Orthopedic Coding Alert

E/M Often Leads to Arthrocentesis

When a possible arthrocentesis patient arrives at the practice, the physician will make the decision for arthrocentesis based (at least partly) on the evaluation and management (E/M) service, confirms Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

“Depending on the presenting patient symptoms or complaints, the provider may examine the patient and suggest arthrocentesis,” she explains. “Arthrocentesis can be performed for swollen or painful joints. The goal could be fluid removal for sampling or draining the joint, instillation of medication to decrease inflammation or pain and preserve the joint.”

Report the E/M that leads to arthrocentesis with a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) set. The physician might need to confirm the need for arthrocentesis through X-rays; when this occurs, be sure to code accordingly.

Don’t forget: If your physician performs any other services prior to arthrocentesis, be sure to report those as well, if it is allowable.

“In the … inpatient setting, need for arthrocentesis is commonly based off of E/M, US [ultrasound], and MRI [magnetic resonance imaging],” explains Brian Piazza, MD, MSc, Pediatric Orthopaedic Surgeon at Children’s Orthopaedic and Scoliosis Surgery Associates, associated with Johns Hopkins All Children’s Hospital. “Advanced imaging is commonly performed prior to aspirating deep joints such as a hip.”

Use These Codes to Report Arthrocentesis

When the physician makes a decision to perform arthrocentesis, you’ll choose among the following codes for the service:

• 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)
• 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance)
• 20611 (… with ultrasound guidance, with permanent recording and reporting)

You’ll notice that the descriptors include details on the size of the joint: small, intermediate, or major. But there are about 350 joints in each human being, so deciding the joint size can get tedious.

Do this: “I decide the code based off relative size of joint related to joints that are listed in descriptors,” Piazza says. He lists a small key that you can use to compare joint sizes:

• Small joints or bursa: Fingers or toes
• Intermediate joints or bursa: Temporomandibular, acromioclavicular, wrist, elbow, ankle or olecranon bursa or midfoot joints
• Major joints or bursa: Shoulder, hip, knee, subacromial bursa.

Check Out This Clinical Example

To get an idea of how arthrocentesis might look in the real world, check out this example from Pohlig:

A patient with osteoarthritis of the left knee reports complaining of progressive joint pain in the left knee. It is becoming more difficult to get around, climb stairs and do normal activities. The patient has been on oral medication and tried conservative measures. After reviewing the images of the updated X-rays from radiology, the physician confirms the progression and suggests a viscosupplementation injection to the left knee in an effort to cushion and lubricate the joint. The physician injects the patient in the left knee with 2 mL of Synvisc. Encounter notes indicate a moderate level of medical decision making (MDM) during the encounter.

For this encounter, you’d report:

• 20610 for the arthrocentesis 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99214 to show that the E/M and arthrocentesis were separate services
• M17.12 (Unilateral primary osteoarthritis, left knee) appended to 20610 and 99214 to represent the patient’s osteoarthritis.