This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Arthrocentesis or needling of a bursa may be considered medically necessary when ALL of the following criteria are met:

• *Conservative therapy (rest area and avoid activity, cryotherapy, compression dressings, elevation of affected area above heart, other modalities like electrical stimulation/ultrasonography/phonophoresis, NSAIDs, or corticosteroid injections) to control pain and inflammation has failed; and
• Affected area continues with symptoms of severe pain along with swelling and inflammation; and
• Movement of joint remains limited due to pain; and
• The response to therapy must be documented for medical review prior to additional therapy authorizations.

*Conservative therapy is considered a failure of treatment if no improvement or resolution of pain within 6 weeks from the start of therapy.

When 76942 is reported in conjunction with codes 20600, 20604, 20605, 20606, 20610, and 20611 payment will be denied as not medically necessary.

Except for local anesthetics, reimbursement for the cost of the drugs or biologicals used in an arthrocentesis joint injection is allowed, in addition to the procedure.  If a separate charge for a local anesthetic is reported, it should be denied as not covered. 

Arthrocentesis reported for other areas of the spine; should be processed as injection of trigger points. When a doctor reports his services as arthrocentesis by fluoroscopy, the service should be processed under the appropriate procedure code for arthrocentesis of the type joint involved. Itemized charges should be combined and processed under the appropriate arthrocentesis code. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

See Medical Policy Bulletin G-25 for information on intra-articular injections of hyaluronan (Synvisc or Hyalgan) for osteoarthritis of the knee.

See Medical Policy Bulletin S-240 for information on Trigger Point Injections. 

FEP Guidelines

Arthrocentesis, aspiration and/or injection of a joint or bursa is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the non-covered service.

• Link to Provider Resource Center for the Medical Policy Update

06/2015, Reporting Arthrocentesis With Ultrasonic Guidance

• Link to Diagnosis Codes

• Link to References