CPT® code 20610 is used to report arthrocentesis, aspiration, and/or injection of a major joint or bursa, such as the shoulder, hip, knee, or subacromial bursa. This procedure may be performed for diagnostic or therapeutic purposes, including the removal of joint fluid or administration of medication.
What is CPT 20610?
CPT 20610 describes a procedure performed to either aspirate fluid (to relieve pressure or obtain a sample for analysis) or inject a therapeutic agent (such as a corticosteroid, hyaluronic acid, or anesthetic) into a major joint or bursa.
Major joints and bursae include:
- Shoulder
- Hip
- Knee
- Subacromial bursa
This procedure is commonly used in the treatment of inflammatory conditions, such as bursitis, arthritis, or synovitis, as well as in the diagnosis of joint disorders.
Note: CPT 20610 may be performed with or without image guidance. If ultrasound guidance is used, it should be reported separately using CPT code 76942 with appropriate documentation.
When to report CPT code 20610
You may report 20610 when:
- The procedure involves a major joint or bursa
- The provider aspirates synovial fluid, injects a substance (e.g., steroid, anesthetic), or performs both
- The service is performed in an outpatient, office, or inpatient setting
- Proper documentation includes site, technique, and purpose (aspiration, injection, or both)
Billing tips and additional considerations
- CPT 20610 is often reported alongside a J-code for the medication injected (e.g., J3301 for triamcinolone).
- If an E/M service is provided on the same day for a separate issue, append modifier -25 to the E/M code.
- If ultrasound guidance is used, include detailed documentation and report CPT 76942 separately.
- Medicare and commercial payers may have specific policies on coverage for joint injections, frequency limits, and necessity of image guidance.
Streamline Procedure Documentation and Billing with OptiMantra
For practices that frequently perform in-office procedures like joint injections or aspirations, OptiMantra offers built-in tools to ensure accurate coding, streamlined documentation, and efficient billing for CPT 20610 and associated services. With OptiMantra, providers can:
- Use procedure-specific templates to document joint injections or aspirations
- Automatically populate CPT and HCPCS codes based on clinical inputs
- Track medication inventory and usage linked to each encounter
- Attach image guidance reports and documentation when applicable
- View payer-specific rules to avoid coding errors or denials
Whether you're managing musculoskeletal complaints, performing joint procedures, or coordinating multidisciplinary care, OptiMantra gives you the tools to deliver high-quality, compliant, and billable care—all from one unified platform.
Try OptiMantra for free here!
