Don’t Get Stuck When Reporting 20610 for Joint Injections

How best to report bilateral 20610 to Medicare, 20610 problem code, Code Carefully for Bilateral Procedures, bilateral 20610 medicare

Who knew getting paid for performing joint injections could get so complicated! Reporting incorrect modifiers on claims for CPT® code 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa [eg, shoulder, hip, knee, subacromial bursa]; without ultrasound guidance) leaves your claim at risk for rejection.

20610 — A Problem Code?

When your provider performs arthrocentesis, which is a puncture and aspiration of a major joint, or when your provider injects a substance into a major joint, you report the procedure with 20610. Notice that the use of ultrasound guidance is not part of this code, so if your clinician performs ultrasound guidance as part of the injection or aspiration, you should instead report 20611 (… with ultrasound guidance, with permanent recording and reporting).

Stay Sharp! Code Carefully for Bilateral Joint Injection Procedures

The Medicare Administrative Contractor (MAC) Noridian Healthcare Solutions recently shared handy tips for reporting these injection codes, reviewing CPT® descriptions, billing scenarios, and modifier usage with CPT® injection codes. Why are modifiers indicating multiple sites or bilateral locations so difficult? Because it’s easy to mistake bilateral to mean something on the left and the right! The modifier choice you use to report bilateral or right and left is dependent upon the body parts being injected. Check out these scenarios.

Injection to Right Shoulder and Left Shoulder

When a provider injects the same joint on both sides, the procedure is considered bilateral. For bilateral procedures, you’ll use CPT® modifier 50. For example, if your provider performed an injection of 40 mg of Depo-Medrol to each shoulder, you’d report the following:

  • 20610 50

Don’t forget the HCPCS code for the injection of the steroid itself! You’d report J1030 (Injection, methylprednisolone acetate, 40 mg), this way:

  • J1030, 2 units

Injections to Different Joints on Each Side

Now here’s where it gets tricky. What happens when your patient needs an injection in two different major joints on both sides of the body? Don’t be fooled into thinking this is bilateral because both sides were treated. Because two different structures were injected, you can’t use the bilateral modifier to report these. Instead, you’d use LT and RT, as follows.

  • 20610 RT
  • 20610 LT

Don’t forget to bill for the injected material with an appropriate HCPCS code!

Injections to Two Different Joints on the Same Side

Without including the detailed documentation supporting the services in this example, which of course you would be including with your claims in all of these examples, this CPT® code and modifier pair looks redundant. But it’s not, because the provider injected the right shoulder and the right knee. Here’s what you would report:

  • 20610 RT
  • 20610 RT 76

As you can see, RT is used on both lines, and Modifier 76 goes online two to indicate a repeated procedure. As always, don’t forget to bill for the injected drug with the appropriate HCPCS codes.  Remember, this is Noridian’s instruction. Other payers may have different rules for use of 76 and may prefer that you use another modifier like 59 (Distinct procedural service) when the sites are different.

Aspiration, then Injection to the Same Joint

This one is the simplest of all. When the same joint is treated more than once on the same date of service, even with aspiration followed by injection or with two injections to the same joint, you can only bill one CPT® 20610 code. No modifier is attached: you just bill 20610.

How About You?

Have you had frustrations figuring out how best to report bilateral 20610 to Medicare? Or has this process been smooth for you? We’d love to hear your experiences. Let us know in the comment box below.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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2 Comments For This Post

  1. Rebecca Evans Says:

    As a patient, I want to know if the procedure for a syn-visc injection, billed as 20610 and done in an orthopedic department examining room, not in the Outpatient Surgery department, is considered by a Medicare Advantage plan and paid by the patient as “outpatient surgery.”

    Thanks for any info you can give.

  2. Sheri Says:

    If the doctor is injecting the GH joint as well as the AC joint of the right shoulder, would you bill 20611 (for GH joint as it’s considered a major joint) and also 20606 (for AC joint since it’s considered an intermediate joint)??

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