Overview of CPT Code 20691:arthrocentesis-aspiration-and-or-injection-into-a-major-joint-or-bursa
CPT Code 20691 refers to the procedure of arthrocentesis, which involves aspiration or injection into a major joint or bursa. This procedure is commonly performed to relieve pain, reduce swelling, or obtain synovial fluid for diagnostic purposes.
When CPT Code 20691 is Used?
This procedure is indicated in various clinical scenarios.
- Joint swelling or effusion due to arthritis or injury.
- Diagnostic evaluation of joint disorders.
- Injection of corticosteroids for inflammatory conditions.
- Relief of pain in conditions like bursitis or tendinitis.
Symptoms Indicating This Procedure
Patients may report several symptoms that warrant this procedure.
- Swelling in the affected joint.
- Pain or discomfort during movement.
- Stiffness or reduced range of motion.
- Warmth or redness around the joint.
Causes and Risk Factors
Several factors can lead to the need for arthrocentesis.
- Osteoarthritis or rheumatoid arthritis.
- Injury or trauma to the joint.
- Infection in the joint (septic arthritis).
- Gout or pseudogout.
Diagnostic Tests Before Procedure
Certain tests may be conducted to guide the procedure.
- X-rays to assess joint structure.
- Ultrasound to visualize joint effusion.
- Blood tests to check for inflammatory markers.
- Joint fluid analysis if previously aspirated.
Procedure Description
The procedure is performed in a clinical setting.
- Patient is positioned comfortably.
- Skin over the joint is cleaned with antiseptic.
- Local anesthesia may be administered.
- A sterile needle is inserted into the joint space.
- Fluid is aspirated or medication is injected as needed.
- Needle is removed, and a bandage is applied.
Preparation for the Procedure
Patients should follow specific guidelines before the procedure.
- Inform the doctor about any medications being taken.
- Avoid blood thinners or anti-inflammatory medications as advised.
- Wear loose-fitting clothing for easy access to the joint.
- Arrive at the appointment with a support person if needed.
Recovery and Aftercare
Post-procedure care is essential for recovery.
- Rest the joint for 24-48 hours.
- Apply ice to reduce swelling.
- Take prescribed pain medications as needed.
- Follow up with the doctor for reassessment.
Possible Complications
While generally safe, complications can occur.
- Infection at the injection site.
- Bleeding or hematoma formation.
- Nerve or blood vessel injury.
- Allergic reaction to injected medication.
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Post-Procedure Follow-Up
Monitoring after the procedure is important.
- Schedule a follow-up appointment within a week.
- Monitor for signs of infection or increased pain.
- Discuss the effectiveness of the procedure with the doctor.
Alternative Treatments
Other management options may be considered.
- Physical therapy to improve joint function.
- Oral anti-inflammatory medications.
- Corticosteroid pills for systemic inflammation.
- Lifestyle modifications such as weight management.
Home Care Tips
Patients can take steps to aid recovery at home.
- Keep the joint elevated to reduce swelling.
- Avoid strenuous activities for a few days.
- Use over-the-counter pain relievers as directed.
- Stay hydrated and maintain a balanced diet.
Patient Education & Prevention
Education is key to preventing recurrence.
- Understand the importance of joint health.
- Engage in regular low-impact exercise.
- Maintain a healthy weight to reduce joint stress.
- Seek early treatment for joint pain or swelling.
Billing and Coding Information
CPT Code: 20691
Category: Surgical Procedures
Common Modifiers:
- 50 - Bilateral procedure
- 59 - Distinct procedural service
Average Cost and Insurance Coverage
Costs can vary based on location and insurance.
- Average cost ranges from $150 to $500.
- Most insurance plans cover the procedure.
- Check with your provider for specific coverage details.
Related CPT Codes
- 20692 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa
- 20693 - 'Arthrocentesis, aspiration and/or injection into a major joint or bursa'
- 20694 - Arthrocentesis, aspiration and/or injection into a major joint or bursa
References and Sources
Frequently Asked Questions (FAQs)
What is arthrocentesis?
Arthrocentesis is a procedure to remove fluid from a joint or inject medication.
Is the procedure painful?
Most patients experience minimal discomfort, especially with local anesthesia.
How long does recovery take?
Recovery is usually quick, with most patients resuming normal activities within a few days.
Are there any risks involved?
As with any procedure, there are risks such as infection or bleeding.
