May 01, 2015
Area(s) of Interest: Emergency Medicine Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Four questions commonly arise when coding for joint aspiration or injection:
- When is it appropriate to report guidance in addition to joint aspiration/injection?
- When is it appropriate to report multiple code units for joint aspiration/injection?
- May I report an evaluation and management (E/M) service in addition to joint aspiration/injection?
- Should I report supplies separately with joint aspiration/injection?
Before answering these questions, let’s consider coding basics for these procedures.
During either joint aspiration or injection, imaging guidance may be employed to ensure accurate needle placement. For CPT® 2015, the American Medical Association revised the previous joint (or bursa) aspiration/injection codes to specify “without ultrasonic guidance,” while adding codes to describe the same procedures with ultrasonic (US) guidance:
- 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance
- 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting
- 20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
- 20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting
- 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance
- 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting
If the provider performs joint aspiration/injection with US guidance, select 20604, 20606 or 20611 (depending on the joint targeted). If the provider aspirates/injects the joint/bursa without guidance of any kind, select from among 20600, 20605 and 20610.
Some guidance may be separate
CPT® allows you to separately report fluoroscopic, CT or MRI guidance for needle placement during joint/bursa aspiration/injection, when performed. Claim the “without ultrasonic guidance” code for the aspiration/injection, plus 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device); 77012 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation; or 70021 Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation, as appropriate.
Reporting multiple units
Report a single unit of 20600-20611 for each joint treated, regardless of how many aspirations and/or injections occur in a single joint.
You may report multiple units of a single code for aspiration/injection of multiple joints of same size (e.g., two large joints, left knee and left shoulder). If aspirations and/or injections occur on opposite, paired joints (e.g., both knees), report one unit of 20610 with modifier 50 Bilateral procedure appended, per Centers for Medicare and Medicaid (CMS) instruction. Non-Medicare payers may specify different methods to indicate a bilateral procedure.
If the provider performs injections on separate, non-symmetrical joints (e.g., left shoulder and right knee), report two units of the aspiration/injection code and append modifier 59 Distinct procedural service to the second unit (e.g., 20610, 20610-59).
20610 and same-day E/M
Do not report an E/M service with a planned injection service if the patient presents without complications or a new problem. CPT Assistant (March 2012) offers the following example:
A patient complained of left knee pain. At a previous visit, the physician evaluated the knee, ordered a prescription of a nonsteroidal anti-inflammatory drug and scheduled a follow-up visit two weeks later for performance of an arthrocentesis if not improved. The patient returned, wherein the physician performed an arthrocentesis and injection of the left knee joint and scheduled a follow-up visit for one month later.
It would not be appropriate to report the E/M service at the two-week follow-up visit because the focus of the visit was related to the performance of an arthrocentesis. Only code 20610 for the arthrocentesis would be reported.
If an E/M service is separately identifiable from the typical pre-service work of an aspiration/injection, you may report the E/M service separately with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended. A separate E/M might also be appropriate if the physician performs the injection/aspiration and also evaluates the patient for a different or exacerbated condition.
Documentation must substantiate that the E/M service was significant; a best practice is to separate the documentation for the joint injection/aspiration and the E/M service. Only if the E/M service stands on its own may you report it separately with modifier 25.
For Medicare payers, the aspiration/injection codes do not include the drug supply (other than local anesthetic) for injection. If the provider paid for the drug, he or she may report the supply separately using the appropriate HCPCS supply code.