Internal Medicine Coding Alert

Question: An established patient reports to the internist after falling from a ladder. She is complaining of pain in her right wrist, which is swollen and red. The internist drained fluid from the wrist and injected 20 mg of Depo-Medrol into the joint. Can we report separate codes for the injection and drainage?

Connecticut Subscriber

Answer: There is a single CPT code to represent the injection and drainage. On the claim, therefore, you would report the following:

• 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) for the injection and drainage.

• 719.44 (Pain in joint; hand) to represent the patient's injury.

• E881.0 (Fall from ladder) to indicate the cause of the patient's injury.

• J1020 (Injection, methylprednisolone acetate, 20 mg) for the drug supply.

-- Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of government program services for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.