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Question: A 42-year-old patient presented to the emergency department (ED) with left elbow pain and swelling that began approximately four days prior. The patient described the pain as sharp and constant, significantly worsened by movement; there was no history of recent trauma, injuries, or overuse. The pain and swelling hampered their ability to perform daily activities.

Upon examination, the left elbow showed noticeable swelling and redness, with limited range of motion due to pain and tenderness throughout the joint. The ED physician ordered an X-ray of the elbow to exclude any fractures or other bone-related anomalies. A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were ordered to assess for possible systemic infection. The CBC showed elevated white blood cells (WBCs); the ESR and CRP were elevated also.

Following the tests, the physician decided to proceed with an arthrocentesis to drain fluid from the elbow joint and administer medication directly into the joint to relieve pain. The physician used ultrasound (US) guidance during the procedure.

How should I report this encounter?

RCI Subscriber

Answer: The procedure would be reported with CPT^庐 code 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting).

As with all codes that include US guidance, the CPT^庐 code descriptor requires permanent recording of the US image to report any 鈥渨ith ultrasound guidance鈥� codes. If no permanent images are saved, the coder must assign the arthrocentesis code designates without ultrasound guidance 鈥� 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance). CPT^庐 does remind you that you would not report ultrasonic guidance code 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) with any of the 鈥渨ith ultrasound guidance鈥� codes.

Considering all the elements of the evaluation and management (E/M) service, you can report 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for that portion of the encounter. Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99284 to show that it is a significant and separate service from the arthrocentesis.

It is also worth noting that the ED physician injected medication into the elbow during the arthrocentesis procedure. This action isn鈥檛 counted as a separate service. Coders should note that only a single arthrocentesis code should be assigned per joint, irrespective of the number of aspirations and/or injections performed on that joint during the same session. Therefore, whether the ED physician performed both an aspiration and an injection or administered two injections at different sites of the same joint, the code for the arthrocentesis is only reported once.

As for the ICD-10 codes in this case, based on the labs and fluid analysis, the ED physician鈥檚 final diagnosis of septic arthritis of the left elbow would be coded as M00.822 (Arthritis due to other bacteria, left elbow). This code requires an additional code from the B96.- (Other bacterial agents as the cause of diseases classified elsewhere) family to identify the bacteria that is the underlying cause of the infection.  Without a specific bacteria documented, the coder would report B96.89 (Other specified bacterial agents as the cause of diseases classified elsewhere).

Todd Thomas, CPC, CCS-P, President, ERcoder, Inc.