CurrentUnitedHealthcarePolicy N/A

Tendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal Tunnel Injection Reimbursement

Defines UnitedHealthcare Community Plan Medicaid reimbursement criteria for injections into tendon/tendon sheath, ligaments, ganglion cysts, and carpal or tarsal tunnel and who may bill for these services using CMS-1500/UB04 forms.

Policy Summary

PayerUnitedHealthcare

PolicyTendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal Tunnel Injection Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReport ICD-10-CM diagnosis codes at the claim line level linked to the procedure code; reimbursement requires an appropriate ICD-10 diagnosis on the claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4procedure codes referenced for reimbursement

Medicaidproduct scope

IN, KS, DCstates with explicit exceptions

ICD-10 claim linediagnosis reporting requirement

Reimbursement Coverage Criteria

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Reimbursement criteria

UnitedHealthcare Community Plan reimburses listed CPT codes when the claim line includes an ICD-10-CM diagnosis code indicating a problem in the corresponding anatomical region.

ALL of the following

ALL of the following
- ONE OF
  - CPT 20526 — injection, carpal or tarsal tunnel
  - CPT 20550 — injection, tendon sheath or ligament
  - CPT 20551 — injection, tendon sheath or ligament (extended)
  - CPT 20612 — injection, ganglion cyst
An ICD-10-CM diagnosis code indicating a problem with the corresponding anatomical region is included on the claim line and accurately reflects the member's condition
Diagnosis must be reported at the claim line level linked to the CPT/HCPCS procedure code for reimbursement
Services that do not include an appropriate ICD-10-CM diagnosis code on the claim will not be reimbursed

State exceptions

State-specific exceptions and exclusions

ALL of the following

Indiana: Additional ICD-10-CM diagnosis codes are payable in Indiana beyond the published list; certain Indiana MLTSS Pathways populations are excluded from this policy (see state tables).
Kansas: Kansas is excluded from this policy based on state requirements (policy does not apply in Kansas).
Washington, DC: Per state requirements, CPT codes 20526 and 20612 are not covered in Washington, DC.

Procedure Codes and Diagnosis Linkage

Reimbursable procedure codes when appropriately linked to diagnosisCPTCovered

20526	Injection, carpal or tarsal tunnel (procedure listed)
20550	Injection, tendon sheath or ligament (procedure listed)
20551	Injection, tendon sheath or ligament (extended; procedure listed)
20612	Injection, ganglion cyst (procedure listed)

Diagnosis linkage requirement — ICD-10-CM required for reimbursement

Linkage levelDiagnosis must be reported at the claim line level linked to the CPT/HCPCS procedure code.

Consequence of missing/incorrect diagnosisUnitedHealthcare Community Plan will not reimburse when an appropriate ICD-10-CM diagnostic code is not included on the claim or does not accurately reflect the condition.

Billing and Documentation Requirements

Documentation Required

Claim-level/line-level diagnosis requirement

Report ICD-10-CM diagnosis codes at the claim line level linked to the CPT/HCPCS procedure code; reimbursement will only be made when an appropriate ICD-10 diagnosis code reflecting the member's condition is included on the claim.

Diagnosis must be reported on the same claim line as the CPT/HCPCS procedure code.
Claims lacking an appropriate ICD-10-CM code linked to the procedure will not be reimbursed.

Definitions and Scope

Reimbursable injections for tendon/tendon sheath, ligament, ganglion cyst, carpal/tarsal tunnel

Tendon sheath/ligament injectionsCPT 20550 and 20551 are reimbursable for injections into the tendon/tendon sheath or ligament when an appropriate ICD-10-CM diagnosis is listed on the claim.

Ganglion cyst injectionCPT 20612 is reimbursable for injection to treat a ganglion cyst when an appropriate ICD-10-CM diagnosis is listed on the claim.

Carpal or tarsal tunnel injectionCPT 20526 is reimbursable for injections for carpal tunnel or tarsal tunnel when an appropriate ICD-10-CM diagnosis is listed on the claim.

ScopePolicy applies to injections to treat problems in the tendon/tendon sheath, ligament, ganglion cyst, carpal tunnel, or tarsal tunnel and reimbursement is conditioned on diagnosis linkage.

CPT/CMS/code reference guidance (definitional only)

Purpose of referencesReferences to CPT, CMS or other coding guidelines are provided for definitional purposes only.

No guarantee of paymentMentioning CPT or other sources does not imply any right to reimbursement.

Use in policy developmentPolicy uses CPT, CMS and other coding guidelines along with reimbursement logic, regulatory requirements and benefits design when developed.