2025 CPT code 20611
Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.
Modifiers may be applicable in certain circumstances, such as for bilateral procedures (modifier 50), multiple procedures (modifier 51), reduced services (modifier 52), or distinct procedural services (modifier 59).
Medical necessity must be supported by documentation of the patient's symptoms, the diagnostic purpose of the arthrocentesis/injection, or the therapeutic rationale for the injection.
The physician prepares the patient, administers anesthesia, inserts the needle under ultrasound guidance, aspirates fluid or injects medication, records the ultrasound findings, and manages any bleeding post-procedure. The physician also sends the aspirated fluid to the lab for analysis if necessary.
In simple words: The doctor uses ultrasound to guide a needle into a large joint, like your shoulder or knee, to either drain fluid or inject medicine. They record the ultrasound images for their records.
This code describes a procedure where a physician uses ultrasound guidance to insert a needle into a major joint or bursa (such as the shoulder, hip, knee, or subacromial bursa) to either remove fluid (aspiration) or inject medication. The procedure includes permanent recording and reporting of the ultrasound findings.
Example 1: A patient presents with a swollen, painful knee. The physician uses ultrasound guidance to perform an arthrocentesis to remove fluid for diagnostic testing and to inject a corticosteroid to reduce inflammation., A patient with shoulder pain undergoes an ultrasound-guided aspiration of the subacromial bursa to diagnose the cause of the pain and inject a local anesthetic and/or corticosteroid., A patient with hip osteoarthritis undergoes an ultrasound-guided injection of hyaluronic acid into the hip joint to relieve pain and improve mobility.
Documentation should include details of the procedure, including the joint or bursa aspirated or injected, the type of ultrasound guidance used, the medications injected (if any), the amount of fluid aspirated, the diagnosis, and any complications.
- Specialties:Orthopedic Surgery, Pain Management, Sports Medicine, Rheumatology
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Ambulatory Surgical Center, and other applicable outpatient settings.