E/M with Procedure

E/M with Procedure

June 20, 2019

Question:
Can you provide the CPT code for this procedure? Also can I report an E/M service for this patient encounter?

Patient is a pleasant 60 year-old gentleman who presents in our office for a follow-up visit for left knee pain. He continues to have some left sided knee pain. We drained his knee three months ago and he did well with that. He was also injected with cortisone. He was hoping he could have that again. His discomfort is worse with using the stairs, standing and walking. It is mostly over the anterior and medial aspect of the knee. He rates his discomfort between a 3 and an 8/10. It is an achy sensation.  I examined the knee and performed the following:  The inferior medial patellar pole of the knee was prepped as stated above. Using the linear transducer of the SonoSite ultrasound unit, a 20 gauge needle was inserted into the left knee under ultrasound guidance until it engaged with the fluid level. Under direct ultrasound guidance, 4 mL clear yellow fluid was aspirated and then he was injected with 40 mg of Depo-Medrol and 3 mL of 1% lidocaine. Pictures were saved for documentation purposes. The needle was withdrawn and the area was cleaned with alcohol. Due to the patient’s complex anatomy, ultrasound guidance was necessary to safer and appropriately complete the injection.

Answer:
The CPT codes to report for the procedures is 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting).  Don’t forget to report CPT code J1030 for the 40mg of Depo-Medrol.  I would not report an E/M service since the focus of the visit is pain relief and the need for another injection which does not justify an E/M service in addition to the procedure.  Keep in mind there is an inherent E/M service in every procedure.

*This response is based on the best information available as of 06/20/19.

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