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Internal Medicine Coding Alert

You Be the Coder:
Same Code For Aspiration and Injection During Arthrocentesis

Question: When our physician performed arthrocentesis of the left shoulder, he performed an aspiration and then injected Kenalog. He used ultrasound guidance during the procedure. Should I report the procedure with two units of the code (20611x2 - one for aspiration and the other for the injection) or only unit of the code?

Arkansas Subscriber

Answer: You are correct in choosing 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) for the procedure performed as your clinician used ultrasound guidance for performing the placement of the needle into the joint. During the procedure, he will perform placement of the needle only once. With the needle in place, he will use it for aspiration of the fluid and perform the injection.

As both the aspiration and injection is part of the same procedure, you will only have to report one unit of the code and not two units.

Remember: In addition to reporting 20611, you should also report the supply of the medication with a separate code. Report either J3300 (Injection, triamcinolone acetonide, preservative free, 1 mg) or J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) for the medication. If you are reporting J3300, report one unit for every 1 mg of the medication while you have to report one unit of the code for every 10 mg for J3301.