LCD Reference Article Billing and Coding Article

Billing and Coding: Sacroiliac Joint Injections and Procedures

A59192

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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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59192
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
04/18/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

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

Article Guidance

Article Text

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

  1. All documentation must be maintained in the patient's medical record and made available to the A/B MAC 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 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.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
032X Radiology - Diagnostic - General Classification
036X Operating Room Services - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
076X Specialty Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
27096 Inject sacroiliac joint
64451 Njx aa&/strd nrv nrvtg si jt

Group 2

(1 Code)
Group 2 Paragraph

The following CPT®/HCPCS codes are non-covered. This is not an inclusive list of non-covered codes.

Group 2 Codes
Code Description
64625 Rf abltj nrv nrvtg si jt

Group 3

(1 Code)
Group 3 Paragraph

For ASC facility and OPPS hospital outpatient department claims only:

Group 3 Codes
Code Description
G0260 Inj for sacroiliac jt anesth
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

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.

A/B MACs 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
032X Radiology - Diagnostic - General Classification
036X Operating Room Services - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
076X Specialty Services - General Classification
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/18/2024 R5

Under Article Text revised second paragraph, second sentence to read “Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare” and removed broken hyperlink.

01/25/2024 R4

Under Article Text: Coding Guidance subheading Diagnostic and Therapeutic procedures sixth paragraph was revised to read “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.” Under CPT/HCPCS Codes Group 3: Paragraph verbiage was revised to read “For ASC facility and OPPS hospital outpatient department claims only.” Under CPT/HCPCS Codes Group 3: Codes deleted 77002 and 77012. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph verbiage was added to read “CPT® codes 27096, 64451, and HCPCS code G0260.” Formatting was corrected throughout the article.

10/12/2023 R3

Under Article Text the broken hyperlink for NCCI requirements was corrected.

08/31/2023 R2

Formatting, punctuation and typographical errors were corrected throughout the article. Acronyms were inserted where appropriate throughout the article.

03/19/2023 R1

Under Article Text subheading Coding Guidance: Diagnostic and Therapeutic procedures verbiage in the second sentence was revised to read “For professional services performed by the physician and billed on a CMS 1500 or electronic equivalent.” In the third paragraph, third sentence verbiage was revised to read “Do not report a SIJI (CPT® 27096) and a sacral nerve block (CPT® 64451) for the same side, per the policy.” The fourth paragraph verbiage was revised to read “For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center (ASC).” The sixth paragraph verbiage has been revised to read “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. G0260 should be reported with an imaging code specific to the imaging modality employed. Report CPT® 77002 for fluoroscopic guidance or CPT® 77012 for CT guidance in the ASC and the hospital outpatient department.” Seventh paragraph verbiage was added to read “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 policy.” This revision is retroactive effective for dates of service on or after 3/19/23.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39402 - 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
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
04/08/2024 04/18/2024 - N/A Currently in Effect You are here
01/16/2024 01/25/2024 - 04/17/2024 Superseded View
10/04/2023 10/12/2023 - 01/24/2024 Superseded View
08/22/2023 08/31/2023 - 10/11/2023 Superseded View
05/24/2023 03/19/2023 - 08/30/2023 Superseded View
01/23/2023 03/19/2023 - N/A Superseded View

Keywords

  • SIJI
  • SI joint
  • SI pain