CPT 20610 can be reported for a major joint or bursa injection or aspiration without ultrasound guidance. Modifier RT, LT, 50, 59 and JW can be needed to report the 20610 CPT code properly. The reimbursement rate for facility charges is $46.76 and for non-facility charges $65.60.
20610 CPT Code Description
Without ultrasound guidance, the 20610 CPT code is billed for a major joint or bursa injection or aspiration.
After administering a local anaesthetic, the physician inserts a needle through the skin and into a joint or bursa.
A fluid sample may be removed from the joint for examination or a fluid may be injected for lavage or drug therapy. The needle is then withdrawn and pressure is applied to stop any bleeding.
Official Description of CPT 20610: Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
This code can be used for:
- sub acromial bursa.
CPT 20610 includes two services that can be performed separately or combined as per a patient’s need and medical decision-making.
First, physicians can order and perform arthrocentesis only on a major joint like the hip, shoulder, or wrist joint to reduce the pressure exerted on the joint capsule due to fluid accumulation.
The second service is injecting medication in a separate encounter or the same encounter after performing aspiration of accumulated fluid from any significant joint.
Therefore, the relative value units of CPT 20610 are designed because it always includes the reimbursement of the whole procedure, i.e., aspiration and an injection of medication into the major joint.
Therefore, there is no need to be concerned about adding a separate modifier or line item to cover charges for both segments of the service (CPT 20610) performed.
This service will be coded and billed in a single line item without adding any pricing modifier into the claim.
While coding for the major joints, the most important aspect should be kept in mind, that there is a difference between CPT 20610 and CPT 20611.
So, the relevant coder should pick the precise CPT vigilantly. Of course, it will impact the revenue significantly, but if the payer calls an audit and finds out the service is performed with the benefits of CPT 20611, it will lead to a potential penalty.
And even some clauses of the statute governing the regulatory affairs can make a physician stop the practice in a specific period for up to one year.
The difference in both services CPT 20610 and CPT 20611, is pronounced. But the coders are very prone to such a mistake as a slight oversight when reading the description of this procedure.
It can lead to an inappropriate code selection that may result in an overpayment or underpayment.
The only difference between CPT 20610 and CPT 20611 is ultrasound guidance during the procedure.
At the same time, the remaining segments of both services are the same. Both procedures can be executed on major body joints for aspiration and injection of any medication into joint space.
The fee for service (FFS) comparison between both CPTs is that CPT 20610 can be charged $44 – $46 for facility and $66 – $68 for non-facility. While CPT 20611 can be charged $60 – $62 for facility and $102 – $108 for non-facility.
Selecting suitable CPT as per the description of the procedure has a huge impact on the whole revenue cycle.
Does CPT Code 20610 Need a Modifier?
The one-word answer to the above question is a big YES. CPT code 20610 may always require a laterality modifier to represent the side of the body on which the service is executed, as we know that all major joints in the human body are bilateral, i.e., Wrist, Knee, Hip.
To represent the side of the body, there is always a need for a right or left modifier.
Modifiers For The 20610 CPT Code
Following are some of the modifiers which can be used with CPT 20610 as below:
1. Laterality Modifier:
This CPT will always require an ‘RT’ or ‘LT’ modifier to represent the side of the anatomical location on which the service is accomplished.
And this CPT is one of the most common denial reasons. If the appropriate laterality modifier has not been applied per the diagnosis code used in the claim, it may be denied for any payments.
2. Pricing Modifier:
Pricing modifier 22 can be used with CPT 20610, but its usage depends on the circumstances.
For example, if the procedure takes a longer time than anticipated due to any physical or physiological circumstance of the patient like increased swelling of the joint, muscle rigidity, ligaments rapture, etc., then it may require increased physician effort to perform the procedure.
In this case, we can append modifier 22 with the CPT 20610 in the primary position. And the physician can claim the augmented payment because the service is now accomplished with more effort than the usual procedure.
With CPT 20610, in the case of Medicare, the modifier 50 will act as both pricing and laterality modifier.
As for government payers, we have to represent laterality in a single line item to act as both types of modifiers.
3. Payment Eligible Modifiers:
Such modifiers can make claims eligible for payments, and claims may be denied without them.
The use of such modifiers depends on the specific scenarios, i.e., the most common is modifier 59. That is the most commonly used modifier to bypass comprehensive component edit.
For the same reason, one can use XS, XP, XU to bypass the CCE issue. Most frequently, this series of modifiers is used for Government payers.
The other most common problem is when the service is performed in any global period of the previous procedure.
To avoid such instances, one may have to apply modifier 79 to bypass the claim. This represents the insurance that the 20610 CPT code is unrelated to the previous service executed on back dates for a different reason.
CPT 20610 And Modifier 50
Most of insurances require Modifier 50 with the 20610 CPT code whenever both sides are performed but some insurances may instruct you to use Modifier RT and Modifier LT on separate lines to show if both sides are performed.
Check the insurance guidelines when selecting a Modifier.
Some payment reduction will apply when billing with Modifier 50 as per Medicare guidelines.
Some important of cases when to use and when to not use this Modifier for 20610:
- Don’t use Modifier 50, If right knee is injection and left hip is also injection.
- Don’t use Modifier 50 when a commercial payer does not allow that.
- Use Modifier 50 when right knee and left knee if injected.
- Use Modifier 50 when one hip is injected and other hip is aspirated.
- Don’t use Modifier 50 when right knee and right hip is injected.
