ED Coding and Reimbursement Alert

Do you know what separates small/intermediate/ major joints?

When patients report to the ED for joint/bursa injections, things can get tricky fast for coders.

Why? There are different codes for different joint sizes — and the distinction isn’t always so clear. Also, there’s the question of guidance, and which kind, the provider used during the injection to ensure correct coding.

During her HEALTHCON 2022 session, Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor, ran attendees through some of the more pressing questions surrounding these injections. Check out what she had to say.

Size Matters on Joint Injections

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,” explained 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.

Remember, Descriptors Don’t Cover All Joints

Finding out what constitutes small, intermediate, and major joints/bursas can be tricky. “They do identify the different types of joint as examples within the code description, but naturally they do not list every joint or bursa,” said 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.”

One expert who has had a lot of experience with these coding riddles is Jennifer Sanders, MBA, CPC, CPB, CPMA, CPPM, COSC, CPC-I, CCS-P, AAPC Fellow, AHIMA-Approved Revenue Cycle Manager, instructor and subject matter expert at CCO.us. “I have found the CPT^® descriptions to be accurate for the type of joint injections provided. Our providers indicated which injection was performed using anatomy, which [joint] matches the CPT^® descriptions, and their knowledge/ experience in the field,” she explains.

Tip: You should check with your provider or physician if you have trouble determining joint size; don’t just wing it. And there is guidance out there, though it might not be formal. “Per one of our providers, the information we use: small joints are fingers/ toes; medium joints are elbow, ankle, wrist and acromioclavicular; large joints are knee, shoulder, hip,” Sanders says.

Find Proof of US Before Using These Codes

The codes discussed above were for a joint injection without US guidance, but there are also codes you’ll use when the provider uses US during a joint injection. Those codes are:

• 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 stressed — 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 pointed out.

Per CPT^® 2022, 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].”

Keep on Point Records to Document Shots, Medication

Documentation should include the procedure, where it was done (anatomically), the dosage, and the medication type along with any problems or how the injection was handled by For example, a 50-year-old female presents with a hip effusion. She is known to have very difficult anatomy and CT guidance is used to place a large bore needle followed by joint aspiration. Report 20611 and 77012 for this encounter.