OIG Highlights Compliance Risk for SI Joint Injections

The findings of an Office of Inspector General (OIG) audit report released August 5 should get the attention of pain management practices. The report (OAS-25-9-021) is based on an audit the federal agency conducted on Medicare payments for sacroiliac (SI) joint injections.

The OIG estimates in the report that Medicare improperly paid physicians approximately $15.2 million for 134,526 of 186,842 SI joint injection sessions between Oct. 1, 2023, through Sept. 30, 2024 (audit period).

Of the 100 sessions sampled, 72 did not comply with one or more Medicare requirements. The OIG also found that billing for 25 sampled sessions did not meet Medicare guidance because the injections were billed as therapeutic when they should have been classified as diagnostic.

The $15.2 million estimate certainly gets attention, but the more important compliance takeaway is understanding exactly what the OIG found when it reviewed the medical records. The findings were not limited to CPT® coding errors.

What the OIG Audit Revealed

The OIG found that clinical documentation often did not meet specific Medicare coverage requirements for SI joint injections.

One of the most significant areas of noncompliance involved the indications for the patient’s pain.

The applicable local coverage determination (LCD) requirements include specific criteria related to the location and duration of pain, provocative maneuvers, conservative treatment, radiculopathy, and whether another condition may explain the patient’s symptoms. The documentation also must support the requirements surrounding imaging, pain assessment, and progression from diagnostic to therapeutic injections.

Table A shows what the OIG found in its sample of 100 SI joint injection sessions.

Table A

* A single session could have more than one deficiency; the individual findings should not be added together to determine the number of noncompliant claims.

Fixing Insufficient Documentation

When you look at the findings from this overall perspective, the compliance issue becomes much clearer. Simply having an SI joint diagnosis documented in the medical record does not establish that all Medicare coverage requirements have been satisfied. The documentation needs to demonstrate the stated clinical criteria supporting the procedure.

Pain Levels

The applicable LCDs require documentation of the patient’s primary pain level before the injection and the post procedure pain level at the end of the session.

The OIG found that 31 of the 100 sampled sessions did not have the required pain level documented at the end of the session. That is almost one-third of the entire sample with a deficiency involving one specific documentation element.

Pain Relief

The progression from diagnostic to therapeutic injections deserves similar attention. Under the requirements evaluated by the OIG, a subsequent diagnostic injection is not considered reasonable and necessary when the initial diagnostic injection fails to produce at least 75 percent pain relief.

Before proceeding to a therapeutic injection, the diagnostic injection must provide at least 75 percent relief of the patient’s primary pain. Subsequent therapeutic injections require evidence that the prior therapeutic injection resulted in at least 50 percent consistent pain relief or functional improvement for at least three months.

This demonstrates why auditing SI joint injections should include more than a review of an individual procedure note. Documentation from previous encounters and injections may be necessary to establish whether the next procedure meets Medicare requirements. Likewise, a practice auditing only the current date of service could potentially miss an important area of compliance risk.

Audit Considerations for SI Joint Injections

The report gives us a roadmap of the issues government auditors are identifying when reviewing SI joint injection services.

If your organization performs these procedures, now is the time to look at your own claims. An effective audit should not simply ask whether the CPT® code matches the procedure performed. It should evaluate:

• the complete clinical and billing pathway, including the characteristics and duration of the patient’s pain,
• provocative testing,
• conservative treatment,
• imaging requirements,
• pre-procedure and post-procedure pain assessments,
• response to previous injections, progression from diagnostic to therapeutic services,
• modifier usage,
• frequency limitations, and
• other procedures performed during the same session.

Practices should audit against the requirements applicable to their specific Medicare Administrative Contractor (MAC) jurisdiction. OIG specifically highlighted differences among MAC jurisdictions, including the fact that two of the seven MACs did not have an SI joint injection LCD or related reference article during the audit period.

The goal of a proactive compliance audit is not simply to find errors. It is to identify patterns, determine why those patterns are occurring, provide education where necessary, and correct processes before those issues become repayment demands, extrapolated findings, or larger compliance concerns.

With 72 of 100 sampled sessions failing one or more Medicare requirements, this report should be a strong signal for practices performing SI joint injections to assess their own risk.

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Stephanie Allard

Stephanie Allard, CPC, CEMA, RHIT, is CEO and president Stephanie Allard Consulting, LLC.
She brings 20 years of medical and management experience with a strong understanding of the entire medical billing and coding process. She has managed large teams of coders and understands the importance of quality reviews, productivity tracking, and coding education.

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• OIG Highlights Compliance Risk for SI Joint Injections - September 22, 2026