Refer to the proposed Local Coverage Determination (LCD) DL39462 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.
Bilateral SIJIs procedures reported with 27096 or 64451 should be reported with modifier 50.
For services performed in the ASC (specialty 49), do not bill on one claim line using modifier 50. For ASC (specialty 49), report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.
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
- All documentation must be maintained in the patient's medical record and made available to the contractor 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:
- 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.
