ICD 10 Coding Alert

Knowing exactly which part of the foot or ankle are affected by joint effusion is paramount to selecting an accurate diagnosis code.

The condition causes swelling of the tissues in or around your joint because of extra fluid, according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. This can cause a “puffy” appearance to your joints along with symptoms like pain and stiffness. Effusion describes swelling that is inside a joint.

Don’t Miss These Effusion Symptoms

Question 2: What are some symptoms of joint effusion?

• According to Falbo, common joint effusion symptoms include:
• Swelling (ranging from mild puffiness to severe swelling)
• Pain (ranging from a dull throb to sharp, stabbing pains that interfere with mobility)
• Redness and warmth (associated with inflammation and/ or infection)
• Limited joint mobility

Distinguish Foot Effusion

Question 3: What ICD-10-CM codes are used for effusion of the foot?

If the patient suffers from effusion of the foot, you should look to the following codes:

• M25.474 (Effusion, right foot)
• M25.475 (Effusion, left foot)
• M25.476 (Effusion, unspecified foot)

Specify Ankle Effusion

Question 4: Which ICD-10-CM codes would I use for ankle effusion?

You have the following ICD-10-CM codes for ankle effusion:

• M25.471 (Effusion, right ankle)
• M25.472 (Effusion, left ankle)
• M25.473 (Effusion, unspecified ankle)

Be Familiar With Treatment Options for Joint Effusion

Question 5: What are some treatment options for joint effusion?

The diagnosis of joint effusion by a provider is based on the patient’s medical history, which includes any incidents of trauma or disease, a physical examination, and the use of imaging methods such as X-rays.

The treatment approach can vary based on the underlying cause and may involve the use of medications like nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antirheumatics, or antibiotics. Other potential treatments include the use of moist heat and ice applications, or joint aspiration.

A provider may suggest rest, ice, and raising the joint (elevation) to help with pain and swelling. Surgery may be needed to repair the damage.

Code Arthrocentesis Correctly

Question 6: My provider performed arthrocentesis to treat a patient with effusion. Which CPT^® code should I report?

Arthrocentesis defined: Arthrocentesis is a procedure in which the provider uses a needle and a syringe to drain or withdraw fluid from the joint.

If your provider performs arthrocentesis to treat effusion, you have several procedure codes to choose from. They are as follows:

• 20600 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance)
• 20604 (… with ultrasound guidance, with permanent recording and reporting)
• 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance)
• 20606 (… with ultrasound guidance, with permanent recording and reporting)

Note: Never report 20600, 20604, 20605, or 20696 in conjunction 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation), 0489T (Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells), or 0490T (Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands). “When reviewing codes in CPT^® that include imaging guidance we should not bill separately, as the guidance is already reimbursed as part of the code value,” says Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC, in Bella Vista, Arkansas.

Distinguish Small and Intermediate Bursa and Joint

Question 7: What are the differences between these arthrocentesis codes: 20600, 20604, 20605, and 20606?

Small joint or bursa: If the notes indicate that your provider injected a small joint or bursa, choose either 20600 or 20604. As the descriptors indicate, small joints/bursa include (but are not limited to) fingers and toes.

Intermediate joint or bursa: If the notes indicate that you provider injected an intermediate joint or bursa, choose either 20605 or 20606. As the descriptors indicate, intermediate joints/ bursa include (but are not limited to) wrists, elbows, and ankles.

Don’t Forget to Add Modifier 50 on This Claim

Question 8: My provider performed arthrocentesis on both the patient’s left and right ankles. They used ultrasound (US) guidance. Should I append a modifier to the procedure code?

If you’re reporting the same code for the left and right side of the patient’s body, you should append modifier 50 (Bilateral procedure) to the code. For example, if the notes indicate that your provider performed arthrocentesis aspirations on both of the patient’s ankles with US, report 20606 with modifier 50 appended.

Coding note: “You will want to verify with individual insurance payers how they will process the claim when the procedure is bilateral. Some will want you to identify laterality on two claim lines such as 20606-LT (Left side) and 20606-RT (Right side). They will typically pay 150 percent of the fee schedule for bilateral procedures,” says McNamara.