Problem Code: 20610
Answer three common uncertainties when reporting joint aspiration and/or injection.
Coding is not easy, but some codes seem to cause more than their share of confusion. Based on feedback from Healthcare Business Monthly readers, and what we hear on AAPC Member Forums, one such “problem code” is 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa); without ultrasound guidance.
The same three questions keep coming up about this code:
- When is it appropriate to report multiple units of 20610?
- May I report an evaluation and management (E/M) service in addition to 20610?
- Should I report supplies separately with 20610?
We’ll answer each of these questions, in turn.
First, Some Background Information
CPT® 20610 describes aspiration (removal of fluid) from, or injection into, a major joint (defined as a shoulder, hip, knee, or subacromial bursa), or both aspiration and injection of the same joint. The procedure may be performed for diagnostic analysis and/or to relieve pain and swelling in the joint.
For arthrocentesis of a small joint or bursa, report similar code 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa, (eg, fingers, toes); without ultrasound guidance; and for an intermediate joint or bursa, report 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance.
These procedures are distinct from aspiration or injection of a ganglion cyst (20612 Aspiration and/or injection of ganglion cyst(s) any location) and sacroiliac (SI) joint injection without image guidance (20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)).
Effective for claims with dates of service on or after Jan. 1, 2015, you may no longer report image guidance separately with 20600, 20605, or 20610. Instead, you would report 20604, 20606, or 20611, as appropriate.
See “Coding Arthrocentesis, Aspiration, or Injection Is a Joint Effort” for new guidelines.
Reporting Multiple Units
Report only a single unit of 20610 for each joint treated, regardless of how many aspirations and/or injections occur in a single joint. For example, if the physician administers two injections, one on either side of the right knee, you would report 20610 x 1. The Centers for Medicare & Medicaid Services (CMS) instructs that you should also “Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT® 20610).” Source: “Intra-articular Injections of Hyaluronan (INJ-033) Billing and Coding Guidelines”
You may report multiple units of 20610 only if aspiration/injection is performed in more than one major joint (e.g., both knees or left knee and left shoulder). If aspirations and/or injections occur on opposite, paired joints (e.g., both knees), you may report one unit of 20610 with modifier 50 Bilateral procedure appended, per CMS instruction. Non-Medicare payers may specify different methods to indicate a bilateral procedure (e.g., 20610-LT and 20610-RT); check with individual payers for their requirements.
If the provider performs injections on separate, non-symmetrical joints (e.g., left shoulder and right knee), you may report two units of 20610 and append modifier 59 Distinct procedural service to the second unit (e.g., 20610, 20610-59) to indicate the second procedure occurred at a different joint.
Many payers will impose frequency limitations on 20610. For example, BlueCross BlueShield (BCBS) policies generally stipulate, “Reimbursement for arthrocentesis, aspiration and/or injection of major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa), CPT 20610, will not exceed four (4) services per site within a thirty (30) day period.”
Source: BCBS policy search
20610 and Same-day E/M
Often, insurers will deny a claim reporting 20610 and an E/M service for the same encounter; however, there are circumstances that call for this combination.
The Medicare Physician Fee Scheduled Relative Value File assigns 20610 a zero-day global period. This means the procedure is valued to include an initial assessment and other pre-service work; therefore, you would not report an E/M service for a planned injection service where the patient presents without complications or a new problem.
The March 2012 CPT® Assistant offers this example:
A patient complained of left knee pain. At a previous visit, the physician evaluated the knee, ordered a prescription of a nonsteroidal anti-inflammatory drug and scheduled a follow-up visit in two weeks later for performance of an arthrocentesis if not improved. The patient returned, wherein the physician performed an arthrocentesis and injection of the left knee joint and scheduled a follow-up visit for one month later ….
It would not be appropriate to report the E/M service at the two-week follow-up visit because the focus of the visit was related to the performance of an arthrocentesis. Only code 20610 for the arthrocentesis would be reported. But if the E/M service is significant and separately identifiable from the typical pre-service work of 20610, you may report the E/M service separately with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.
For instance, the provider may justify reporting a separate E/M if she first has to evaluate the patient during the same visit to determine if the patient is a candidate for the procedure.
For example: A patient presents with knee pain. The physician evaluates the knee and determines that the problem may be gout or infectious arthritis. She aspirates the joint and sends the fluid for analysis to confirm a diagnosis. Because the E/M is significant and determines the need for the aspiration, you may report both 20610 and the documented E/M service with modifier 25 appended (e.g., 99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity).
A separate E/M code might also be appropriate if the physician provides the injection and also evaluates the patient for a different and/or exacerbated condition.
For example: A patient arrives for a scheduled injection for right shoulder pain, but also has a new complaint of right ankle pain. The physician provides the injection and evaluates the patient for the new complaint. In this case, as long as the E/M service is sufficiently documented, you may report it (with modifier 25 appended) in addition to 20610.
Documentation must substantiate that the E/M service was significant; best practice is to separate the documentation for 20610 and the E/M service. Only if the E/M service stands on its own may you report it separately with modifier 25.
Don’t accept denials for properly reported claims. If your payer routinely denies an E/M service reported on the same day as 20610, appeal with office notes to show, for instance, that the E/M service was necessary to determine definitive care, or was for a new or exacerbated problem that required additional workup.
For Medicare payers, 20610 does not include the drug supply (other than local anesthetic) for injection. If the provider paid for the drug, he or she may report the supply separately using the appropriate HCPCS Level II supply code.
For example: A patient presents for a scheduled injection of Euflexxa® for primary, localized osteoarthritis of the left knee. The physician office supplies the drug. You may report the injection using 20610 and the drug supply using J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (once unit, per dose) linked to a diagnosis of M17.12 Unilateral primary osteoarthritis, left knee.