# 20610&77002, vs. 23350&77002



## Pinky726 (Mar 3, 2016)

We are currently billing the 20610 along with 77002 for fluoro. guided injections w/contrast into the shoulder joint for viscosupplementation. Currently our knee injections are exactly the same, but billed with 27370&77002. We recently looked into the more specific code of 23550 for the shoulder injections, and have had some concerns with it being billable along with the 77002.

Does anyone have any input?
We are a clinic not facility, specialty not general, and all services are performed by the same physician.
The shoulder would be billed with the DX codes M19.011 and M19.012.
Our knees are billed with DX coeds M17.0, M17.12, M17.11.

Thanks for you input!


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## kivbar16 (Mar 3, 2016)

When you are billing the 27370, are you really doing the knee arthrography?  Per CPT (copied from encoder): 

27370: Injection of contrast for knee arthrography; lay descripition - The physician injects contrast for knee arthrography. The patient is placed supine (lying on the back) on an x-ray table with the knee flexed over a small pillow. A skin anesthetic may be applied. The physician passes a 20-gauge needle into the femoropatellar space. Air and a single or double contrast agent are injected into the space in preparation for knee arthrography. After the injection is complete, the patient is asked to move the knee to ensure adequate distribution of the contrast material in the joint structures. Multiple roentgenographic views are taken of the knee.  <---  Are you taking films?  

Your post makes me question what you are doing; you can certainly bill 20610 & 77002 for the arthrocentesis and fluoro (respectively), as well as the Jxxxx code for the visco (such as Synvisc, etc).  But if you are NOT doing a true arthrography, I would be very careful in what you are billing. I have a hard time believing your providers are actually doing what is being billed for simple visco injections.


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## ollielooya (Mar 3, 2016)

*I'm wondering about your scenario, too*

Our provider performs similar service as yours, sometimes involving both joints, and in this case we use the XS modifier on the 2nd 20610.


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## Pinky726 (Mar 7, 2016)

*Response*

kivbar16
When you are billing the 27370, are you really doing the knee arthrography? Per CPT (copied from encoder): 

(Answer: Yes, we maintain a permanenet image of every injection procedure performed, all injections are performed with fluoro. guidance. 
Arthrography definition: Arthrograpy is a procedure involving multiple x rays of a joint using a fluoroscope, or a special piece of x-ray equipment which shows an immediate x-ray image. A contrast medium (in this case, a contrast iodine solution) injected into the joint area helps highlight structures of the joint.)

Our physicians do not perform a singe blind injection, all are guided. I understand that this is not common, but it is our procedure protocol. 

My questioning in this blog was using the shoulder specific code(23350), vs. the large joint code (20610) when shoulder joints are injected. The 23350 code states - Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography. My concern is since it is an "or" code, will it get kicked being billed with the 77002. We are billing the 77002 to specify  that it was not for CT/MRI, it was guided using fluoro. 



27370: Injection of contrast for knee arthrography; lay descripition - The physician injects contrast for knee arthrography. The patient is placed supine (lying on the back) on an x-ray table with the knee flexed over a small pillow. A skin anesthetic may be applied. The physician passes a 20-gauge needle into the femoropatellar space. Air and a single or double contrast agent are injected into the space in preparation for knee arthrography. After the injection is complete, the patient is asked to move the knee to ensure adequate distribution of the contrast material in the joint structures. Multiple roentgenographic views are taken of the knee. <--- Are you taking films? 

Your post makes me question what you are doing; you can certainly bill 20610 & 77002 for the arthrocentesis and fluoro (respectively), as well as the Jxxxx code for the visco (such as Synvisc, etc). But if you are NOT doing a true arthrography, I would be very careful in what you are billing. I have a hard time believing your providers are actually doing what is being billed for simple visco injections.


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## mhstrauss (Mar 7, 2016)

Buckmiller26 said:


> kivbar16
> When you are billing the 27370, are you really doing the knee arthrography? Per CPT (copied from encoder):
> 
> (Answer: Yes, we maintain a permanenet image of every injection procedure performed, all injections are performed with fluoro. guidance.
> ...





