How To Use CPT Code 20610

CPT code 20610 describes the procedure of arthrocentesis, aspiration, and/or injection in a major joint or bursa without ultrasound guidance. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 20610?

CPT 20610 is used to describe the procedure of arthrocentesis, aspiration, and/or injection in a major joint or bursa without the use of ultrasound guidance. This code is used when a healthcare provider inserts a needle through the patient’s skin and into a major joint or bursa to remove fluid or inject medication for therapeutic purposes.

2. Official Description

The official description of CPT code 20610 is: ‘Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa) without ultrasound guidance.’

3. Procedure

In this procedure, the healthcare provider inserts a needle through the patient’s skin and into a major joint or bursa. Using a syringe attached to the needle, the provider can remove fluid from the joint or bursa for diagnostic purposes. The fluid sample may be sent to a laboratory for further examination. Additionally, the provider may inject medication into the joint or bursa for therapeutic purposes, such as pharmacotherapy or lavage. After the procedure, the provider removes the needle and applies pressure to stop any bleeding. It is important to note that ultrasound guidance is not used during this procedure.

4. Qualifying circumstances

CPT code 20610 is used when the healthcare provider performs arthrocentesis, aspiration, and/or injection in a major joint or bursa without the use of ultrasound guidance. The procedure is typically performed on patients who require fluid removal or medication injection in joints or bursae. It is important to ensure that the patient meets the specific criteria for this procedure and that ultrasound guidance is not used.

5. When to use CPT code 20610

CPT code 20610 should be used when a healthcare provider performs arthrocentesis, aspiration, and/or injection in a major joint or bursa without the use of ultrasound guidance. It is important to accurately document the procedure and ensure that the patient meets the qualifying circumstances for this code.

6. Documentation requirements

To support a claim for CPT code 20610, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for arthrocentesis, aspiration, and/or injection
• Specific joint or bursa targeted for the procedure
• Date and time of the procedure
• Details of the procedure, including the use of aspiration, injection, or both
• Medication injected, if applicable
• Any complications or adverse reactions
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 20610, ensure that the procedure is performed without the use of ultrasound guidance. It is important to follow the specific guidelines provided by the payer and accurately document the procedure to support the claim. Additionally, be aware of any bundling or unbundling rules that may apply to this code.

8. Historical information

CPT code 20610 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2015, with an updated description that included specific examples of major joints and bursae.

9. Similar codes to CPT 20610

There are several similar codes to CPT code 20610 that describe procedures related to arthrocentesis, aspiration, and/or injection in major joints or bursae. Some similar codes include:

• CPT 20600: Arthrocentesis, aspiration, and/or injection, small joint or bursa (eg, fingers, toes)
• CPT 20605: Arthrocentesis, aspiration, and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
• CPT 20611: Arthrocentesis, aspiration, and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa) with ultrasound guidance, with permanent recording and reporting

9. Examples

1. A healthcare provider performing arthrocentesis on a patient’s knee to remove fluid for diagnostic purposes.
2. A healthcare provider injecting medication into a patient’s shoulder joint to alleviate pain and inflammation.
3. A healthcare provider performing arthrocentesis on a patient’s hip to remove fluid and relieve symptoms of bursitis.
4. A healthcare provider injecting a corticosteroid into a patient’s subacromial bursa to treat inflammation and pain in the shoulder.
5. A healthcare provider performing arthrocentesis on a patient’s ankle to remove fluid and diagnose the cause of swelling and pain.
6. A healthcare provider injecting hyaluronic acid into a patient’s knee joint to treat symptoms of osteoarthritis.
7. A healthcare provider performing arthrocentesis on a patient’s temporomandibular joint to remove fluid and alleviate symptoms of TMJ disorder.
8. A healthcare provider injecting a local anesthetic into a patient’s acromioclavicular joint to provide pain relief.
9. A healthcare provider performing arthrocentesis on a patient’s wrist to remove fluid and diagnose the cause of swelling and limited mobility.
10. A healthcare provider injecting a corticosteroid into a patient’s olecranon bursa to treat symptoms of bursitis.