Wednesday, November 13, 2019

ST Join INJECTION CPT code - 27096, G0259, G0260


CPT Description

64450 Injection, anesthetic agent; other peripheral nerve or branch

27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

G0259 Injection procedure for sacroiliac joint, arthrography.

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

20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). [Use when the provider does not use fluoroscopy or CT image guidance].




Billing and Coding Guidelines


L31359 LCD Title Sacroiliac Joint Injections Contractor's Determination Number MS-009 General

1. Procedure code 27096 is to be used only with imaging confirmation of intra-articular needle positioning.
2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection.
3. It is not appropriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
4. Procedure code 27096 represents a unilateral procedure. If bilateral SI joint arthrography is performed, 27096 should be reported with a –50 modifier.
5. A SI joint injection (27096) is not a stand-alone code and one of the following codes should be billed in conjunction with this code:
a. When a formal SI joint arthrography is performed with the SI joint injection, procedure code 73542 should be reported for the radiologic supervision and interpretation of sacroiliac joint arthrography.
b. Do not bill CPT code 73542 (Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation) for injection of contrast to verify needle position. The CPT code 73542 is only to be billed for a medically necessary diagnostic study and requires a full interpretation and report.
c. When fluoroscopic guidance is used to locate the specific anatomic site for needle insertion, procedure code 77003 should be reported.
d. When CT guidance is used to locate the specific anatomic site for needle insertion, procedure code 77012 should be reported.
6. CPT code G0260 should be billed by facilities paid by OPPS.
7. Use CPT code 64999 (Unlisted procedure, nervous system) for pulsed radiofrequency and the denervation procedures of the sacro-iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary. Sacro-iliac joint/nerve denervation procedures are also considered investigational and not medically necessary.


General

1. Procedure code 2709 6 is to be used o nly with imaging confirmation of intra -articular needle positioning.
2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection.
3. It is not appr opriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
4. Procedure code 27096 re presents a unilateral proce dure. If bil ateral SI joint arthrography is performed, 27096 should be reported with a –50 modifier.
5. CPT code G0260 should be billed by facilities paid by OPPS.
6. Use CPT code 64999 (Unlisted procedure, ne rvous system) for pulsed radiofrequency and the denervation procedures of the sacro- iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational a nd therefore, not m edically necessary. Sacroiliac joint/nerve denervation procedures are also considered investigational and not medically necessary.

Spinal Cord Stimulators Description


Spinal cord stimulators, also known as dorsal column stimulators (“stimulators”), are implantable devices used to treat chronic pain. Electrodes are surgically placed within the dura mater via laminectomy, or by percutaneous insertion into the epidural space. Low voltage electrical signals are delivered to the dorsal column of the spinal cord in order to override or mask sensations of pain. The patient’s pain distribution pattern determines the level at which the stimulation lead is placed. The lead may incorporate four (4) to eight (8) electrodes, with 8 electrodes typically used for complex pain patterns, such as bilateral pain or pain extending from the limbs to the trunk. Implantation is typically a 2-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed (defined as at least 50% reduction in pain), the electrodes and radio receiver/ transducer are permanently implanted.

Extensive programming of the neurostimulators is often required to achieve optimal pain control.

General Requirements
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following:
**  Prescription strength anti-inflammatory medications and analgesics
**  Adjunctive medications such as nerve membrane stabilizers or muscle relaxants
**  Physician-supervised therapeutic exercise program or physical therapy
**  Manual therapy or spinal manipulation
**  Alternative therapies such as acupuncture
**  Appropriate management of underlying or associated cognitive, behavioral, or addiction disorders

Documentation of compliance with a plan of therapy that includes elements from these areas is required. Exceptions may be considered on a case-by-case basis. Reporting of symptom severity – Severity of pain and its impact on activities of daily living (ADLs) is a key factor in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs. Imaging studies -- All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.


Indications and Limitations of Coverage 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.

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. 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. 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.


Subject: Sacroiliac Joint Injections


DESCRIPTION:


The sacroiliac (SI) joint connects the sacrum with the pelvis. The SI joint lies between the sacrum and the ilium, and functions more for stability than for movement. Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. The sacroiliac joint transmits all the forces of the upper body to the pelvis and legs. The joint’s stability is maintained in part by several large ligaments and muscle groups. Dysfunctions of the sacroiliac joint may be described as sacral, iliac, pubic and sacroiliac joint pain. They are typically without consistent, demonstrable radiographic, or laboratory findings, and most commonly exist in the setting of morphologically normal joints. Pain may arise in the joint itself or in the related muscles and ligaments. Pain may be felt in the lower back or may radiate to one or both hips and/or one or both legs. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the individual. Conservative treatment for sacroiliac joint dysfunction generally centers on restoring motion in the joint and may include:

**  Medications
**  Physical therapy
**  Chiropractic or osteopathic manipulation
**  Sacroiliac joint injections.

Sacroiliac joint injections are divided into two phases, the diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. A second injection may be needed in the diagnostic phase. If there is no pain relief after the diagnostic injection (s) (negative block), the therapy is not continued.

Sacroiliac joint injections are expected to be given at intervals no sooner than every week during a diagnostic phase and no sooner than every eight (8) weeks during the therapeutic phase.

POSITION STATEMENT:
Sacroiliac joint injection performed under fluoroscopy or with arthrography meets the definition of medical necessity when ALL the following criteria are met:

**  Sacroiliac joint pain for more than 3 months; AND
**  Sacroiliac joint injections are part of a comprehensive pain treatment plan; AND
**  Continued pain after 6 weeks with ALL of the following treatments:
**  NSAIDS ≥ 4 weeks (if not contraindicated); AND
**  Activity modification ≥ 6 weeks; AND
**  Physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks; OR
**  Worsening pain after 2 weeks with ALL of the following treatments:
**  NSAIDS (if not contraindicated); AND
**  Activity modification; AND
**  Physical therapy, chiropractic therapy or home exercise program.
**  In the diagnostic phase, up to two (2) injections may be administered, at intervals of no sooner than one (1) week.
**  In the therapeutic phase, each subsequent injection requires that prior injection provided ≥ 50% pain reduction for at least six (6) weeks.

Sacroiliac joint injections do not meet the definition of medical necessity if medical documentation indicates the injection procedures are not effective. Sacroiliac joint injection performed with ultrasound guidance is considered experimental or investigational. There is insufficient evidence to support conclusions regarding effects on net health outcomes.

NOTE: It is not expected that epidural blocks, multiple facet joint injections, sacroiliac joint injections, and sympathetic nerve blocks in any and all combinations would be administered to the same individual on the same day. If the first procedure used to treat the presumptive diagnosis fails to produce improvement and rules out that possibility, then it may be appropriate to proceed to the next logical treatment.


CPT Coding:
27096 Injection procedure for sacroiliac joint, anesthetic/ steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

HCPCS Coding:
G0259 Injection procedure for sacroiliac joint; arthrography
G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid AND/OR other therapeutic agent, with or without arthrography

ICD-10 Diagnosis Codes That Support Medical Necessity:
M46.1 Sacroiliitis, not elsewhere classified
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.08 Spinal stenosis, sacral and sacrococcygeal region
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M54.18 Radiculopathy, sacral and sacrococcygeal region
M54.30 – M54.32 Sciatica
M54.40 – M54.42 Lumbago with sciatica
M54.5 Lower back pain
M54.6 Pain in thoracic spine
S33.2XXA, D, S Dislocation of sacroiliac and sacrococcygeal joint
S33.6XXA, D, S Sprain of sacroiliac joint

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