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Arthrogram vs Injections or Aspiration

  1. #1
    Default Arthrogram vs Injections or Aspiration
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    I have a doc who wants to code and charge an Arthrogram with injections at the same site. Im not finding much information on this so I wanted to gather a general consensus here. Here is the note I have:

    Informed consent was obtained after explanation of the procedure of the left shoulder arthrogram under fluoroscopic guidance, including risk of infection and bleeding. After time-out procedure, and following local skin preparationand anesthesia, a 22-guage needle was advanced into the left shoulder space. A small amount of contrast was injected to confirm intraarticular location followed by the injection of 9 cc of a combination of bupivacaine and kenalog.
    There is irregularity of distribution of contrast within the shoulder joint consistent with some internal debris.
    IMPRESSION: medication injection without complication. Degenerative changes and probable debris within the shoulder join

    Would you code this as an arthrogram and also the injections?

  2. #2
    Sioux Falls South Dakota
    Yes, you would bill both the injection procedure and the radiological supervision and interpretation. The instructions to code this way are under 23350, injection procedure for shoulder arthrography....

    If done in the hospital you would use modifier 26 on your radiology code (73040)

    Hope this helps!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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