Below is from the outpatient hospital/asc final rule from 2013, it appears they have some confusion regarding G0259/G0260. I am interested in July 2013 to see if they have changed their stance on G0260 when they come out with the 2014 proposed outpatient hospital/ASC rule. I think it is important to note that Medicare does not cover diagnostic procedures such as discograms or myelograms in ASC setting due to the fact they soley diagnostic. Was there steroid/anesthetic injected with SI joint procedure you are reviewing?
G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography
Panel Recommendation: CMS should
delete HCPCS code G0259 (Injection
procedure for sacroiliac joint;
arthrography) and HCPCS code G0260
(Injection procedure for sacroiliac joint;
provision of anesthetic, steroid and/or
other therapeutic agent, with or without
arthrography), and instead use CPT code
27096 (Injection procedure for sacroiliac
joint, anesthetic/steroid, with image
guidance (fluoroscopy or CT) including
arthrography, when performed) with a
status indicator of ‘‘T,'' and assign CPT
code 27096 to APC 0207 (Level III Nerve
Injections).
Response: In the CY 2013 OPPS/ASC
proposed rule, we did not accept the
Panel's recommendation to delete
HCPCS code G0259 and G0260 and
instead use CPT code 27096 with a
status indicator of ‘‘T'' and assign CPT
code 27096 to APC 0207. For CY 2012,
we assigned CPT code 27096 to status
indicator ‘‘B,'' meaning that this code is
not payable under the OPPS. In order to
receive payment for procedures
performed on the sacroiliac joint with or
without arthrography or with image
guidance under the OPPS, hospitals
must use either HCPCS code G0259,
which is assigned to status indicator
‘‘N'' for CY 2012, or HCPCS code G0260,
which is assigned to status indicator
‘‘T'' for CY 2012, as appropriate. CMS
created HCPCS codes G0259 and G0260
to separate and distinguish the image
guidance procedure from the
therapeutic injection procedure for the
sacroiliac joint. As stated above,
guidance procedures are packaged
under the OPPS because we believe that
they are typically ancillary and
supportive to a primary diagnostic or
therapeutic modality and are an integral
part of the primary service they support.
We believe that the existence of
HCPCS codes G0259 and G0260 is
necessary to assign appropriate
packaged payment for the image
guidance procedure, according to our
established packaging policy, and
separate payment for the therapeutic
injection procedure. Therefore, we did
not accept the Panel's recommendation
and followed the previously established
code G0259 to status indicator ‘‘N,''
HCPCS code G0260 to status indicator
‘‘T,'' and CPT code 27096 to status
indicator ‘‘B'' for CY 2013.
Comment: Several commenters
disagreed with CMS' proposal to not
accept the Panel's recommendation on
HCPCS codes G0259 and G0260 and to
continue to assign a status indicator of
‘‘B'' for CPT code 27096. One
commenter expressed concern that the
continued use of HCPCS codes G0259
and G0260 instead of the CPT code
27096 is administratively burdensome
to hospitals because it does not allow
standardized code reporting among all
payers.
Another commenter stated that there
is no CPT code that would describe the
radiological portion of the procedure to
be reported in addition to HCPCS code
G0259 because the AMA deleted CPT
code 73054. As of January 1, 2012, the
commenter stated that CPT code 27096
is always a complete procedure that
includes the injection of a diagnostic or
therapeutic agent and the associated
imaging. The commenter recommended
that CMS recognize CPT code 27096 and
assign the appropriate APC code to this
CPT code based on the CY 2011 claims
data for HCPCS code G0259 with CPT
code 73542 and HCPCS code G0260 or
modify the descriptor of HCPCS code
G0259 to include the radiological
portion of the procedure and assign the
appropriate status indicator and APC for
the complete procedure.
One commenter stated that CPT codes
77003 (Fluoroscopic guidance and
localization of needle or catheter tip for
spine or paraspinous diagnostic or
therapeutic injection procedures
(epidural or subarachnoid)) and 77012
(Computed tomography guidance for
needle placement (eg, biopsy,
aspiration, injection, localization
device), radiological supervision and
interpretation) that are billed with
HCPCS code G0260 have a NCCI edit
with an indicator of ‘‘1.'' Therefore, the
commenter stated that CPT codes 77003
and 77012 cannot be reported with
modifier ‘‘59'' because the imaging
guidance is not separate and distinct
and it is instead part of the procedure.
The commenter stated that providers
cannot accurately report the cost of the
imaging guidance (either fluoroscopy or
CT) due to the CCI edits and the fact that
the HCPCS code G0260 descriptor does
not indicate if either fluoroscopy or CT
imaging is bundled into the procedure
code. Therefore, the commenter asked
that CMS establish a new HCPCS code
to describe the sacroiliac injection
procedure performed with imaging
(fluoroscopy or CT) or allow the
assign the appropriate APC code to this
CPT code based on the CY 2011 claims
data for HCPCS code G0259 with CPT
code 73542 and HCPCS code G0260 or
modify the descriptor of HCPCS code
G0259 to include the radiological
portion of the procedure and assign the
appropriate status indicator and APC for
the complete procedure.
One commenter stated that CPT codes
77003 (Fluoroscopic guidance and
localization of needle or catheter tip for
spine or paraspinous diagnostic or
therapeutic injection procedures
(epidural or subarachnoid)) and 77012
(Computed tomography guidance for
needle placement (eg, biopsy,
aspiration, injection, localization
device), radiological supervision and
interpretation) that are billed with
HCPCS code G0260 have a NCCI edit
with an indicator of ‘‘1.'' Therefore, the
commenter stated that CPT codes 77003
and 77012 cannot be reported with
modifier ‘‘59'' because the imaging
guidance is not separate and distinct
and it is instead part of the procedure.
The commenter stated that providers
cannot accurately report the cost of the
imaging guidance (either fluoroscopy or
CT) due to the CCI edits and the fact that
the HCPCS code G0260 descriptor does
not indicate if either fluoroscopy or CT
imaging is bundled into the procedure
code. Therefore, the commenter asked
that CMS establish a new HCPCS code
to describe the sacroiliac injection
procedure performed with imaging
(fluoroscopy or CT) or allow the
reporting of CPT code 27096 and revise
the status indicator from ‘‘B'' to ‘‘T.''
Response: We continue to believe that
assigning HCPCS codes G0259 to status
indicator ‘‘N'' is necessary in order to
designate appropriate packaged
payment for the image guidance
procedure, according to our established
packaging policy, and separate payment
for the therapeutic injection procedure.
However, we will reevaluate the
descriptors for HCPCS code G0259 and
G0260 for CY 2014 in light of the
commenter's concerns on the AMA's
modification of the descriptor for CPT
code 27096 in CY 2012 to include the
arthrography services described by CPT
code 73542.
After consideration of the public
comments we received, for CY 2013, we
are continuing to assign a status
indicator of ‘‘N'' to HCPCS code G0259,
a status indicator of ‘‘T'' to HCPCS code
G0260, which is assigned to APC 0207
with a final CY 2013 geometric mean
cost of approximately $582, and a status
indicator of ‘‘B'' to CPT code 27096.
Panel Recommendation: CMS provide
data to the APC Groups and SI
Subcommittee on the following
arthrography services, so that the
Subcommittee can consider whether the
SI for these services should be changed
from ‘‘N'' to ‘‘S'':