Aspiration and Injection of Major Joint
CPT® 20610 Arthrocentisis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance 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.
Report similar codes 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance for arthrocentesis of a small joint or bursa, (e.g., fingers or toes) or 20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance for an intermediate joint or bursa (e.g., wrist, elbow, ankle, etc.). 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)).
Imaging Guidance Is Separate
You may report imaging guidance—other than ultrasound guidance—separately with 20610, using the code appropriate to the type of guidance:
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)
77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation
77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation
For aspiration and/or injection of major joint or bursa with ultrasound guidance, report 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.
Reporting Multiple Units
Report 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 provider administers two injections, one on either side of the right knee, report 20610 x 1. Per Centers for Medicare & Medicaid Services (CMS) instructions, 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).”
You may report multiple units of 20610 only if aspiration/injection was performed in more than one major joint. (e.g., both knees, 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 your 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 that the second procedure occurred at a different joint.
Finally, many payers will impose frequency limitations on 20610. For example, Blue Cross/Blue Shield 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.”
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