“My partner prefers to inject the subtalar joint under fluoroscopy. What would be the best procedure code to bill for an injection of the subtalar joint and does the use of fluoroscopy change things?”
When it comes to injecting a joint in the foot or the ankle, the guidelines and the CPT codes of note changed as of January 1, 2015. The CPT codes are defined as the following:
CPT 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg. fingers, toes); without ultrasound guidance
CPT 20604 With ultrasound guidance, with permanent recording and reporting
CPT 20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg. temporomandibular, acromioclavicular, wrist,
elbow or ankle, olecranon bursa); without ultrasound guidance
CPT 20606 With ultrasound guidance, with permanent recording and reporting
Based upon the definitions of the above CPT codes, would the subtalar joint be considered a small joint or an intermediate joint? Well, the subtalar joint is larger than a joint in a toe and smaller than the ankle. I would consider the subtalar joint to be an intermediate joint. Since ultrasound guidance is a nonissue in the above post, the most appropriate CPT code for an injection into the subtalar joint would be CPT code 20605: Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg. temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance.
The subtalar joint is being injected under fluoroscopy. Unlike the joint injections where ultrasound guidance is included in the CPT definition, this does not apply to “fluoroscopy guidance” of a joint injection. The appropriate CPT code to bill for a fluoroscopic guided injection is CPT code 77002 which is defined as: Fluoroscopic guidance for needle placement (eg. biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure).
When CPT code 77002 is billed in addition to CPT code 20605, it is important to note the following:
1. Since CPT code 77002 is classified as Radiologic Guidance as opposed to a procedure, the only modifier to be appended would be the anatomical modifier, RT or LT. The 59 modifier to indicate a Distinct Procedural Service is not needed.
2. It is imperative to have a permanent recording of the fluoroscopic guidance and a written report of what was performed. Per the CPT manual, a written report (eg. handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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