Orthopedic Coding Alert

Question: The patient was brought to the table and laid in prone position. Their right knee was flexed to 90 degrees, and their right Achilles tendon was identified using an ultrasound. Their skin was cleaned in the usual sterile fashion using Betadine and alcohol. Under the guidance of ultrasound, a 22-gauge needle was inserted below the Achilles tendon and after negative aspiration of blood,10 cc of 1 percent lidocaine was injected above the fat pad and under the Achilles tendon, hydro-dissecting the two layers. Patient tolerated the procedure well and there were no complications. A bandage was applied. Patient noted immediate improvement in the pain after the injection. Achilles tendinitis (M76.61) was the diagnosis for this patient. Which CPT^® code should I report for this procedure?

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Answer: This will depend on the practitioner’s notes. If your surgeon doesn’t specify that the tendon was directly injected, then you should report 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting) with a diagnosis of Achilles tendinitis, as you stated. However, if the tendon was directly injected, you should report 20551 (Injection(s); single tendon origin/insertion).

Coding note: According to Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC. Bella Vista, Arkansas, you can also report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) with 20551 if you have medical documentation to justify this, but it would be far less typical than simply using code 20606.