Description

Arthrocentesis or aspiration is the removal of fluid from a joint or bursa. Bursas are saclike structures between skin and bone or between tendons, ligaments, and bone. The bursa are lined by synovial tissue, which produces fluid that lubricates and reduces friction between these structures.

Criteria

Arthrocentesis or needling of a bursa may be considered medically necessary when ALL of the following criteria are met:

• "Conservative therapy (rest area and avoid activity, cryotherapy, compression dressings, elevation of affected area above heart, other modalities like electrical stimulation/ultrasonography/phonophoresis, NSAIDs, or corticosteroid injections) to control pain and inflammation has failed; and
• Affected area continues with symptoms of severe pain along with swelling and inflammation; and
• Movement of joint remains limited due to pain; and
• The response to therapy must be documented for medical review prior to additional therapy authorizations.

*Conservative therapy is considered a failure of treatment if no improvement or resolution of pain within 6 weeks from the start of therapy.

When 76942 is reported in conjunction with Codes 20600, 20604, 20605, 20606, 20610, and 20611, payment will be denied as not medically necessary.

Except for local anesthetics, reimbursement for the cost of the drugs or biologicals used in an arthrocentesis joint injection is allowed, in addition to the procedure. If a separate charge for a local anesthetic is reported, it should be denied as not covered.

Arthrocentesis reported for other areas of the spine should be processed as injection of trigger points. When a doctor reports his services as arthrocentesis by fluoroscopy, the service should be processed under the appropriate procedure code for arthrocentesis of the type of joint involved. Itemized charges should be combined and processed under the appropriate arthrocentesis code. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Procedure Codes

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review - no changes

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.