2025 CPT code 20610
(Active) Effective Date: N/A Revision Date: N/A Surgery - Arthrocentesis Musculoskeletal System Feed
Arthrocentesis, aspiration, and/or injection of a major joint or bursa without ultrasound guidance.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., modifier 51 for multiple procedures, modifier 76 for a repeat procedure by the same physician).
Medical necessity for this procedure is established based on the presence of symptoms such as pain, swelling, or limited range of motion in a major joint or bursa.Diagnostic aspiration is warranted when the cause of the symptoms is unclear.Therapeutic injection is medically necessary when conservative measures fail to relieve symptoms. This should be documented in the patient's chart.
The physician or qualified healthcare professional is responsible for preparing the patient, performing the arthrocentesis and injection (if applicable), and ensuring appropriate documentation and laboratory testing.
In simple words: The doctor inserts a needle into a large joint or sac (like the shoulder, hip, knee, or a sac near the shoulder) to remove fluid or inject medicine to help with pain and swelling.This is done without using ultrasound imaging to guide the needle.
This CPT code describes the procedure of arthrocentesis, which involves aspiration (removal of fluid) from, or injection into, a major joint (shoulder, hip, knee, or subacromial bursa), or both aspiration and injection of the same joint.The procedure may be performed for diagnostic analysis and/or to relieve pain and swelling.Ultrasound guidance is not used for needle placement.The injection, if performed, typically uses an anti-inflammatory medication such as a steroid.
Example 1: A patient presents with acute pain and swelling in the right knee joint due to suspected gout. The physician performs an arthrocentesis to aspirate synovial fluid for analysis and injects a corticosteroid for pain relief., A patient experiences chronic shoulder pain associated with subacromial bursitis. The physician performs an arthrocentesis of the subacromial bursa to aspirate fluid and inject a local anesthetic and corticosteroid for pain and inflammation management., A patient with a history of osteoarthritis in the hip joint experiences a sudden increase in pain and limitation of movement. The physician performs an arthrocentesis of the hip joint to analyze the synovial fluid and, based on results, may inject hyaluronic acid for joint lubrication and pain relief.
* Patient's medical history and clinical presentation (including pain location, duration, and severity).* Documentation of the joint or bursa aspirated.* Volume of fluid aspirated (if any).* Type and amount of medication injected (if any).* Results of any laboratory testing performed on the aspirated fluid.* Post-procedure assessment of the patient's condition.
** This code does not include ultrasound guidance. If ultrasound guidance is used, report CPT code 20611 instead.The type and amount of any injected medication should be documented and may be reported separately using appropriate medication codes.
- Revenue Code: P6B (Minor Procedures - Musculoskeletal)
- RVU: This information is not available in the provided sources.Consult the current year's CPT codebook or a medical billing resource for RVU values.
- Global Days: The provided text does not specify a global period for this code.Consult the current CPT codebook for global period information.
- Payment Status: Active
- Modifier TC rule: The provided text does not specify whether a Technical Component (TC) modifier applies.Consult the current CPT codebook or relevant guidelines for information on this.
- Fee Schedule: This information is not available in the provided sources.Consult the CMS website or other relevant resources for historical fee schedules.
- Specialties:Orthopedics, Rheumatology, Sports Medicine
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center, Urgent Care Facility