August 5, 2021
Our sports medicine physician submitted an office note with documentation that he performed an “elbow injection.” We are new to orthopaedic coding and wondering if CPT code 20605 (he did not use ultrasound guidance) is the correct code.
Your question is not just because you’re new to orthopaedics; we hear this with some frequency and allows you a great opportunity to meet with the physician and review documentation requirements.
KZA is not able to state if CPT code 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)) is correct or not.
Let’s take a look at a few options and diagnosis code may play an important part in directing you to the correct code in addition to documentation of the exact location.
As noted, CPT code 20605 describes an injection in the joint or surrounding bursa, in this example, the elbow. This may be for a diagnosis of osteoarthritis, bursitis, joint pain, hemarthrosis or effusion if the elbow joint is aspirated of blood or fluid.
CPT code 20551 (Injection(s); single tendon origin/insertion) may be given to the origin site of the extensor carpi radialis brevis (ECRB) tendon for treatment of lateral epicondylitis as an example. The injection is not “in the joint or bursa” but is at the location of where the tendon originates.
CPT code 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) differs from CPT code 20551 in that the injection is to the tendon “sheath” or ligament, not the tendon at the origin/insertion site. In the hand, this is commonly the code reported for trigger finger injections. However, in the elbow, the tendon sheath may be injected for epicondylitis, bursitis, tenosynovitis, as examples.
As you can see, automatically defaulting to CPT code 20605 may be incorrect. Work with the physician to understand the code descriptors to allow him to improve his documentation including the exact location and diagnosis.
*This response is based on the best information available as of 08/05/21.