weeks from the start of therapy.

When 76942 is reported in conjunction with codes 20600, 20604, 20605, 20606, 20610, and 20611 payment will be denied as not medically necessary.

Except for local anesthetics, reimbursement for the cost of the drugs or biologicals used in an arthrocentesis joint injection is allowed, in addition to the procedure.  If a separate charge for a local anesthetic is reported, it should be denied as not covered. 

Arthrocentesis reported for other areas of the spine; should be processed as injection of trigger points. When a doctor reports his services as arthrocentesis by fluoroscopy, the service should be processed under the appropriate procedure code for arthrocentesis of the type joint involved. Itemized charges should be combined and processed under the appropriate arthrocentesis code. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

20600

20604

20605

20606

20610

20611

76942




Related Policies

Refer to medical policy G-25 Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee for more information. 


Place of Service: Outpatient

Arthrocentesis, aspiration and/or injection of a joint or bursa is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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