Coding Arthrocentesis Is a Joint Effort

Don’t get stuck when trying to select the right code for reporting joint aspiration and injection procedures.

Time for a refresher on reporting joint aspiration and injection procedures. Let’s start with a little bit of background information. When a joint causes pain, swells, is red, or has a limited range of motion, a doctor may recommend using a needle and syringe to remove synovial fluid from the joint. This procedure is called arthrocentesis, commonly known as joint aspiration. Usually performed in a doctor’s office, arthrocentesis is often used both as a diagnostic and a therapeutic tool for various clinical situations.

This minor surgical procedure may be done to obtain fluid for diagnostic lab testing to identify the etiology of acute arthritis, as a therapeutic measure to alleviate pressure and relieve joint pain (drainage of effusion, injection of medications), or both. Coding for joint arthrocentesis can be tricky, but knowing what to look for, following a few simple rules, and pulling your coding resources together makes it easier.

Deconstruct the Descriptors

First, let’s work our way through the code descriptors. The CPT® codes for reporting arthrocentesis are 20600–20615. The descriptors start by stating that the codes represent arthrocentesis — aspiration from or injection into a joint, or both aspiration and injection of the same joint. Proper code selection is based on two factors:

• The type of joint or bursa, and
• Whether ultrasound guidance is used.

Report arthrocentesis on:

Small joints or bursa — for example, fingers or toes — using:

20600   Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance

20604              with ultrasound guidance, with permanent recording and reporting

Intermediate joints or bursa — for example, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa — using:

20605   Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance

20606              with ultrasound guidance, with permanent recording and reporting

Major joints or bursa — for example, the shoulder, hip, knee, subacromial bursa — using:

20610   Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance

20611              with ultrasound guidance, with permanent recording and reporting

Note the requirement of permanent recording and reporting for the ultrasound guidance; if there is no permanent recording and reporting, you must report the code for the service without ultrasound guidance (20600, 20605, or 20610). As expected, CPT® guidelines instruct you not to report ultrasonic guidance code 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation with any of the above-listed codes. Also, do not report 20610 or 20611 with 27370 Injection of contrast for knee arthrography.

For other types of imaging guidance, report the appropriate radiology code:

+77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)

77012   Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation

77021   Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

Reporting Multiple Units

Report only a single unit of the applicable arthrocentesis code, such as 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 left knee, you will report 20610 x 1. Likewise, if aspiration is performed on a major joint/bursa, and an injection is performed immediately following the aspiration on the same major joint/bursa, report 20610 one time per CPT® guidance.

You may report multiple units of 20610 only if aspiration or injection is performed in more than one major joint. When aspiration and/or injection occur bilaterally in opposite, paired joints (e.g., both knees), report one unit of 20610 with modifier 50 Bilateral procedure appended, according to the Centers for Medicare & Medicaid Services (CMS).

When the provider performs arthrocentesis on two different non-symmetrical joints (e.g., right shoulder and left knee), 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.

Laterality Matters

When reporting codes for unilateral joint arthrocentesis, the use of modifier RT or LT on the injection procedure (e.g., CPT® 20610) may be appropriate to indicate which knee was injected. For example, a patient presents to the office for an injection of 40 mg of triamcinolone to the right hip for trochanteric bursitis of the right hip. The following codes should be reported:

20610-RT

J3301   Injection, triamcinolone acetonide, not otherwise specified, 10 mg (x 4)

M70.61 Trochanteric bursitis, right hip

Don’t Forget to Report Supplies

For Medicare payers, the aspiration/injection codes do not include the drug supply (other than local anesthetic) for the injection. When medication is injected, report the appropriate HCPCS Level II J code separately if the provider paid for the drug.

For example, a patient presents for a scheduled injection of Euflexxa® for primary, localized osteoarthritis of the right knee. The physician’s office supplies the drug. You may report the injection using 20610-RT and the drug supply using J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (one unit, per dose) linked to a diagnosis of M17.11 Unilateral primary osteoarthritis, right knee.

Additional Services May Be Payable

Insurers will often deny a claim reporting an arthrocentesis code, such as 20610, and an evaluation and management (E/M) service for the same encounter. The Medicare Physician Fee Schedule (MPFS) 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 when the patient presents without complications or a new problem.

But if the provider performs an E/M service that is significant and separately identifiable from the typical pre-service work of 20610 (or any code with a zero-day global period), you may be able to report the E/M service 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 to the appropriate E/M service code.

For instance, a provider may justify reporting a separate E/M service if they start the series of injections after performing an evaluation during the same visit to determine if the patient is a candidate for the procedure. In another example, a separate E/M code may be appropriate if the physician performs the injection and also evaluates the patient for a different condition.

In any case, the E/M service must stand on its own to report it separately with modifier 25. Best practice is to separate the documentation for the joint injection/aspiration from that of the E/M service. The documentation must demonstrate how the E/M service was significant and separate from the standard E/M service for the arthrocentesis.

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Stacy Chaplain

Stacy Chaplain, MD, CPC, is an executive editor at AAPC. She has worked in medicine for almost 20 years and has more than five years' experience in medical writing & editing. Prior to AAPC, she led a compliance team as director of clinical coding quality for a multispecialty group practice. Chaplain received her Bachelor of Arts in Biology from The University of Texas at Austin and her Medical Doctorate from The University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Ore. local chapter.

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