I think the answer will depend on the intent of the physician when the service was ordered. If the injection was ordered as a diagnostic study, then the arthrogram code would be more appropriate. But if it was ordered as an injection to treat, with the fluoro/contrast injection strictly being used for guidance (which it sounds like it was; we perform these also), then the major joint injection code with fluoro guidance 77002 would be correct. See this article from Supercoder as a reference; the Q&A is for hip, but same concept applies:

HI,
Can you help me understand the difference in cpt code 27093 VS 20610.
What would be the "KEY" words in the procedure note to be able to tell the difference between these 2 codes?
Thanks,
Dawn
SuperCoderPosted 3 years ago
The codes in question include 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), 27093 (Injection procedure for hip arthrography; without anesthesia)..
Current CCI edits list 20610 as a Column 2 code of 27093, which means you shouldn't normally report both procedures together if the physician performs the arthrogram and injection on the same hip. The bundle does allow you to report a modifier, however, to differentiate between services in some instances. Check your documentation to determine whether a modifier such as 59 (Distinct procedural service) might be justified.
If you can't report both 20610 and 27093 for the encounter, submit only 27093
When a small amount of contrast is injected into the hip under fluoroscopic guidance to ensure proper needle location before administering an anesthetic or steroid injection, it is appropriate to submit code 77002, Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), to report the fluoroscopic imaging performed. Fluoroscopic guidance is the radiologic technique by which the images are produced. As stated in the descriptor nomenclature, code 77002 is used to describe fluoroscopic guidance for all types of needle placement, such as for biopsy, aspiration, injection, or placement of a localization device. The injection of a steroid or an anesthetic agent into the hip would also be reported using the joint injection code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa. To further clarify,
Hip injection of an anesthetic or steroid under fluoroscopic guidance should not be confused with hip arthrography. When a conventional (radiographic) hip arthrogram is performed, it is reported with an arthrography injection code (code 27093, Injection procedure for hip arthrography; without anesthesia, or code 27095, Injection procedure for hip arthrography; with anesthesia), and the arthrography imaging code 73525, Radiologic examination, hip, arthrography, radiological supervision and interpretation. In this instance, code 77002 is not reported in addition to code 73525 because current imaging practice dictates that fluoroscopy [77002] is considered a component of organ/anatomic-specific radiological supervision and interpretation procedures (ie, 73525).
The key is not the actual volume of contrast injected, but the intention. If the contrast is injected only to confirm needle position within the joint, the quantity does not matter. If instead the contrast is injected with the intention to outline the joint surface to perform a radiographic arthrogram, then it is an arthrogram even if only a few cc’s of contrast material are injected. Again, it is not the volume of contrast but the intention that defines the service.
- See more at: https://www.supercoder.com/my-ask-an-expert/topic/27093-vs-20610#sthash.HSfAiCzu.dpuf

Found at this link:

https://www.supercoder.com/my-ask-an-expert/topic/27093-vs-20610


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## amexnikki23 (Mar 2, 2017)

*There is still that burning question of... what constitutes a true arthrogram?*

Radiologyinfo.org states that "Arthrography is medical imaging used to help evaluate and diagnose joint conditions and unexplained pain. It is very effective at detecting disease within the ligaments, tendons and cartilage. It may be indirect, where contrast material is injected into the bloodstream, or direct, where contrast material is injected into the joint. Arthrography may use computed tomography (CT) scanning, magnetic resonance imaging (MRI) or fluoroscopy – a form of real-time x-ray... In some cases, local anesthetic medications or steroids may be injected into the joint along with the contrast material. These medications may temporarily decrease joint-related pain or inflammation and provide physicians additional information about possible sources of joint pain."

So even though in some cases, a local anesthetic may be injected, this still appears to be for diagnostic purposes, and not therapeutic- even though it may decrease pain. The intent is still an attempt to identify the source of the pain; therefore, diagnostic. In my humble opinion, I'm thinking that to justify coding the injection of contrast (for an arthrogram) and the arthrogram R&I, the documentation should specifically state the arthorgram was performed either to diagnose a condition, or locate the source of the pain via a steroid joint injection; otherwise, it would appearing to be for contrast/needle localization purposes.  

Thoughts?


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## maryorr (Apr 11, 2017)

If my doctor is taking a patient to the hospital to do a hip injection under fluoro and i bill for him not the facility, do i code 20610 and 77002?


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