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Local Coverage Article Billing and Coding

Billing and Coding: Sacroiliac Joint Injections and Procedures

A59192

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Contractor Information

Article Information

General Information

Article ID
A59192
Article Title
Billing and Coding: Sacroiliac Joint Injections and Procedures
Article Type
Billing and Coding
Original Effective Date
03/19/2023
Revision Effective Date
03/19/2023
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 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:

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 policy.

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. 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. 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 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 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 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 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.

Coding Information

CPT/HCPCS Codes

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Group 1

(2 Codes)
Group 1 Paragraph

N/A

 Group 1 Codes
CodeDescription
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
CodeDescription
64625 Rf abltj nrv nrvtg si jt

Group 3

(3 Codes)
Group 3 Paragraph

For ASC facility claims only: G0260 must be billed with fluoroscopy (77002) OR CT (77012).

 Group 3 Codes
CodeDescription
77002 Needle localization by xray
77012 Ct scan for needle biopsy
G0260 Inj for sacroiliac jt anesth

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(4 Codes)
Group 1 Paragraph

N/A

 Group 1 Codes
CodeDescription
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

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

N/A

ICD-10-PCS Codes

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.

CodeDescription
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

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.
CodeDescription
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

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
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.

Associated Documents

Related Local Coverage Documents
LCDs
L39402 - Sacroiliac Joint Injections and Procedures
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
05/24/2023 03/19/2023 - N/A Currently in Effect You are here
01/23/2023 03/19/2023 - N/A Superseded View

Keywords

  • SIJI
  • SI joint
  • SI pain

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