Eli's Rehab Report

Question: Sometimes when our doctor is performing arthrocentesis, he first aspirates the knee joint and then performs a therapeutic injection into the knee, both during the same office visit. Should we be billing the arthrocentesis code twice, or should we use the -59 modifier?

Anonymous PM&R Biller
Yardley, Pa.

Answer: When doctors perform both the aspiration and injection on the same patient during the same visit, they usually aspirate the joint, leave the needle intact, remove the syringe with the aspirated fluid, and replace it with the syringe containing the injection solution. Since the arthrocentesis code, CPT 20610 (arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) states aspiration and/or injection, there is no need to bill the code twice. You should bill 20610 only once when the doctor performs both aspiration and injection. Remember when billing for the injection, however, that the appropriate HCPCS J code must be billed to indicate the type of solution injected into the site.