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Herbie Lorona
04-30-2009, 09:12 AM
The Dr. gives a patient a steroid injection in the left sacroiliac. What CPT code would you come up with?

RebeccaWoodward*
04-30-2009, 09:28 AM
Does CPT code 27096 support your documentation?

Herbie Lorona
04-30-2009, 09:31 AM
Well I was not to sure exactly what 27096 consists of. Can you give me more info on this code?

RebeccaWoodward*
04-30-2009, 09:41 AM
Description
An injection procedure for sacroiliac joint arthrography and/or an injection of anesthetic or steroid is performed. The skin over the injection site is cleansed and a local anesthetic is injected. A needle may be inserted into the joint and fluid aspirated with a syringe. If arthrography is performed, a radiopaque substance is injected into the sacroiliac joint. Once the radiopaque substance has been distributed throughout the joint, separately reportable radiographic images are obtained. An anesthetic or steroid injection may also be administered separately or in conjunction with the arthrography procedure.

Musculoskeletal System, 27096, 20610 (Q&A)

Question

If an injection is administered into the sacroiliac (SI) joint without fluoroscopic imaging guidance, would it be appropriate to report code 20610 or code 27096?

AMA Comment

From a CPT coding perspective, if an injection is administered into the SI joint without fluoroscopic imaging guidance, then it would be appropriate to report code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa), for the injection administered into the SI joint without fluoroscopic imaging guidance. Doing it blindly is injecting the L5-S1 facet joint.

The first parenthetical under 27096 clearly makes this point, ie, 27096 is to be used only with imaging confirmation of intra-articular needle positioning.

It would not be appropriate to report code 27096, Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid, as fluoroscopic guidance is crucial to identify the optimal site for access to the joint. Code 27096 should only be reported when imaging confirmation of intra-articular needle position has been performed.

Herbie Lorona
04-30-2009, 09:47 AM
Thank you Rebecca,

This was done in the office so I am saying it is 20610.