Rheumatology Coding Corner Answer: Coding for a Knee Injection

CPT: 20611-LT, J7325 X 1
ICD-9: 715.16—Osteoarthritis, localized, primary, lower leg
ICD-10: M17.12—Unilateral primary osteoarthritis, left knee

Note: When billing for 20611—Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa), with permanent recording and reporting, there must be a permanent photograph of the needle placement in the patient’s medical chart. Just a reminder that as of Jan. 1, 2015, CPT updated the injection codes, and there are separate codes to reflect an injection/aspiration with or without ultrasound guidance.

As a coding rule, it’s not necessary to code the left knee effusion if it is an integral part of the patient’s osteoarthritis. If the effusion is deemed as a separate symptom that is not a part of the osteoarthritis, it will be necessary to indicate this in the documentation and address it separately; the ICD-10 code for left knee effusion is M25.462.