How To Use CPT Code 20611

CPT 20611 refers to arthrocentesis, aspiration, and/or injection of a major joint or bursa with ultrasound guidance, permanent recording, and reporting. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 20611 procedures.

1. What is CPT 20611?

CPT 20611 is a medical procedure code used to describe arthrocentesis, aspiration, and/or injection of a major joint or bursa with the use of ultrasound guidance, permanent recording, and reporting. This code is used by medical coders and billers to accurately document and bill for this specific procedure.

2. 20611 CPT code description

The official description of CPT code 20611 is: “Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.”

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider inserts a needle through the skin and into the large-sized joint or bursa, typically the shoulder, hip, knee, or subacromial bursa.
3. Under ultrasound guidance, the provider uses a syringe with the needle to remove fluid from the joint or bursa.
4. The provider permanently records the findings.
5. The fluid sample is sent to the laboratory for further examination.
6. The provider may also inject a drug into the joint or bursa for therapeutic purposes, such as pharmacotherapy or lavage.
7. The needle is removed, and pressure is applied to stop any bleeding.

4. Qualifying circumstances

Patients eligible to receive CPT 20611 services are those experiencing pain, swelling, or other symptoms in a major joint or bursa, such as the shoulder, hip, knee, or subacromial bursa. The procedure may be performed for diagnostic purposes, to examine the synovial fluid for the presence of infection or inflammation, or for therapeutic purposes, such as relieving pain and swelling or administering medication.

5. When to use CPT code 20611

It is appropriate to bill the 20611 CPT code when the provider performs arthrocentesis, aspiration, and/or injection of a major joint or bursa with ultrasound guidance, permanent recording, and reporting. This code should only be used for large-sized joints or bursae, such as the shoulder, hip, knee, or olecranon bursa. If the provider performs the procedure without ultrasound guidance, use code 20610 instead.

6. Documentation requirements

To support a claim for CPT 20611, the following information should be documented:

• Patient’s medical history and symptoms related to the joint or bursa
• Physical examination findings
• Indication for the procedure
• Details of the procedure, including the joint or bursa involved, use of ultrasound guidance, and any medications injected
• Permanent recording and reporting of the ultrasound findings
• Results of laboratory analysis of the aspirated fluid, if applicable
• Post-procedure care and follow-up instructions

7. Billing guidelines

When billing for CPT code 20611, keep in mind the following guidelines and rules:

• Do not report CPT 20611 in conjunction with codes 27369 or 76942.
• If fluoroscopic, CT, or MRI guidance is performed, use codes 77002, 77012, or 77021 instead.
• Ensure that all required documentation is complete and accurate to support the claim.

8. Historical information

CPT 20611 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Similar codes to CPT 20611

Five similar codes to CPT 20611 and how they differ are:

• CPT 20610: Arthrocentesis, aspiration, and/or injection of a major joint or bursa without ultrasound guidance.
• CPT 20612: Arthrocentesis, aspiration, and/or injection of a small joint or bursa with ultrasound guidance, permanent recording, and reporting.
• CPT 20604: Arthrocentesis, aspiration, and/or injection of a small joint or bursa without ultrasound guidance.
• CPT 20605: Arthrocentesis, aspiration, and/or injection of an intermediate joint or bursa without ultrasound guidance.
• CPT 20606: Arthrocentesis, aspiration, and/or injection of an intermediate joint or bursa with ultrasound guidance, permanent recording, and reporting.

10. Examples

1. Arthrocentesis of the shoulder joint with ultrasound guidance to aspirate synovial fluid for laboratory analysis in a patient with suspected infection.
2. Arthrocentesis of the hip joint with ultrasound guidance to inject corticosteroids for pain relief in a patient with osteoarthritis.
3. Arthrocentesis of the knee joint with ultrasound guidance to remove excess fluid in a patient with a Baker’s cyst.
4. Arthrocentesis of the subacromial bursa with ultrasound guidance to inject a local anesthetic for pain relief in a patient with bursitis.
5. Arthrocentesis of the olecranon bursa with ultrasound guidance to aspirate fluid and inject corticosteroids in a patient with gout.
6. Arthrocentesis of the shoulder joint with ultrasound guidance to inject hyaluronic acid for lubrication in a patient with adhesive capsulitis.
7. Arthrocentesis of the hip joint with ultrasound guidance to aspirate synovial fluid for laboratory analysis in a patient with suspected rheumatoid arthritis.
8. Arthrocentesis of the knee joint with ultrasound guidance to inject a local anesthetic and corticosteroid for pain relief in a patient with patellofemoral pain syndrome.
9. Arthrocentesis of the subacromial bursa with ultrasound guidance to remove excess fluid and inject a corticosteroid in a patient with impingement syndrome.
10. Arthrocentesis of the olecranon bursa with ultrasound guidance to aspirate fluid for laboratory analysis and inject a corticosteroid in a patient with septic bursitis.