Code This Arthrocentesis Procedure Correctly
Question: A 57-year-old established patient came into our office with complaints of increasing pain, swelling, and stiffness in the right ankle that has progressively worsened over the past two weeks. The physical examination revealed a visible joint effusion with tenderness and decreased range of motion. An X-ray ruled out a fracture, but there was fluid accumulation within the ankle joint. The podiatrist determined that arthrocentesis was medically necessary to relieve the patient’s symptoms. The physician prepared the site using a sterile technique and inserted a needle into the right ankle joint. They aspirated 12 mL of straw-colored synovial fluid and then injected a corticosteroid to reduce any inflammation. No ultrasound guidance was necessary during the procedure, and the patient tolerated the treatment without complications. How should I code this procedure? Arizona Subscriber Answer: When your podiatrist performs arthrocentesis to treat effusion in the ankle, you have these procedure codes to choose from: Because the physician didn’t use ultrasound guidance during the procedure, you would choose 20605 and append modifier RT (Right side) to indicate the physician performed the surgery on the patient’s right ankle. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