Remember, the drug charge is not included in this code, if doctor has provided the drug, he can bill drug code from HCPCS code section but patient has brought own medication, only use 20610 and document the instance in Medical documents.
Modifier 59 & Modifier JW
Modifier 59 is also used for for CPT code 20610. This Modifier can be reported when aspiration and injection is performed on two different sites.
One unit of the 20610 CPT code can be reported with Modifier 59.
Modifier JW can be used with the drug code. This Modifier is used when some part of drug is wasted or unused.
The drug code will have separate line with JW Modifier and appropriate units and it should be documented in patient’s medical record.
Medicare LCD For CPT Code 20610
Medicare LCD provides the medical necessity and other important coverage guidelines for the 20610 CPT code.
Most of the points are common in all the LCDs of different states but some diagnosis may get differ. LCDs are arranged based on drug codes with CPT 20610 or CPT 20611.
Most common use of the 20610 CPT code is osteoarthritis and pain associated to it.
The following factors need to be considered when billing to Medicare or insurances that follow the Medicare guidelines:
- A radiological exam should be performed earlier to support the diagnosis.
- A 6 month time gap is needed if injections are given in a series.
- Significant improvement is necessary.
- One unit is allowed to be billed if an aspiration and injection is performed at same site.
- Use Modifier 25 with if another E&M service is performed on same day as CPT 20610
- Use CPT 20611 instead of CPT 20610 if ultrasound guidance is performed (as both of codes have same description except for ultrasound guidance).
- An E&M services for subsequent visit after the first injection of series for same diagnosis should not be reported, especially when the purpose of visit to check the effectiveness of earlier injection.
- If there is another problem that requires some work, bill E&M code with that diagnosis as primary setting of RVU.
Billing Guidelines for Medicare, Commercial Payers, and the Reimbursement Policy.
The individual payer groups govern billing guidelines, but we will broadly classify it into two categories: Government payer. i.e., Medicare/ Medicaid, and the other one is Commercial payers.
For government payers (Medicare/ Medicaid), the primary difference is in the billing pattern of line item.
Medicare accepts medical claims in a single line item with modifier 50 to present if the CPT 20610 is performed on the body’s right side, left side, or both laterality.
In such instances, modifier 50 is defined as both laterality and is represented as a pricing modifier. And it may cause an increase in payments of about 125%. But applying a modifier is not the only solution to get claims paid.
Appropriate medical necessity should be billed in the claim that can be verified easily from the state LCD, available on the CMS website.
For example, suppose the service is performed on bilateral sides. In that case, it must be billed with both right and left side ICD 10 CM codes, or if the situation is otherwise, a single diagnosis code is available to represent both sides of the body on which the service executes.
For commercial payers, the requirements are different here. The coders or billers have to bill the services as separate line items if performed on bilateral sides.
Both lines must require a particular laterality modifier, and the service should be proven by medical necessity as per the state local coverage determination.
It is more convenient and appropriate to use different ICD 10 CM codes for the right and left sides of the body in a single claim instead of a combination code presenting both sides of the body.
Government and Commercial payers discourage such a practice to bill an evaluation and management code for the same reason the service procedure 20610 is performed.
And literally, it is a usual reason for denial of Evaluation and Management on the same day of the 20610 CPT code procedure.
Although the coders can code and bill evaluation and management code along with CPT code 20610, if the reason for the encounter is based on a separate medical issue, or physician seems necessary to aspire or inject medication in the major joint on the same day.
The MUE adjudication indicator for CPT code 20610 is three, meaning the services can be billed more than twice daily for the right reasons.
And most importantly, it should be supported with medical documentation.
For Medicare, it is required to bill all wastage of drugs, if used in the procedure, along with NDC, qualifier, and quantifier in ml.
If the drug comes in a package of 10 ml per vial and only 7 ml is used, the remaining 3ml of the drug for Medicare claims should be billed in a separate line item with modifier JW. The physician can claim the cost of 10ml and get maximum reimbursement.
20610 CPT Code Reimbursement
If aspiration services are performed bill only CPT 20610. Underneath the charges for facilites and non facilities.
Facility charges: $46.76
Non-facility charges: $65.60
The estimated physician time that is required for CPT 20610 is 21 minutes excluding anaesthesia services.
Be aware that many insurances routinely deny the E&M code with CPT 20610. Make sure to provide the proper documentation to get the 20610 CPT code reimbursed.
A doctor should document the E&M service in medical chart as separately identifiable service, which will be used to appeal for claims that are denying inappropriately.
One unit for CPT 20610 is used for each site injected or aspirated but if the aspiration and injection is performed on same site, use one unit for both procedures.
If the aspiration and injection is performed on two different sites, use one unit of the 20610 CPT code with modifier 59.
The MUI indicator for CPT 20610 is 2. This means that no more than 2 units per DOS can be billed. Any service performed and billed more than allowed units will be denied.
A 58 years old patient came to the provider’s office with severe right knee pain and generalized muscle pain.
The physician evaluates the patient, and with his medical decision making, he recommends some pain killers and decides to perform aspiration and injection, without ultrasound guidance, into his knee.
In the details of this procedure, it is mentioned that the site is first disinfected with a sterile solution. Then without US (ultrasound) guidance, the needle is inserted into joint space, and the aspiration is performed and the site is injected with Hyalgan 5ml.
- CPT 99213: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
- CPT 20610: Arthrocentesis, aspiration, and/or injection; major joint or bursa (eg, shoulder, hip, knee, subacromial bursa) without ultrasound guidance (right knee aspiration and injection)
- CPT 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (Hyalgan 5ml injection)