Podiatry Coding & Billing Alert

Question: The patient was brought to the table and laid in prone position. Her right knee was flexed to 90 degrees, and her right Achilles tendon was identified using an ultrasound. Her 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. There were no complications. Band-Aid was applied. Patient noted improvement in 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: Check your medical documentation. If your podiatrist doesn’t specify that the tendon was directly injected, then you should report 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance) with a diagnosis of bursitis. However, if the tendon was injected, you should report 20551 (Injection(s); single tendon origin/insertion).