Documentation to include
- History / PE findings to justify injection
- Patient consent
- Injection of (mg of specific steroid) mixed with (volume of anesthetic) in usual sterile fashion
- Site prepared with (chlorhexidine/povidine-iodine/alcohol/etc)
- Joint space injected, with site confirmed with immediate post-procedure relief
- Excellent hemostasis achieved and no immediate complications noted (or what happened and how it was addressed)
Select CPT codes
20610: Injection/Aspiration/Arthrocentesis of major joint or bursa
Examples: Shoulder, Hip, Knee, Subacromial bursa
- Usually use 80mg of methylprednisolone for these joints
- If using ultrasound, code is 20611
20605: Injection/Aspiration/Arthrocentesis of intermediate joint or bursa
Examples: Wrist, Elbow, Ankle, Olecranon bursa, Temporomandibular, Acromioclavicular
- Usually use 40mg of methylprednisolone for these joints
- If using ultrasound, code is 20606
20600: Injection/Aspiration/Arthrocentesis of small joint or bursa, Ex:
Examples: Finger, Toe
- Usually use 20mg of methylprednisolone for these joints
- If using ultrasound, code is 20604