You Be the Coder: Report Arthrocentesis with HCPCS Code For Medicines

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 Subscriber

Answer: 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 [...]

- Published on 2011-10-17