Primary Care Coding Alert

Question: The physician used ultrasound guidance when performing arthrocentesis on the patient's knee to withdraw fluid from a baker's cyst; she then injected the area with Kenalog. Do we report the aspiration and injection separately and the ultrasound guidance for each, or do we consider everything a single procedure? Washington SubscriberAnswer: You should report 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) once. Most providers will not puncture a bursa twice because each puncture increases the risk of infection. Instead, most providers puncture the bursa and withdraw fluid, then unscrew the syringe and replace it with a syringe filled with medication (Kenalog, in your example). The needle stays in place the entire time. You'll also only report the ultrasound guidance once. Submit 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for this portion of [...]