Coding Snapshot: 4 Answers to Ace Major Joint Arthrocentesis

coding for arthrocentesis

Time for an arthrocentesis refresher! Today we’re digging into the details of 20610 and 20611 with four questions and answers.

1. What Are the Major Components of These Codes?

Let’s start by working our way through the code descriptors:

  • 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance)
  • 20611 (… with ultrasound guidance, with permanent recording and reporting).

Both descriptors start by stating the codes represent arthrocentesis, which is puncture and aspiration of a joint, according to Dorland’s Illustrated Medical Dictionary. Of course you’ll want to pay attention to the descriptors themselves which clarify that the codes are appropriate whether the provider performs aspiration, injection, or both.

The next element is that the codes apply when the service is for a major joint or bursa. Examples include the shoulder, hip, knee, and subacromial bursa. A bursa is a fluid-filled sac or cavity located in areas of the body that would develop friction if the bursa were absent.

The final element is where the codes differ. Code 20610 applies when the provider does not use ultrasound guidance. Code 20611 applies when the provider does use ultrasound guidance. Note the requirement for permanent recording and reporting for the guidance. AMA CPT® Assistant (November 2015) confirmed that without the permanent recording and reporting, you have to report 20610.

You shouldn’t be surprised that CPT® guidelines instruct you not to report ultrasonic guidance code 76942 with 20610 or 20611. For other types of guidance, you may use 77002 (fluoroscopic), 77012 (CT), or MRI (77021).

2. What’s the Difference in Reimbursement?

The ultrasound guidance does raise the reimbursement under the Medicare Physician Fee Schedule (MPFS). Below you’ll see the national Medicare rates for these codes. (The final payment may vary based on things like geographic adjustment and additional procedures performed on the same date.)

20610

  • Facility: $47.47
  • Nonfacility: $61.63

20611

  • Facility: $63.07
  • Nonfacility: $94.06

If you do some quick calculations, you can see that the rates for a service performed in a facility differ by about $15. For services in a nonfacility setting, the difference is about $32. (Services in a nonfacility setting pay more because the physician is responsible for more expenses there. In a facility setting, the facility covers some of the expenses and is reimbursed accordingly.)

3. What Else Can We Learn From the MPFS?

The MPFS includes so much more than fees, and checking the details can make a real difference in your understanding of proper coding and reimbursement. Here are some examples for 20610 and 20611.

Global days: Both codes have a global period of 000. The definition for 000 is “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

Multiple procedures: The multiple procedure indicator for these codes is 2, so performing more than one procedure may result in reduced reimbursement for the additional codes Here is the official wording: “Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.”

Bilateral: A payment adjustment applies for bilateral services, too. The bilateral indicator for these codes is 1: “50% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.”

Tip: Check for LCDs and policy articles specifying proper use of modifiers, such as RT (Right side) or LT (Left side) for unilateral services and 50 (Bilateral procedure) for bilateral arthrocentesis.

4. What Are the MUEs?

Both codes have practitioner and facility medically unlikely edits (MUEs) of 2. The MUE adjudication indicator (MAI) for these codes is 3.

Let’s unpack that. MUEs are basically frequency edits, letting you know the maximum number of units Medicare expects to see for a code. The MAI offers more information about the MUE. MAI 3 lets you know you’re dealing with a date of service (DOS) MUE based on clinical benchmarks. If you go over the MUE for a code on a single DOS, expect to see claim lines denied. But the good news is that you may get reimbursed for the extra units if you appeal or convince the MAC to bypass the edit through your stellar documentation of medical necessity.

What About You?

Do you think the MUEs for these arthrocentesis codes should be increased? Do you think the extra payment for ultrasound guidance is adequate?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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