Neurology & Pain Management Coding Alert
Remember Permanent Recording Portion of Arthrocentesis
Question: Encounter notes indicate that the provider performed arthrocentesis on a patient’s right shoulder. The provider used ultrasound (US) guidance during the procedure. Can I report 20611 for this service? Michigan Subscriber Answer: Yes … provided you have proof of permanent recording and reporting. Why? It is required per the descriptor for 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting). So go back and check the record to see if there is permanent recording and reporting for the arthrocentesis. If you can confirm it, report 20611 with modifier RT (Right side) appended to indicate laterality. If you cannot find evidence of permanent recording and reporting, ask the performing provider if they can help. If that fails, call the payer and explain the situation; then report as instructed.
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