Straight Up Coding for Sacroiliac Joint Injections

Proper reporting requires modifier and radiological guidance knowledge.

Why Inject the SI?
SI joint dysfunction generally refers to pain caused by abnormal motion (too much or too little) in the SI joint, which in turn results in inflammation of the joint (sacroiliitis). The purpose of a SI joint injection is two-fold:
Diagnostic: SI joint injection is used to confirm a suspected diagnosis of sacroiliac joint dysfunction. A local anesthetic (usually lidocaine or bupivacaine) typically is injected into the joint, with the goal of determining immediate pain relief to confirm the SI joint as the pain’s source.
Pain Relief: A therapeutic SI joint injection is done to provide relief of the pain associated with sacroiliac joint dysfunction. An anti-inflammatory medication (usually a corticosteroid) may help reduce inflammation within the joint, which is intended to alleviate the pain over time (typically, for several months, up to a year).
At times, a patient will undergo a purely diagnostic or therapeutic injection. Often, however, the two are combined in a single injection.
SI injection is a minor procedure, usually performed in an operating or dedicated procedure room. After informed consent has been obtained, the patient lies face down on his or her stomach on the radiography table. A pillow might be placed under the hips for patient comfort. Depending on the physician and the patient’s preference, an intravenous line may be inserted to deliver medication to help the patient relax. The patient’s vitals (e.g., pulse rate and blood pressure) are monitored throughout the procedure.
The needle insertion site often is numbed using local anesthetic. When the needle enters the SI joint under fluoroscopy guidance, contrast (dye) is injected to verify needle placement and the spread of solution within the joint. When the needle has been guided into the joint successfully, diagnostic and/or therapeutic medications are injected into the joint. The patient goes home on the same day.
Look to Radiological Guidance when Coding
Code selection for SI joint injection depends mainly on the radiological guidance used. Normally, SI joint injection is done with the fluoroscopic or computed tomography (CT) guidance, but it may also be performed with ultrasound guidance, or without radiological guidance.
Report 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed for SI joint injection of anesthetic/steroid with fluoroscopy or CT guidance. Do not report the guidance separately: It’s included in 27096. If an arthrogram is performed along with the injection, the arthrogram is not separately reportable.
Note that 27096 is a unilateral procedure. For bilateral injection, you may append modifier 50. For example, if a 38-year-old male undergoes bilateral SI joint injection with fluoroscopic guidance, report 27096-50.
Do not report 27096 for SI joint injection with ultrasonic guidance, or if done without radiological guidance. For these circumstances, CPT® directs us to report 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s), along with 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation for the ultrasonic guidance (when provided). Do not report 20552 with modifier 50, even if bilateral injections are performed.
For example, if a 56-year-old female undergoes bilateral SI joint injection with ultrasonic guidance, report 20552, 76942.
If SI joint injection with or without ultrasonic guidance is performed along with the trigger point injections in more than three muscles, turn to 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s). In this case, you cannot bill the SI joint injection separately.
For example, a 36-year-old male undergoes right side SI joint injection with ultrasonic guidance and trigger point injections at quadriceps, psoas, and trapezius muscles. Proper coding is 20553, 76942.
Because appropriate reimbursement is based on the guidance used, providers should document this clearly.
Bio: Thangaraj Arunachalam, CPC, is an assistant manager at Synthesis Healthcare Services, specializing in surgery, radiology, and interventional radiology coding.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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