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Arthrogram and steroid with anesthesia

  1. Default Arthrogram and steroid with anesthesia
    Medical Coding Books
    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

    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

    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.




  2. #2
    Smile 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 .


  3. #3
    I was thinking 20610 also...this code includes aspiration AND/OR injection.

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