Posted on 02 November 2010. Tags: big toe, CPT code, depo-medrol, gout, great toe, ICD-10, ICD-9, injection, Joint, Kenalog, metatarsophalangeal, MTP, osteoarthritis, pain, procedure, steps, tuberculin syringe, turf toe
By Chris Faubel, MD –
Just need to get the needle under the joint capsule, not necessarily inside the joint.
aka. “Great toe injection”, “Big toe injection”
Indications
- First metatarsophalangeal (1st MTP) joint painful osteoarthritis
- Gout (in the “great toe” joint) — most common location
- Turf Toe
- **see all ICD-9 and ICD-10 codes at end of post
CPT code: 20600 “Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)”
Materials Needed
- Pen – clicking type
- Gloves – non-sterile
- Alcohol swabs (or povidone-iodine)
- Band-aid
- Tuberculin needle/syringe OR 1-ml syringe with 25-gauge 5/8″ needle (depending on body habitus)
- Injectate
- 0.5-ml of 40mg/ml Depo-Medrol or Kenalog (or 0.5ml of 6mg/ml Celestone)
- 0.5-ml of 1% lidocaine
Technique / Procedure Steps
- Always start with informed consent from the patient, and then a time-out to verify correct patient and injection site.
- Mark the injection site with the pen tip in order to leave an impression in the skin.
- Clean the skin thoroughly with as many alcohol swabs as needed (usually only 1-2 are needed).
- Patient position: Perform lying supine with the foot off the end of the table, OR, supine with knee bent and foot flat on the table.
- With the tuberculin needle/syringe, enter perpendicular to the skin. If bony resistance is met, redirect the needle until you feel you are inside the joint. Note: Ultrasound may be needed if extensive osteophytes make it difficult to find an entry path. Also, the needle tip does NOT need to be inside the joint; just under the capsule surrounding the joint.
- Aspirate to make sure you’re not in any vessel.
- After negative aspiration, inject the full contents of the syringe. Should flow easily.
- Withdraw the needle after syringe if fully empty, and apply band-aid.
Tips
- Finding the injection site
- Can palpate the joint space best on the medial surface.
- May help to distract the phalanx distally to open the joint space.
- Numbing the skin
- Find out all about “Taking the Sting Out” (of injections) by going here.
- Since I use a tiny tuberculin needle, most patients have no problem with the injection and don’t need any extra lidocaine skin wheal or freezing spray.
- I tell them numbing the skin with lidocaine will probably hurt more than the actual injection.
- Because this is a sensitive area, ethyl chloride “numbing” spray may be used.
- After the injection
- Have the patient move their toe around while you throw away supplies.
- Then, re-mobilize the 1st MTP joint so they can see the immediate results of the lidocaine.
- Explain to the patient that the lidocaine will wear off in an hour or so, and that they will be back to their normal pain until the steroids start kicking in (anywhere from 1-7 days).
- May also ask the patient to not do much activity on that foot for 12-24 hours.
Diagnostic Codes
- First metatarsophalangeal (1st MTP) joint painful osteoarthritis
- ICD-9 codes:
- 715.17 “osteoarthrosis, localized, primary, ankle and foot”
- 719.47 “pain in joint, ankle and foot”
- ICD-10 codes:
- M19.071 “primary osteoarthritis, right ankle and foot”
- M19.072 “primary osteoarthritis, left ankle and foot”
- M79.674 “pain in right toe(s)
- M79.675 “pain in left toe(s)
- Gout (in the big toe joint)
- ICD-9 code:
- 274.0 “gouty arthropathy”
- 274.9 “gout, unspecified”
- ICD-10 code:
- M1a.071 “idiopathic chronic gout, right ankle and foot”
- M1a.072 “idiopathic chronic gout, left ankle and foot”
- M10.071 “idiopathic gout, right ankle and foot”
- M10.072 “idiopathic gout, left ankle and foot”
- Sprain of first metatarsophalangeal joint (turf toe)
- ICD-9 code:
- 845.12 “sprain of metatarsophalangeal (joint) of foot”
- ICD-10 code:
- S93.5 “sprain and strain of toe(s)”
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Posted in 1st Metatarsophalangeal Joint, Lower Extremity, Procedures
Posted on 31 October 2010. Tags: corticosteroid, CPT code, depo-medrol, ICD-10, ICD-9, injection, pain, plantar fascia, plantar fascial fibromatosis, Plantar fasciitis, procedure, skin wheal, steps
By Chris Faubel, MD –
MUST go all the way down to the periosteum (gently), and then back up only a mm.
Indications
- Plantar fasciitis / Plantar fascial fibromatosis
- ICD-9 code: 728.71 “plantar fascial fibromatosis”
- ICD-10 code: M72.2 “plantar fascial fibromatosis”
CPT code: 20550 “injection(s); single tendon sheath, or ligament, aponeurosis””
Read the full story
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Posted in Lower Extremity, Plantar Fascia, Procedures
Posted on 31 October 2010. Tags: bursitis, corticosteroid, CPT code, depo-medrol, ICD-10, ICD-9, injection, Kenalog, pain, pes anserine bursa, pes anserinus bursa, procedure, skin wheal, steps, steroid
By Chris Faubel, MD –
Medial to the patellar tendon and tibial tuberosity (dotted yellow). The bursa lies between the conjoint tendon of three muscles (superficially; sartorius, gracilis, and semitendinosis muscles), and the medial collateral ligament and tibia (deep).
