Neurology & Pain Management Coding Alert

Question: A patient with a diagnosis of post-traumatic right knee osteoarthritis reports to the PM specialist for arthrocentesis. The PM specialist performs arthrocentesis, injecting Depo-Medrol during the procedure. How should I code this encounter? 

New Jersey Subscriber

Answer: For the arthrocentesis, you’ll choose from 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) or 20611 (… with ultrasound guidance, with permanent recording and reporting) once you confirm whether the provider used ultrasound (US) guidance during the service. If the payer requires a laterality modifier, append modifier RT (Right side) to 20610 or 20611.

Also, don’t forget to choose J1020 (Injection, methylprednisolone acetate, 20 mg), J1030 (… 40 mg), or J1040 (… 80 mg), depending on the amount of Depo-Medrol the provider uses.

Finally, be sure to append M17.31 (Unilateral post-traumatic osteoarthritis, right knee) to 20610 or 20611 to represent the patient’s condition.

Explanation: There are three levels of arthrocentesis:

• 20600 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance) and 20601 (… with ultrasound guidance, with permanent recording and reporting) for small joints;
• 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporoman­dibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance) and 20606 (… with ultrasound guidance, with permanent recording and reporting) for intermediate joints; and
• 20610 and 20611 for large joints.

As indicated in the code descriptors, 20610 and 20611 are the correct choice for large joints such as the knee. If you’re unsure of a joint’s size, check the CPT® code descriptors, or check your payer’s policy, before choosing an arthrocentesis code.