High School

Mrs. Jones, an established patient, is seen by the rheumatologist for repeated pain in her left knee due to osteoarthritis. Today she presents with pain and swelling. The rheumatologist performs an arthrocentesis of the left knee followed by injection of Dexa-Methasone sodium phosphate, 5 mg. No E/M service is performed.

Select the appropriate ICD-10-CM and CPT code(s):

A) M17.12, 20610, J1100 5u
B) M17.32, 20605, J1100 5u, 99212-25
C) M17.12, 20605, 99212-25
D) M17.12, 20610, 99212-25, J1100 5u

Answer :

To determine the appropriate ICD-10-CM and CPT codes for this scenario, we need to break down the details of the patient's visit and the procedures performed.

  1. Diagnosis Code (ICD-10-CM):

    • The patient, Mrs. Jones, is experiencing repeated pain in her left knee due to osteoarthritis. The specific ICD-10-CM code for osteoarthritis of the left knee is M17.12.
  2. Procedure Codes (CPT):

    • Arthrocentesis (Aspiration/Injection of Joint): This is the procedure where fluid is drawn from a joint (in this case, the knee). The appropriate CPT code for an aspiration or injection procedure in a large joint, like the knee, is 20610.
    • Injection of Dexamethasone: Dexamethasone sodium phosphate is the medication injected. The HCPCS code for dexamethasone is J1100, with each unit representing 1 mg. Since 5 mg is administered, you would code this as J1100 5u.
    • No Evaluation and Management (E/M) service was performed or documented, so any options that include an E/M code (e.g., 99212) are not applicable here.

Based on the details provided, the correct choice is:

A) M17.12, 20610, J1100 5u

This option correctly codes the diagnosis and procedures done for Mrs. Jones's knee on this visit.