LCD Reference Article Billing and Coding Article

Billing and Coding: Sacroiliac Joint Injections and Procedures

A59246

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A59246
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Sacroiliac Joint Injections and Procedures
Article Type
Billing and Coding
Original Effective Date
03/19/2023
Revision Effective Date
06/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

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Article Guidance

Article Text

Refer to the Local Coverage Determination (LCD) L39464 Sacroiliac Joint Injections and Procedures for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.

Coding Guidance

Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

This policy applies only to sacroiliac joint injections (SIJI) and procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).

Diagnostic and Therapeutic procedures:

Sacroiliac joint injections may be performed unilateral or bilateral in the same session.

For professional services performed by the physician and billed on a CMS 1500 or electronic equivalent:

Bilateral SIJIs procedures reported with CPT 27096 or 64451 should be reported with modifier 50. If a unilateral joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.

For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center:

ASC facility claims (specialty 49) report bilateral procedures on two separate lines, with one unit each. Modifiers -LT and -RT are appended to each line. ASC facilities should not report modifier 50. Professional services performed in the ASC should continue to report bilateral procedures with modifier 50.

CPT 27096 is not a covered service for ASC facility (specialty 49) claims and is not recognized under OPPS. ASC facilities and OPPS hospital outpatient departments should report HCPCS code G0260 for sacroiliac joint injections. The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCPCS code G0260. Image guidance is packaged into G0260, and no separate payment is made to the ASC or OPPS hospital outpatient department for CPT codes 77002 and 77012.

Injections of the nerves innervating the sacroiliac joint should be reported with CPT 64451. CPT 64451 includes imaging guidance. Imaging codes should not be reported with CPT 64451. 

For sacro-iliac joint injections performed without CT or fluoroscopic guidance in patients who are not pregnant and who do not have contrast allergies, do not bill CPT codes 27096, 20610, or 20611. Use CPT code 20552, one unit, for unilateral or bilateral sacroiliac joint injection(s).

Critical Access Hospitals (TOB 85X) should report sacroiliac joint injection with CPT 27096 and a sacral nerve block with CPT 64451. Bilateral injections should be reported using modifier 50. If a unilateral sacroiliac joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.

Physician services in an ASC setting should report codes as noted above in the section on Professional services performed by the physician.

KX modifier requirements:

The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first one or two required to confirm the diagnosis, after beginning treatment are not reasonable and necessary.

Utilization Parameters

No more than two (2) diagnostic joint sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.

No more than four (4) therapeutic SIJI sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.

 

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.
  5. Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.
  6. The patient’s medical record should include, but is not limited to:
    • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit
    • Relevant medical history
    • Results of pertinent tests/procedures
    • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
    • Documentation to support the medical necessity of the procedure(s).

Use of Biologicals

There are currently no FDA approved biologicals for use as injectable agents into the sacroiliac joint. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180 Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.

 

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(4 Codes)
Group 1 Paragraph

CPT codes 27096, 64451, and HCPCS code G0260.

Group 1 Codes
Code Description
M43.28 Fusion of spine, sacral and sacrococcygeal region
M46.1 Sacroiliitis, not elsewhere classified
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M53.3 Sacrococcygeal disorders, not elsewhere classified
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.


Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
06/01/2024 R5

Revision Effective DOS 6/1/2024
Under Coding Guidance, added, “For sacro-iliac joint injections performed without CT or fluoroscopic guidance in patients who are not pregnant and who do not have contrast allergies, do not bill CPT codes 27096, 20610, or 20611. Use CPT code 20552, one unit, for unilateral or bilateral sacroiliac joint injection(s).”

01/25/2024 R4

Under Coding Guidance, Diagnostic and Therapeutic procedures, 6th paragraph, removed “G0260 should be reported with an imaging code specific to the imaging modality employed" and "Report CPT 77002 for fluoroscopic guidance or CPT 77012 for CT guidance in the ASC and the hospital outpatient department” and added, “The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCPCS code G0260" and "Image guidance is packaged into G0260, and no separate payment is made to the ASC or OPPS hospital outpatient department for CPT codes 77002 and 77012.”


Under CPT/HCPCS Codes Group 3 Paragraph, verbiage was revised to read, "For ASC facility and OPPS hospital outpatient department claims only:" Under Group 3 Codes CPT 77002 and 77012 were deleted. Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph, verbiage was added “CPT codes 27096, 64451 and HCPCS code G0260.”


These updates are effective 01/25/2024.

03/19/2023 R3

Updated hyperlink for NCCI Requirements found under Article Guidance.

03/19/2023 R2

Updated to indicate this article is an LCD Reference Article.

03/19/2023 R1

Revision Effective Date: 3/19/2023

Editorial/clarification changes or updates made to the Coding Guidance section.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39464 - Sacroiliac Joint Injections and Procedures
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
05/31/2024 06/01/2024 - N/A Currently in Effect You are here
01/19/2024 01/25/2024 - 05/31/2024 Superseded View
12/08/2023 03/19/2023 - 01/24/2024 Superseded View
11/16/2023 03/19/2023 - N/A Superseded View
06/02/2023 03/19/2023 - N/A Superseded View
01/27/2023 03/19/2023 - N/A Superseded View

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