Wiki Aspiration of knee joint


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Patient came into clinic complaining of "swollen knee, like last time I had fluid in the joint," The clinic note states the provided attempeted three time to aspirate fluid from the patient's knee joint in the clinic. None of the attempts returned any fluid. The provider noted "failed knee joint aspiration" in her note. There was no radiology before or after the attempt. Not sure how to code this, as a failed procedure, or as the aspiration with modifier 52 for reduced services. The provider said it is a 99212 E&M level, which I disagree with.
Would need documentation

First - this is not my area of expertise, and you might be better served by posting this kind of question in the Orthopedic forum...

That being said ...

It's hard to tell without the documentation. If the procedure was performed (and documented), even if no fluid was aspirated, then it's a complete procedure.

Hope that helps.

F Tessa Bartels, CPC, CEMC
You will want to append the 52 modifier for a procedure that was attempted and not fully carried out.