One-liner#

Office aspiration and/or injection of common joints (e.g., knee, shoulder) for diagnostic and/or therapeutic purposes.

Don’t miss / refer urgently#

• Hot, swollen joint with systemic symptoms or severe pain out of proportion (concern for septic arthritis)
• Neurovascular compromise after injection/trauma
• Suspected fracture/dislocation

Indications#

• Suspected inflammatory/crystal arthropathy (diagnostic aspiration)
• Symptomatic effusion
• Pain control in OA or inflammatory conditions (therapeutic injection; payer rules vary)

Contraindications (common)#

• Overlying cellulitis or suspected septic joint (do not inject; aspiration may be appropriate with urgent workup)
• Uncontrolled bleeding risk/anticoagulation concerns (individualize)
• Allergy to planned medication

Minimum documentation (what to chart)#

• Procedure indication and laterality
• Consent (risks/benefits/alternatives)
• Site/prep, anesthesia (if used), technique summary, needle size if relevant
• Medication(s) injected with drug name + concentration + volume (and lot/expiry if required locally)
• Aspirate appearance and what was sent (cell count, crystal, Gram stain/culture) if applicable
• Patient tolerance and complications
• Aftercare instructions and follow-up plan

Coding (common) + RVU table scaffold#

Populate RVUs annually from the CMS PFS RVU file (facility vs non-facility PE differs).

Common add-ons/notes (payer-specific):

• Ultrasound guidance may be separately reportable (rules vary; document images and guidance details).
• Drug supply may be separately billable depending on medication/site-of-care rules (often not relevant for common steroids).