The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacroiliac Joint Injections and Procedures L39402.
The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
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.
The related LCD 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:
SIJIs 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 SIJI 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 SIJI (CPT® 27096) and a sacral nerve block (CPT® 64451) for the same side, per the LCD.
For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center (ASC):
ASC facility claims (specialty 49) report bilateral procedures on 2 separate lines, with 1 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 SIJIs. 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 SJ should be reported with CPT® 64451. CPT® 64451 includes imaging guidance. Imaging codes should not be reported with CPT® 64451.
Critical Access Hospitals (TOB 85X) should report SIJI with CPT® 27096 and a sacral nerve block with CPT® 64451. Bilateral injections should be reported using modifier 50. If a unilateral SIJI (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 SIJI (CPT® 27096) and a sacral nerve block (CPT® 64451) for the same side, per the LCD.
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 1 or 2 required to confirm the diagnosis after beginning treatment are not reasonable and necessary.
Utilization Parameters
No more than 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 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
- All documentation must be maintained in the patient's medical record and made available to the A/B MAC upon request.
- 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.
- 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.
- 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.
- Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.
- The patient’s medical record should include, but is not limited to:
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- 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 Food and Drug Administration (FDA) approved biologicals for use as injectable agents into the SJ. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
