LCD/NCD Portal

L29274

 

SACROILIAC JOINT INJECTION

 

 

01/01/2012

 

Indications and Limitations of Coverage and/or Medical Necessity

• Image guidance is crucial to identify the optimal site for access to the joint.

o Fluoroscopy is often the imaging method of choice.

o Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected.

o Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule.

o Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid.

o 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.

• Medicare will consider the injection procedure of the SI joint medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection.

o In addition, Medicare will consider the injection procedure of the SI joint 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.

o 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.

 

 

CPT/HCPCS Codes

 

27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED

 

 

ICD-9 Codes that Support Medical Necessity

 

For Procedure Code 27096

715.15 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH

715.18 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES

715.25 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH

715.28 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES

715.35 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH

715.38 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING OTHER SPECIFIED SITES

715.95 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING PELVIC REGION AND THIGH

715.98 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES

716.15 TRAUMATIC ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

716.55 UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING PELVIC REGION AND THIGH

716.58 UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING OTHER SPECIFIED SITES

716.95 UNSPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

716.98 UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES

719.45 PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH

719.48 PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES

720.0 ANKYLOSING SPONDYLITIS

720.2 SACROILIITIS NOT ELSEWHERE CLASSIFIED

721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY

724.02 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION

724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

724.2 LUMBAGO

724.3 SCIATICA

724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

724.6 DISORDERS OF SACRUM

724.79 OTHER DISORDERS OF COCCYX

726.5 ENTHESOPATHY OF HIP REGION

739.4 NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED

739.5 NONALLOPATHIC LESIONS OF PELVIC REGION NOT ELSEWHERE CLASSIFIED

756.11 CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION

846.1 SACROILIAC (LIGAMENT) SPRAIN

846.8 OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN

846.9 UNSPECIFIED SITE OF SACROILIAC REGION SPRAIN

847.3 SPRAIN OF SACRUM

 

 

Documentation Requirements

• Medical record documentation maintained by the performing provider must clearly indicate the medical necessity for billing a SI joint injection and that the SI joint injection was performed using imaging confirmation of intra-articular needle positioning.

• As stated in the “Indications and Limitations of Coverage” section, when SI joint injection is used for therapeutic purposes, the documentation must support other noninvasive treatments attempted.

• This information is normally found in the history and physical or the office/progress notes.

 

 

Utilization Guidelines

• The frequency at which a SI joint injection is performed is dependent on the clinical presentation of the patient.

o However, it is generally expected that the patient’s response to the previous injection is important in deciding whether and when to proceed with additional injections for therapeutic indications.

o If the patient has achieved significant benefit after the first injection, a second injection would be appropriate for reoccurring symptoms.

o However, if the patient experiences no symptom relief or functional improvement after two (2) injections, medical literature supports that additional injection would not be expected, because the probability of a positive outcome is low.

o If therapeutic effect is achieved, a maximum of three (3) injections per year, per site, is recommended.

Treatment Logic

• 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.

 

 

Sources of Information and Basis for Decision

 

Aeschbach, A. & Mekhail, N.A. (2000). Common nerve blocks in chronic pain management. Regional Anesthesia, 18 (2). Retrieved June 20, 2002 from the World Wide Web: www.mdconsult.com. This article supports the indications and techniques of this procedure.

 

American Medical Association (2001). CPT 2002 changes: An insider’s view. Chicago: American Medical Association. This reference further explains procedure code 27096.

 

Cardone, D.A. & Tallia, A.F. (2002). Joint and soft tissue injection. American Family Physician. Retrieved July 24, 2002 from the World Wide Web: www.aafp.org. This article supports the therapeutic indications and utilization parameters for therapeutic injections.

 

Dussault, R.G., Kaplan, P.A., & Anderson, M.W. (2000). Fluoroscopy-guided sacroiliac joint injections. Radiology; 214: 273-277. Retrieved July 8, 2002 from the World Wide Web: www.radiology.rsnajnls.org. This study verified that fluoroscopy-guided intra-articular needle insertions is a safe and rapid procedure, and that injection of local anesthetic can be a useful diagnostic test.

 

Tollison, C.D., Satterthwaite, J.R., & Tollison, J.W. (2002). Practical pain management, 3rd ed., (8), 91-97. Philadelphia: Lippincott. This source was used in the LMRP description.

 

Waldman, S.D. (2000). Atlas of pain management injection techniques, (65), 225-227. Philadelphia, W.B. Saunders. This source defined the anatomy of the sacroiliac joint.

 

01/01/2012

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.