Revenue Cycle Insider

Small, medium, or large? Deciding might not be so easy.

When patients report to the orthopedist with joint issues of any kind, arthrocentesis is a possibility.

What is it? Arthrocentesis occurs when the orthopedist uses a needle to puncture a joint to remove fluid, either for diagnostic or therapeutic purposes. Arthrocentesis has many uses, including diagnosing joint disorders, reducing pain and swelling, or treating certain conditions: arthritis, gout, joint infections, etc. There are several considerations you’ll need to consider in order to choose the correct arthrocentesis code.

Check out this expert advice to report arthrocentesis claims right the first time.

Use These Arthrocentesis Codes

The 6-pack of arthrocentesis codes make two distinctions per code: the size of the joint injected and whether the provider employed ultrasound (US) guidance. With these two pieces of information, you can see the differences between the arthrocentesis codes listed below:

• 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)

That’s not all: It might sound easy to select an arthrocentesis code, but the devil’s in the details. Challenges to code selection include determining the joint size and checking for any other codable services.

Compare/Contrast When Determining Joint Size

Obviously, the descriptors for the arthrocentesis codes don’t list every joint — though they do list major joints of each size. The coder’s challenge comes when determining the size of a joint that isn’t listed in the arthrocentesis CPT^® descriptors.

Do this: If a joint isn’t listed in the arthrocentesis descriptors, compare it to the size of a joint that is listed in the descriptors. So, if you’re trying to determine whether a joint is intermediate, compare its size to the joints listed on 20605 or 20606.

Finding the correct joint size via this compare-and-contrast method will take a sound knowledge of anatomy, so make sure your skills are on point. You may want to consider consulting with your medical team to discuss their perspectives on the measurements of various joints, as this could be beneficial for medical coding accuracy.

Also, “there are many places in coding literature that describes what joints are small, intermediate, or major. For example, the AAPC’s Coders Specialty Guide: Orthopedics,” explains Kaitlyn Bohrer, CPC, COSC, orthopedic surgery coder at Eastside Orthopedics & Sports Medicine in Oregon. You might also get some guidance from your local AAPC chapter or another professional organization.

Code E/M-25 Under These Circumstances

Patients who report to the orthopedist and end up having arthrocentesis performed fall into two categories: those who are scheduled for arthrocentesis; and those who report to see the orthopedist, who then determines that the patient needs arthrocentesis.

If the patient is scheduled for the shot, then you can only report the arthrocentesis code. “You would not report an evaluation and management (E/M) service for a planned injection service where the patient presents without complications or a new problem,” Bohrer explains.

For example, a patient reports for a scheduled arthrocentesis shot in their right shoulder without US guidance. For this patient, you’d report 20610 with modifier RT (Right side) appended to indicate laterality.

If, however, the orthopedist performed a separate E/M service that is significant, you might be able to report a code for that service as well.

“When reporting an E/M service with an arthrocentesis documentation, you must substantiate that the E/M service was significant,” says Bohrer. “For example, you can code an office visit with an arthrocentesis if the provider aspirates the joint and sends the fluid for analysis to confirm a diagnosis. Because the E/M is significant and determines the need for the aspiration, you may report both 20610 and the documented E/M service with 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.”

Remember, the codes you’ll use for office visits are 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.). No matter the E/M code choice, be sure to append modifier 25 to the code to indicate that the E/M and arthrocentesis were significant, separately identifiable services.  

Check Out This Clinical Example

Consider this example from Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting in Missouri:

A 15-year-old patient reports to the office after being tackled during football practice at school. While falling, they twisted their left knee. The patient complains of pain and swelling. After an appropriate history and exam, the physician decides to tap the left knee joint as, upon exam, it is spongy, indicating fluid in the joint space (effusion). The procedure is performed after consent is obtained from the patient's parents and the area is prepped. A needle is inserted into the left knee joint space and 20 mL of serosanguinous fluid is withdrawn, under fluoroscopic guidance. A compression bandage is applied and the patient discharged in good condition.

For this patient, you will report:

• 20610 for the arthrocentesis
• +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)) to represent the fluoroscopic guidance
• Modifier LT (Left side) appended to 20610 and +77002 to indicate laterality
• The appropriate code from the 99202 through 99215 code set for the E/M service
• Modifier 25 appended to the E/M code to show that the E/M and arthrocentesis were significant, separately identifiable services
• M25.462 (Effusion, left knee) appended to 20610, +77002, and the E/M code to represent the patient’s knee injury
• Y92.219 (Unspecified school as the place of occurrence of the external cause) appended to 20610, +77002, and the E/M code to represent location where the patient was injured
• Y93.61 (Activity, American tackle football) appended to 20610, +77002, and the E/M code to represent the cause of the patient’s injury.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC