CPT CODE 27096, G0259, g0260 - SACROILIAC (SI) JOINT INJECTIONS

cpt code and description

27096 - Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed - average fee amount - $120 - $160

G0259 - Injection procedure for sacroiliac joint; arthrograpy

G0260 - Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

Medicare Guideline update

Payment to Ambulatory Surgical Centers (ASCs) for G0260 and to Physicians for 27096 when 27096 is Performed in an ASC Note: This article was updated on April 5, 2013, to reflect current Web addresses. All other information remains unchanged.

Provider Types Affected

Physicians and ambulatory surgical centers.

Provider Action Needed 

STOP – Impact to You

Some Medicare carriers have been reimbursing incorrectly for sacroiliac joint injection of anesthetic agents or steroids (HCPCS code G0260) when the procedure is performed in an Ambulatory Surgical Center (ASC). Also, due to several inadvertent coding conflicts, physicians at ASCs who perform an injection procedure for a sacroiliac joint, arthrography, and/or anesthetic/steroid (Procedure  code 27096) may be reimbursed incorrectly as well.


Coverage Indications, Limitations, and/or Medical Necessity

    The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

    Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

    The injection procedure of the SI joint will be considered medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, the injection procedure of the SI joint will be considered medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.

SACROILIAC (SI) JOINT INJECTIONS 

The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.


The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

The injection procedure of the SI joint will be considered medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, the injection procedure of the SI joint will be considered medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.

SACROILIAC (SI) JOINT INJECTIONS 

The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.

STOP – Impact to You

Some Medicare carriers have been reimbursing incorrectly for sacroiliac joint injection of anesthetic agents or steroids (HCPCS code G0260) when the procedure is performed in an Ambulatory Surgical Center (ASC). Also, due to several inadvertent coding conflicts, physicians at ASCs who perform an injection procedure for a sacroiliac joint, arthrography, and/or anesthetic/steroid (CPT code 27096) may be reimbursed incorrectly as well.



CAUTION – What You Need to Know

Some Medicare carriers may not have been paying the facility fee to ASCs when they billed Medicare for HCPCS code G0260—injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrogrophy. In addition, due to several inadvertent coding conflicts, physicians may not have been paid correctly for HCPCS code 27096—injection procedure for sacroiliac joint, arthrography, and/or anesthetic steroid—when administered in an ASC. Both of these issues apply to services rendered on or after July 1, 2003



Be aware that carriers reimburse a facility fee to the ASC for HCPCS code G0260 for services performed on or after July 1, 2003, and that physicians who perform HCPCS 27096 is an ASC should be reimbursed the non-facility payment amount.



Background

HCPCS code G0260 (sacroiliac joint injection of anesthetic agents or steroids) was added to the list of approved ASC procedures for services performed on or after July 1, 2003 (CMS-1885-FC, 3/28/03). Therefore, when a therapeutic sacroiliac joint injection is administered to a Medicare beneficiary at an Ambulatory Surgical Center, it should be reported by the ASC as HCPCS code G0260. HCPCS code G0260, however, is not payable under the Medicare Physician Fee Schedule (MPFS). Physicians use CPCS code 27096 to bill for sacroiliac joint injection of anesthetic agents or steroids. Since HCPCS code 27096 was not on the list of Medicare approved ASC procedures, physicians may have been overpaid when performing this procedure in an ASC.

To rectify this problem, carriers have been instructed to add CPT code 27096 to their file of ASC approved procedures. Physicians who perform a sacroiliac joint injection of anesthetic agents or steroids (CPT code 27096) will now be reimbursed at the correct rate under the Medicare physician fee schedule. Please note that, for those Medicare carriers who did not make this change in a timely manner, there is a time lag between the effective date of July 1, 2003 and their new implementation date of February 2, 2004. Given this difference, claims that are submitted on or after the effective date for date of service, but prior to the implementation date, will be processed under the old rules. If this has affected your payments, you may wish to submit adjustment claims after February 2 in order to correct the payment.


Sacroiliac (SI) Joint Injections (CPT codes 27096 and G0260)

* Medicare does not have a National Coverage Determination (NCD) for Sacroiliac (SI) Joint Injections.

* Local Coverage Determinations (LCDs) which address sacroiliac injections exist and compliance with these LCDs is required where applicable. For state-specific LCD, refer to the LCD Availability Grid (Attachment F).

* For states with no LCDs, see the Wisconsin Physicians Services Novitas LCD for Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections (L34892) for coverage guidelines.

(IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)


These are the only procedure where the CPT codes the ASC facility and the physician will bill may differ – codes are 27096 OR G0260.

27096 - Injection procedure for Sacroiliac Joint, Arthrography and/or Anesthetic/Steroid G0260 - Injection procedure for Sacroiliac Joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without Arthrography to be billed by ASC facilities ONLY.

* The ASC should use the G0260 code to bill SI Joint Injections to Medicare.

* The professional side (Physician claim) for SI Joint Injections should be billed to

Medicare with the 27096 code.

* The G0260 code is on the Medicare ASC list of covered procedures. The 27096 is NOT on the Medicare list of covered procedures. The physician and facility
CPT Codes are Copyrighted by the  claim coding will not match in this instance, but this coding is the correct way to code the procedure.

* The 27096 code is for use when the ASC facility is billing SI Joint Injections to ayors other than Medicare, unless they want the G-code instead. The facility would NOT bill the 27096 code to Medicare.

* Radiology codes – for SI Joint Injections performed with Arthrography, the 73542-TC code should be billed. The Fluoroscopy code to use with SI Joint Injections when Arthrography is not performed is code 77003-TC. These codes are billable provided the payor allows the billing of radiology services – which Medicare does NOT reimburse.

* The G-code and 27096 codes are for use billing SI Joint Injections performed with radiologic guidance. If the SI Joint Injection is performed without the use of radiologic guidance, neither the G-code nor the 27096 should be billed. SI Joint

Injections performed without the use of radiologic guidance should be billed using the 20610 code for an Injection into a Major Joint (which reimbursed at a low rate by Medicare). The 20610 code would be used by both the physician and the ASC
facility.

* For a Radiofrequency Treatment of the SI Joint, use code 64640. The most common diagnosis codes for SI Joint Injection procedures are 724.6 for Disorders of the Sacrum and 720.2 for Sacroiliitis. If an injection is administered in the Sacroiliac Joint without the use of Fluoroscopic guidance, report only the procedure code for the SI Joint Injection.

A formal radiologic report must be dictated when using the 73542 code for the Arthrography. Do not report code 77003-TC with code 73542-TC. The injection of contrast material is inclusive. This is a unilateral procedure; when a bilateral procedure is performed, bill it in a Bilateral manner by appending the -RT/-LT or -50 Bilateral Modifiers. Report CPT code 73542-TC for the Arthrography performed with the –TC Modifier.



ICD-10 Codes that Support Medical Necessity
   
    For Procedure Code 27096
 
    M08.1 Juvenile ankylosing spondylitis
    M12.551 Traumatic arthropathy, right hip
    M12.552 Traumatic arthropathy, left hip
    M12.559 Traumatic arthropathy, unspecified hip
    M12.851 Other specific arthropathies, not elsewhere classified, right hip
    M12.852 Other specific arthropathies, not elsewhere classified, left hip
    M12.859 Other specific arthropathies, not elsewhere classified, unspecified hip
    M13.851 Other specified arthritis, right hip
    M13.852 Other specified arthritis, left hip
    M13.859 Other specified arthritis, unspecified hip
    M16.0 Bilateral primary osteoarthritis of hip
    M16.10 Unilateral primary osteoarthritis, unspecified hip
    M16.11 Unilateral primary osteoarthritis, right hip
    M16.12 Unilateral primary osteoarthritis, left hip
    M16.2 Bilateral osteoarthritis resulting from hip dysplasia
    M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip
    M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip
    M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip
    M16.4 Bilateral post-traumatic osteoarthritis of hip
    M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip
    M16.51 Unilateral post-traumatic osteoarthritis, right hip
    M16.52 Unilateral post-traumatic osteoarthritis, left hip
    M16.6 Other bilateral secondary osteoarthritis of hip
    M16.7 Other unilateral secondary osteoarthritis of hip
    M16.9 Osteoarthritis of hip, unspecified
    M25.551 Pain in right hip
    M25.552 Pain in left hip
    M25.559 Pain in unspecified hip
    M25.751 Osteophyte, right hip
    M25.752 Osteophyte, left hip
    M25.759 Osteophyte, unspecified hip
    M43.27 Fusion of spine, lumbosacral region
    M43.28 Fusion of spine, sacral and sacrococcygeal region
    M45.6 Ankylosing spondylitis lumbar region
    M45.7 Ankylosing spondylitis of lumbosacral region
    M45.8 Ankylosing spondylitis sacral and sacrococcygeal region
    M46.1 Sacroiliitis, not elsewhere classified
    M47.26 Other spondylosis with radiculopathy, lumbar region
    M47.27 Other spondylosis with radiculopathy, lumbosacral region
    M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
    M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
    M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
    M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
    M47.896 Other spondylosis, lumbar region
    M47.897 Other spondylosis, lumbosacral region
    M47.898 Other spondylosis, sacral and sacrococcygeal region
    M48.06 Spinal stenosis, lumbar region
    M48.07 Spinal stenosis, lumbosacral region
    M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region
    M48.8X2 Other specified spondylopathies, cervical region
    M48.8X3 Other specified spondylopathies, cervicothoracic region
    M48.8X4 Other specified spondylopathies, thoracic region
    M48.8X5 Other specified spondylopathies, thoracolumbar region
    M48.8X6 Other specified spondylopathies, lumbar region
    M48.8X7 Other specified spondylopathies, lumbosacral region
    M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region
    M48.8X9 Other specified spondylopathies, site unspecified
    M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
    M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
    M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
    M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
    M53.2X7 Spinal instabilities, lumbosacral region
    M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
    M53.3 Sacrococcygeal disorders, not elsewhere classified
    M53.86 Other specified dorsopathies, lumbar region
    M53.87 Other specified dorsopathies, lumbosacral region
    M53.88 Other specified dorsopathies, sacral and sacrococcygeal region
    M54.14 Radiculopathy, thoracic region
    M54.15 Radiculopathy, thoracolumbar region
    M54.16 Radiculopathy, lumbar region
    M54.17 Radiculopathy, lumbosacral region
    M54.30 Sciatica, unspecified side
    M54.31 Sciatica, right side
    M54.40 Lumbago with sciatica, unspecified side
    M54.41 Lumbago with sciatica, right side
    M54.42 Lumbago with sciatica, left side
    M54.5 Low back pain
    M70.60 Trochanteric bursitis, unspecified hip
    M70.61 Trochanteric bursitis, right hip
    M70.62 Trochanteric bursitis, left hip
    M70.70 Other bursitis of hip, unspecified hip
    M70.71 Other bursitis of hip, right hip
    M70.72 Other bursitis of hip, left hip
    M76.00 Gluteal tendinitis, unspecified hip
    M76.01 Gluteal tendinitis, right hip
    M76.02 Gluteal tendinitis, left hip
    M76.10 Psoas tendinitis, unspecified hip
    M76.11 Psoas tendinitis, right hip
    M76.12 Psoas tendinitis, left hip
    M76.20 Iliac crest spur, unspecified hip
    M76.21 Iliac crest spur, right hip
    M76.22 Iliac crest spur, left hip
    M76.30 Iliotibial band syndrome, unspecified leg
    M76.31 Iliotibial band syndrome, right leg
    M76.32 Iliotibial band syndrome, left leg
    M99.04 Segmental and somatic dysfunction of sacral region
    M99.05 Segmental and somatic dysfunction of pelvic region
    M99.23 Subluxation stenosis of neural canal of lumbar region
    M99.33 Osseous stenosis of neural canal of lumbar region
    M99.43 Connective tissue stenosis of neural canal of lumbar region
    M99.53 Intervertebral disc stenosis of neural canal of lumbar region
    M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
    M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
    Q76.2 Congenital spondylolisthesis
    S33.6XXA Sprain of sacroiliac joint, initial encounter
    S33.6XXD Sprain of sacroiliac joint, subsequent encounter
    S33.6XXS Sprain of sacroiliac joint, sequela
    S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter
    S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter
    S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela
    S33.9XXA Sprain of unspecified parts of lumbar spine and pelvis, initial encounter
    S33.9XXD Sprain of unspecified parts of lumbar spine and pelvis, subsequent encounter
    S33.9XXS Sprain of unspecified parts of lumbar spine and pelvis, sequela


Based on review of the case file the following is noted:


* ISSUE IN DISPUTE: Provider seeking $549.33 in remuneration for G0260-LT Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography, performed 11/21/2014.


* Claims Administrator reimbursement rational: “Service not paid under OPPS.”


* Pursuant to Labor Code section 5307.1(g)(2), the Administrative Director of the Division of Workers’ Compensation orders that Title 8, California Code of Regulations, sections 9789.30 and 9789.31, pertaining to Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule in the Official Medical Fee Schedule, is amended to conform to CMS’ hospital outpatient prospective payment system (OPPS). The Administrative Director incorporates by reference, the Centers for Medicare and Medicaid Services' (CMS) Hospital Outpatient Prospective Payment System (OPPS) certain addenda published in the Federal Register notices announcing revisions in the Medicare payment rates. The adopted payment system addenda by date of service are found in the Title 8, California Code of Regulations, and Section 9789.39(b). Based on the adoption of the CMS hospital outpatient prospective payment system (OPPS), CMS coding guidelines and the hospital outpatient prospective payment system (OPPS) were referenced during the review of this Independent Bill Review (IBR) case


* Based on the provider type, the reimbursement for services is calculated on the Centers for Medicare and Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS). Procedures are assigned APC weights and "Proposed Payment Status Indicators." The surgical HCPCS code G0260 has an assigned indicator of "T". The "T" indicator definition is "Significant procedure, multiple procedure reduction applies" and qualifies for separate APC payment


* UB-04 reflects one line item billed as G0260.


* G0260 code and 27096 codes are for use billing SI Joint Injections performed with radiologic guidance.


* The surgical Procedure  code 27096 has an assigned indicator of “B”. The B indicator definition is “May be paid by fiscal intermediaries/MACs when submitted on a different bill type” and is not paid under OPPS.

* The Operative Report documented “fluoroscopic guidance to the inferior aspect of the left SI jont.”

* A review of the Addendum AA, ASC Covered Surgical Procedures for CY 2014 does not list HCPCS code 27096, but it does list G0260. Addendum B for CY 2014 does not list an APC Relative weight for procedure code 27096 as this codes in not reimbursable under OPPS. However, a relative weight is listed for HCPCS G0260. Therefore, the Provider correctly submitted HCPCS code G0260 for billing an OPPS anesthetic injection to sacroiliac joint and reimbursement is warranted for the ASC payment rate for HCPCS G0260.

* Based on the aforementioned documentation and guidelines, reimbursement is indicated for G0260. 

No comments:

Top Medicare billing tips