Anesthesia Coding Alert

Question: The physician treated a patient with right shoulder bursitis and right biceps tendonitis. He wants to code for both sites, but shouldn't we only code for the more extensive procedure?


North Carolina Subscriber

Answer: When you-re coding anesthesia services, you only report the more extensive procedure when the physician provides multiple services. Coding for pain management services, however, is different. You can report both of the injections for this patient because the physician treated different areas.

Consequently, you should submit 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) for the tendon injection and 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the bursa injection.

Be sure to link the appropriate diagnosis codes (such as 719.41, Pain in joint; shoulder region) to each procedure and append modifier 59 (Distinct procedural service) to the second injection code to show the physician treated separate sites.