Major Joint Injection and Aspiration Coding
Coding for Major Joint Injection and Aspiration Coding.
CPT(R) 20610 may be performed for diagnostic analysis and/or to relieve pain and swelling in the joint. Similarly CPT codes 20600 or 20605 can be reported only that these procedures are distinct from aspiration or injection of a ganglion cyst.
Using the code appropriate to the type of guidance, imaging guidance other than ultrasound guidance can be reported separately with 20610:
- 77002 Fluoroscopic guidance for needle placement (Eg: Biopsy, aspiration, injection, localization device).
- 77012 Computed tomography guidance for needle placement (Eg: Biopsy, aspiration, injection, localization device), radiological supervision and interpretation.
- 77021 Magnetic resonance guidance for needle placement (Eg: For biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.
CPT code 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting should be reported for aspiration and/or injection of major joint or bursa with ultrasound guidance.
Reporting of Multiple Units.
Regardless of how many aspirations and/or injections occur in a single joint, a single unit of 20610 for each joint treated must be reported. For example, if the provider administers two injections, one on either side of the right knee, 20610 x 1 should be reported. Also ?which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT(R) 20610)? as per Centers for Medicare & Medicaid Services (CMS) instructions should be indicated.
Multiple units of 20610 should be reported only if aspiration/injection was performed in more than one major joint. (For Eg both knees, left knee and left shoulder). If aspirations and/or injections occur on opposite, paired joints (Eg. both knees), one unit of 20610 with modifier 50 Bilateral procedure is appended, as per CMS should be reported. Non-Medicare payers may specify different methods to indicate a bilateral procedure (Eg. 20610-LT and 20610-RT). This should be checked with your individual payers for their requirements.
If the provider performs injections on separate, non-symmetrical joints (Eg. Left shoulder and Right knee), two units of 20610 and modifier 59 Distinct procedural service to the second unit (Eg. 20610, 20610-59) should be appended to indicate that the second procedure occurred at a different joint