Arthrogram and steroid with anesthesia

Shirleybala

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Hi
How to code this report is 27095 and 73525-26 is suffice please confirm

History: 58-year-old male with right hip pain for two months,
progressively worsening in the past two weeks. MRI demonstrating
inflammatory arthropathy with synovitis. Patient has ankylosing
spondylitis.

PROCEDURE: Arthrogram and steroid joint injection of right hip.

TECHNIQUE: Written and oral informed consent was obtained after
risks, benefits, and alternatives were explained. Preliminary
scout radiograph of the right hip demonstrates mild spurring of
the acetabular rim. There is mild enthesopathy in the ischial
tuberosity and lesser trochanter. There is fusion of the right
sacroiliac joint consistent with history of ankylosing
spondylitis.

Preliminary localization images were obtained. Appropriate skin
entry site was marked, and prepped and draped in the usual sterile
manner. One percent lidocaine was used to anesthetize the soft
tissues. Under fluoroscopic guidance and sterile technique, a 20
gauge 3.5 inch spinal needle was advanced into the right hip
joint. Approximately 4 cc of straw color viscous intra-articular
fluid were aspirated from the joint and sent to the microbiology
lab for analysis. Approximately 3 cc of omnipaque 240 confirmed
intra-articular position of the needle. One cc of 40 mg/ml
Methylprednisolone and 5 cc of 0.25 % Bupivacaine were then
instilled into the joint. Fluoroscopic images demonstrate
dilution of the contrast within the joint space following
injection of the medication. There were no immediate post
procedural complications. The patient reported immediate relief
of pain.

IMPRESSION:

SUCCESSFUL UNCOMPLICATED RIGHT HIP JOINT STEROID/MARCAINE
INJECTION.

ASPIRATION OF STRAW-COLORED JOINT FLUID FOR ANALYSIS.
 

kamala

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Hip

Hi ,

My suggestion is to use CPT - 20610 , 77002 .

Here no arthrogram procedure performed , instead Injection of steroid and sampling of the fluid is done .


Regards,
Kamala
 

MLS2

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I was thinking 20610 also...this code includes aspiration AND/OR injection.
 
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