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July 2016

Documenting and coding arthrocentesis procedures

Taber’s Cyclopedic Medical Dictionary defines arthrocentesis as “Puncture of a joint space by using a needle; usually done in order to remove accumulated fluid from the joint.”

Arthrocentesis is a widely used and relatively uncomplicated procedure to perform. It's an effective diagnostic and therapeutic method that introduces a corticosteroid or a local anesthetic agent into a joint when medically necessary and appropriate.

Complications, side effects and contraindications for this procedure may include:

  • Exacerbation of infection
  • Damage to joint tissues
  • Tendon rupture
  • Ligament rupture
  • Masking of advancing disease activity
  • Septic arthritis
  • Neuropathic arthropathy
  • Muscle atrophy
  • Local osteoporosis
  • Avascular necrosis
  • Fatty atrophy
  • Delayed healing

Documentation requirements
Medical records must chronologically document the patient’s medical history and physical exam in sufficient detail to ensure that he or she receives high-quality care. This will also allow a fair and accurate review of a physician’s services by payers.

The patient's chart should include:

  • Symptoms and physical findings
  • Diagnosis
  • Specific procedure performed
  • Exact site of injection
  • Amount and dose of the anesthetic agent or the anti-inflammatory agent used in the injection
  • Physician’s rationale for each injection and treatment plan
  • Patient’s condition and response to the procedures

Also, be sure to document the following in the patient's chart:

  • Clearly stated and specific rationale for extending treatment beyond three to five injections for one joint or area
  • Patient response to previous treatments
  • A proposed plan for the resolution of the problem
  • A proposal for alternative therapy if there's inadequate patient response

Coding guidelines
Intra-articular steroid injections are included as part of arthrocentesis surgical procedures. There's no separate reimbursement for the medication.

Code*

Explanation

Guidelines

20600

Arthrocentesis, aspiration or injection; small joint, bursa or ganglion cyst (for example, fingers or toes)

For injections of the fingers or toes, up to and including metacarpophalangeal and metatarsophalangeal joints

20605

Arthrocentesis, aspiration or injection; intermediate joint, bursa or ganglion cyst (for example, temporomandibular, acromioclavicular, wrist, elbow or ankle or olecranon bursa)

For injection of the joints or bursae nearby the fingers, up to and including the wrist and elbow joints. Could include the carpal-metacarpal and wrist joints, elbow and olecranon bursae. In the foot, it would include the tarsal-metatarsal, intertarsal and ankle joints.

20610

Arthrocentesis, aspiration or injection; major joint or bursa (for example, shoulder, hip, knee joint or subacromial bursa)

For injections of the major joints or bursae of the body, including the shoulder, hip, knee joint and subacromial bursa.
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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.
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