# Arthrogram w Steroid Injection



## dyoungberg (Jun 7, 2012)

I'm billing charges for an ASC for Hip Arthrogram under fluroscopy with Intraarticular Steroid Injection.  My instinct was to bill as 20610 w 77002, but then I'm second guessing myself and wonder if it should be 27095.  Any thoughts on this?

_PREOP DIAGNOSIS:   LEFT HIP POSTTRAUMATIC DEGENERATIVE ARTHRITIS 

POSTOP DIAGNOSIS:  SAME

PROCEDURE:   LEFT HIP ARTHROGRAM UNDER FLUOROSCOPY WITH INTRAARTICULAR STEROID INJECTION 

ANESTHESIA:    MAC 

INTRODUCTION:  Routine preop evaluation revealed no medical contraindications to the procedure. The patient and family were consulted at length regarding the relative risks, benefits, and alternatives to the above elected procedure. They understood these risks to include but not be limited to infection, sepsis, osteomyelitis, DVT, PE, stroke, MI, death, nerve or blood vessel damage, RSD, persistent pain, persistent stiffness, requirement for future operative intervention, among others. Understanding the above risks and that no guarantees were made nor implied, the patient freely consented to proceed. 

OPERATIVE PROCEDURE: Patient was taken to the operating room on 6/6/12 where she was transferred to the radiolucent OR table and placed in the supine position without event. The patient was given IV sedation maintained by mask. Prior to initiation of the operative procedure, the American Academy of Orthopedic Surgeons' timeout protocol was instituted. This assured the patient's name, the correct extremity, the correct side, the patient's allergies, their preoperative medications and antibiotics. Following completion of the appropriate timeout and verification of all the above, we proceeded with the operative procedure.  The left inguinal area was prepped and draped in usual sterile fashion. 

An 18G needle was introduced under arthroscopic guidance with the introduction site just lateral and 2.0 cm's inferior to the ASIS. The needle was advanced into the superior glenohumeral joint. Position was confirmed with a 2 cc injection of radiocontrast dye which demonstrated an excellent arthrogram picture. Thereafter, a 10 cc solution of 3 cc Celestone and 7 cc Marcaine was injected intra articularly. The needle was withdrawn. There was no significant bleeding. The puncture site was covered with a band-aid. The patient was thereafter returned to the recovery room in good condition. There were no noted complications. Sponge, needle, and instrument counts were correct at the end of the operative procedure. The patient tolerated the injection well. EBL was _

Thanks very much!

D Youngberg


----------



## dwaldman (Jun 9, 2012)

20610, there is no interpretation in the report that you provided and it doesn't state to see a separate report for the intepretation.


----------