Indications
- Pes anserine bursitis / Pes anserinus bursitis
- ICD-9 code: 726.61 “pes anserinus tendinitis or bursitis”
- ICD-10 code: M70.5 “other bursitis of knee”
CPT code: 20610 “Arthrocentesis, aspiration and/or injection; major joint or bursa”
Read the full story
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Posted in Lower Extremity, Pes Anserine Bursa, Procedures
Posted on 31 October 2010. Tags: calcium pyrophosphate, chondrocalcinosis, corticosteroid, cortisone, CPPD, depo-medrol, gout, ICD-10, ICD-9, injection, intraarticular, Joint, Kenalog, knee, osteoarthritis, pain, procedure, Rheumatoid arthritis, shot, skin wheal, steps, steroid
By Chris Faubel, MD –
Medial Approach. Advance needle at about 15-20 degrees from midline.
Indications
- Osteoarthritis of the knee
- Rheumatoid arthritis of the knee
- Gout (in the knee)
- Calcium pyrophosphate dyhydrate (CPPD)
- **see all ICD-9 and ICD-10 codes at end of post
CPT code: 20610 “Arthrocentesis, aspiration and/or injection; major joint or bursa”
Read the full story
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Posted in Knee Joint, Lower Extremity, Procedures
Posted on 30 October 2010. Tags: 1st CMC, Allen's test, CPT code, first carpometacarpal joint, ICD-10 code, ICD-9 code, injection, procedure, steps, steroid
By Chris Faubel, MD –
Steroid injection of 1st CMC joint. Needle at about a 45-degree angle. Distract the thumb to open the joint space.
Indications
- First carpometacarpal (CMC) joint painful osteoarthritis
- ICD-9 codes:
- 715.14 “osteoarthrosis, localized, primary, hand”
- 719.44 “pain in joint, hand”
- ICD-10 codes:
- M18.0 “primary arthrosis of first carpometacarpal joint, bilateral“
- M18.1 “primary arthrosis of first carpometacarpal joint, unilateral“
- M25.54 “pain in a joint, hand”
CPT code: 20600 “Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)”
Read the full story
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Posted in 1st Carpometacarpal Joint, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: abductor pollicis longus, celestone, CPT code, de quervain's, extensor pollicis brevis, Finkelstein's test, ICD-10 code, ICD-9 code, Kenalog, procedure, radial styloid, stenosing tenosynovitis, steps, tendovaginitis
By Chris Faubel, MD –
Put needle between the abductor pollicis longus and extensory pollicis brevis tendon
Indications
- de Quervain’s tenosynovitis
- ICD-9 code: 727.04 “radial styloid tenosynovitis”
- ICD-10 code: M65.4 “radial styloid tenosynovitis [de Quervain]“
CPT code: 20550 “injection(s); single tendon sheath, or ligament, aponeurosis”
Materials Needed
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Posted in De Quervain's, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: celestone, code, depo-medrol, golfer's elbow, ICD-10, ICD-9, medial epicondyle, medial epicondylitis, pain, post-injection flare, procedure, skin wheal, steps, steroid, tuberculin
By Chris Faubel, MD –
Point of maximal tenderness just distal to the medial epicondyle
Indications
- Medial Epicondylitis / “Golfer’s Elbow”
- ICD-9 code: 726.31 “medial epicondylitis”
- ICD-10 codes:
- M77.01 “medial epicondylitis, right elbow”
- M77.02 “medial epicondylitis, left elbow”
CPT code: 20551
Materials Needed
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Posted in Medial Epicondyle, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: Cozen's test, ICD-10, ICD-9, Lateral epicondyle, lateral epicondylitis, pain, post-injection flare, procedure, steps, steroid, Tennis elbow, tuberculin syringe
By Chris Faubel, MD –
Point of maximal tenderness 1-3cm distal to lateral epicondyle
Indications
- Lateral Epicondylitis / “Tennis Elbow”
- ICD-9 code: 726.32 “lateral epicondylitis”
- ICD-10 codes:
- M77.11 “lateral epicondylitis, right elbow”
- M77.12 “lateral epicondylitis, left elbow”
CPT code: 20551
Materials Needed
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Posted in Lateral Epicondyle, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: biceps, biceps tendon injection, bicipital, bicipital tendinitis, injection, procedure, sheath, skin wheal, steps, steroid, tendon, tenosynovitis
Biceps Tendon Sheath Injection
By Chris Faubel, MD –
Indications
- Bicipital tenosynovitis
- ICD-9 code: 726.12 “bicipital tenosynovitis”
- ICD-10 code: M75.2 “bicipital tendinitis”
CPT code: 20550
Materials Needed
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Posted in Bicipital Tendon Sheath, Procedures, Upper Extremity
Posted on 29 October 2010. Tags: Allen's test, carpal tunnel injection, carpal tunnel syndrome, procedure, steps, steroid, wrist splints
By Chris Faubel, MD –
Carpal Tunnel Injection
Indications
- Carpal Tunnel Syndrome
- ICD-9 code: 354.0 “carpal tunnel syndrome”
- ICD-10 code: G56.0 “carpal tunnel syndrome”
CPT code: 20526
Materials Needed
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Posted in Carpal Tunnel, Procedures, Upper Extremity
