# Arthrogram and steroid with anesthesia



## Shirleybala (Sep 17, 2008)

Hi 
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
      spondylitis.

       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
      spondylitis.

      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.

      IMPRESSION:

      SUCCESSFUL UNCOMPLICATED RIGHT HIP JOINT STEROID/MARCAINE
      INJECTION.

      ASPIRATION OF STRAW-COLORED JOINT FLUID FOR ANALYSIS.


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## kamala (Sep 18, 2008)

*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 .


Regards, 
Kamala


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## MLS2 (Sep 18, 2008)

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


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