AANA Lab Course 1002 -3rd Annual Fellows/Chief Residents-Biologics-Coding-Jeremy M. Burnham, M.D.

Biologics-Coding-Jeremy M. Burnham, M.D.

Pdf Summary

This presentation by Dr. Jeremy M. Burnham, delivered at the AANA Fellow and Chief Resident Course in February 2020, focuses on coding and insurance considerations for biologic treatments in orthopedic practice, specifically hyaluronic acid (viscosupplementation) and platelet-rich plasma (PRP) injections.<br /><br />Key points include:<br />- Hyaluronic acid injections are typically covered by insurance, with clinical guidelines recommending three weekly injections every 6-8 months. Proper documentation of osteoarthritis (OA), osteophytes, chondrosis, and failure of other treatments is necessary for preauthorization, which should be initiated about four weeks before treatment.<br />- PRP injections are generally not covered by commercial insurance, with average costs around $714 but ranging from $380 to $1,390. Coverage may be available under some government programs like VA, Tricare, worker’s compensation, or personal injury attorney payments.<br />- Coding for these treatments involves a combination of J-codes (for drugs) and injection procedure codes. For example, PRP uses the 0232T code, which may not be reimbursed in outpatient settings but can contribute to relative value units (RVUs) and potential payment in hospital or employed physician models.<br />- Providers are advised to understand insurance preferences, use specific electronic medical record (EMR) templates to support requests for PRP reimbursement by non-commercial payors, and track coding data to optimize reimbursements under different employment models.<br /><br />Overall, the presentation highlights the complexity of billing for biologic orthopedic treatments and emphasizes the importance of strategic documentation and coding to secure insurance coverage and appropriate reimbursement.

Keywords

biologic treatments

orthopedic practice

hyaluronic acid

viscosupplementation

platelet-rich plasma

PRP injections

insurance coverage

coding and billing

J-codes

reimbursement optimization