AMA CPT Assistant February 2015
"Both aspiration and/or injection are inherently included as part of the service as noted in the descriptors for these codes. As a result, either code may only be reported once per joint or bursa."
AMA CPT Assistant
March 2001 page 10
Coding Consultation
Musculoskeletal System, Surgery, 20610 (Q&A)
Question
When aspiration of fluid from the knee joint is performed as well as injection of medication into the knee joint, can code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa), be reported two times, once for the aspiration of fluid and once for the injection of medication?
AMA Comment
From a CPT coding perspective, the term "and/or" in the code descriptor of code 20610 indicates that the code includes the performance of one or all of the procedures described in the same major joint or bursa. Therefore, code 20610 should only be reported one time when both aspiration and injection are performed in the same major joint or bursa.