Internal Medicine Coding Alert

Question: The physician used ultrasound guidance when performing arthrocentesis on the patient's knee to withdraw fluid from a baker's cyst; she then injected the area with Kenalog. Do we report the aspiration and injection separately and the ultrasound guidance for each, or do we consider everything a single procedure?

Washington Subscriber

Answer: You should report 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) once. Most providers will not puncture a bursa twice because each puncture increases the risk of infection. Instead, most providers puncture the bursa and withdraw fluid, then unscrew the syringe and replace it with a syringe filled with medication (Kenalog, in your example). The needle stays in place the entire time.

You'll also only report the ultrasound guidance once. Submit 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for this portion of the procedure.

Finally, don't forget to report the appropriate code for the Kenalog itself, which is J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg). Since the descriptor specifies "10 mg," you might need to bill multiple units if the physician administers more than 10 mg. For example, you'll report J3301 with two units of service if the provider administers 20 mg.