Anesthesia Coding Alert

Do you know the difference between intermediate and major joints?

Patients reporting to the pain management (PM) specialist for treatment of certain painful conditions will often undergo a therapeutic procedure using a needle. These can be injections or aspirations, and they’ll often include some tricky coding decisions.

Some payers might not cover certain aspiration procedures, while others will. Check out this expert advice to make sure you are choosing the correct code depending on anatomy and other factors and that you’re coding everything you should with every encounter.

Code for Dry Needling … Maybe

One service your provider could be performing on a patient is dry needling. “This is a technique in which a needle is going to be used to penetrate the skin and stimulate underlying myofascial trigger points, muscles, or connective tissue. This technique is going to be used to treat dysfunctions in skeletal muscle fascia and connective tissue,” explains Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor.

You should report dry needling with one of these codes, depending on encounter specifics:

• 20560 (Needle insertion(s) without injection(s); 1 or 2 muscle(s))
• 20561 (… 3 or more muscles)

“These codes were added a couple years ago, and they described services that are typically referred to is dry needling or trigger point acupuncture,” says Clements. “These services are neither traditional acupuncture and they’re not injections; they kind of fall in between the two.”

Watch Policies for Dry Needling

You should be checking each of your payer contracts for their specifics on 20560 or 20561. Since the codes are relatively new, not all policies are completely set. For example, Clements points out that Part B Medicare Administrative Contractor (MAC) Noridian Healthcare Solutions states dry needling is not a covered procedure in LCD L34218, effective date Oct. 1, 2019, with no revision date. MAC NGS, however, states, “Effective January 21, 2020, Medicare will cover all types of acupuncture including dry needling for chronic low back pain within specific guidelines in accordance with NCD 30.3.3.”

Takeaway: Be sure you review payer policies if you have any doubt about billing for dry needling. Carriers will certainly vary as to whether they cover 20560/20561, and the conditions they’ll reimburse the codes under will also vary.

Size Matters on Joint Injections

Another procedure you could see a lot of in the PM clinic is joint injection. The first set of joint injection codes Clements discussed were:

• 20600 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance)
• 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance)
• 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance)

“These are your joint injections without ultrasound [US] guidance,” explains Clements. “Also, notice that these code descriptions cover the aspiration and/or injection of the joint in the code,” so you’ll report these codes once per joint.

You may find it tricky finding out what constitutes small, intermediate, and major joints/bursas. “They do identify the different types of joint as examples within the code description, but naturally they do not list every joint or bursa,” says Clements. “In that case you’re going to have to kind of make some comparison on the size of the joint that your providers inject and compare it to what is in the parentheses as examples.”

Find Proof of US Before Using These Codes

There are also codes you can use when the provider uses US during a joint injection:

• 20604 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting)
• 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting)
• 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting)

Remember: As the descriptors indicate — and Clements stresses — your claim must satisfy the “permanent recording and reporting” portion in order to rightfully use the injection with US guidance codes.

If you’re lacking permanent recording and reporting in your joint injections, you should not report 20604, 20606, or 20611. In these cases, you’ll need to report 20600, 20605, or 20610.

Code Separately for Fluoro/CT/MRI, but Not US

As you can see, US guidance is indicated in the descriptors for 20604, 20606, and 20611. There are, however, other types of guidance that you might be able to report separately with these codes.

For these joint injection codes, “there is a parenthetical note that tells you that if your provider uses fluoroscopic, computed tomography [CT], or magnetic resonance imaging [MRI] during a joint injection, you should be able to code separately for the service,” Clements points out.

Per CPT^® 2024, under the descriptors for 20604/20606/20611, “If fluoroscopic, CT, or MRI guidance is performed, see +77002 [Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)], 77012 [Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation], 77021 [Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation].”