Orthopedic Coding Alert

"Arthrographies and anesthetic injections can cause confusion when it comes to coding because there is always the question, How do I get paid for all aspects of joint injections?

Adding to Arthrographies

Arthrographies are a diagnostic injection in which the injury is visualized with a contrast dye and which always involves a second radiological code (73115, radiologic examination, wrist, arthrography, radiological supervision and interpretation) in addition to the arthrography injection procedure code (25246), explains Annette Grady, CPC, CPC-H, coding and reimbursement coordinator for the Bone and Joint Center of Bismarck, ND. This procedure is often done on the wrist area, especially if theres tendon damage, says Grady. Code 25246 involves injecting a contrast dye into the wrist joint, and aspirating the joint fluid for culture.

The 25246 and 73115 is a combination procedure, Grady says. These are always a series of two codes if done in an office setting. In fact, 25246 and 73115 together are known as a complete procedure in CPT terminology.

If you try to bill for fluoroscopy as well (76000), you probably will not get paid for it, adds Grady. The definition of 76000 states that it is a separate procedure, and any code which is designated as a separate procedure should only be reported when it is done independently of the other services, Grady explains. The arthrographies, by definition, already include radiologic imaging, and therefore you cannot bill for 76000 as well.

In addition to wrist arthrography, there are separate codes for shoulder (73040), elbow (73085), hip (73525), knee (73580), and ankle (73615). Each one should be billed with the injection code (73115).

Injecting Anesthetics

However, if you are injecting an anesthetic (in which fluoroscopy is sometimes used for guidance) into the joint, and not injecting the dye, you can bill 76000 for fluoroscopic guidance. In this case, you would bill the appropriate injection code. Arthrographies are listed in CPT by anatomical area; in other words, theyre all over the place in the manual. Injections (and/or aspirations) are all listed in the same area: 20600* for a small joint (fingers or toes), 20605* for an intermediate joint (temporomandibular, acromioclavicular, wrist, elbow or ankle), and 20610* for a major joint (shoulder, hip, knee).

Note: If you are injecting marcaine into the wrist, without guidance by contrast dye, but with fluoroscopic guidance, you would use 20605* for the injection, and 76000 for the fluoroscopy.

We usually give these injections in the hip, says Tina Rud, surgical specialist with Twin Cities Orthopedics in Minneapolis, MN, an 18-orthopedist practice.

E/M and Injections

When the marcaine injection (for example), which is given for pain, is done in the office, can you bill for an office visit as well? That depends, says Rud. If its a new problem presented to the physician that day, and the orthopedist and patient agree on trying an injection after the examination and x-ray that day, then you could bill for an office visit as well, she says. We would usually code 99213, with a modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended, and 20610* for the hip.

Tip: Technically, you do not have to use a modifier -25 with 20600*, 20605*, or 20610*, since they are starred procedures. However, most billers have found that it helps with reimbursement, or at least it doesnt hurt.

You cannot bill for the office visit, however, if
you have already diagnosed the problem. For example, lets say the patient comes in on Monday with pain, and you discuss options. The physician recommends medication instead of the injection, but the patient comes back the next week saying the pain isnt any better. The physician does the injection at that follow-up visit, accordingly you can only bill for the joint injection.

Billing for Medication and Trays

Anesthetic medication, such as marcaine, is included in the 20600*, 20605*, and 20610* codes, says Grady. However, if you inject another kind of medication, such as cortisone, you can bill for that using the appropriate HCPCS code. For example, the HCPCS code for cortisone is J0810.

Note: Also billable by some carriers is the surgical tray (04649) used for the procedure when it is performed in your office, as well."