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Thread: injection(s) question

  1. #1

    Question injection(s) question

    AAPC: Back to School
    Hello all,

    I have hip intra-articular injection and then does a trochanteric bursa injection both on the right. Dx's OA hip and trochanteric bursitis.
    This is a Medicare patient....ok to bill 20610-RT and 20610-59, RT


  2. #2
    Join Date
    Apr 2007


    I'm going to go with only reporting once...I know this is for a knee..and for aspiration/injection but I think the concept is still there.

    CPT Assist:
    March 2001 page 10
    Coding Consultation

    Musculoskeletal System, Surgery, 20610 (Q&A)


    When aspiration of fluid from the knee joint is performed as well as injection of medication into the knee joint, can code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa), be reported two times, once for the aspiration of fluid and once for the injection of medication?

    AMA Comment

    From a CPT coding perspective, the term "and/or" in the code descriptor of code 20610 indicates that the code includes the performance of one or all of the procedures described in the same major joint or bursa. Therefore, code 20610 should only be reported one time when both aspiration and injection are performed in the same major joint or bursa.
    Mary, CPC, CANPC, COSC

  3. #3

    Default More info

    I my op note states:
    after hip joint injection given attention was directed to the right trochanteric bursa. An injection of 20 mg triamcinolone with 2cc of 0.5% perservative-free bupivacaine was injected. The procedure was well tolerated and no complications.

    Since the injection given in joint and bursa and code
    states majororbursa....safe to say 20610 x 2???

    Thanks again!

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    Yes you can bill for both as you stated in your first post, the reason they do not allow the aspiration and injection has to do with how it is performed, most of my docs when they do the aspiration and then injection are using the same site, which then makes it billable only once.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5


    Thanks Ladies!!! Have a good weekend

  6. #6
    Join Date
    Apr 2007


    medicare will not accept units you have to bill each one seperate i would attempt to add 59 mod to the second injection, however more than likely one will be denied as a duplicate of the other

  7. #7


    Thanks that is how I billed it

  8. #8


    Hi all,
    can we bill 20610-RT with 2 units for injection in RT knee and RT shoulder?

    Last edited by nayanapatit@gmail.com; 05-21-2014 at 01:40 AM.

  9. #9


    Quote Originally Posted by nayanapatit@gmail.com View Post
    Hi all,
    can we bill 20610-RT with 2 units for injection in RT knee and RT shoulder?

    Report only a single unit of 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 right knee, you would report 20610 x 1. The Centers for Medicare & Medicaid Services (CMS) instructs that you should also ?Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT? 20610).

    Thank you...

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