# Correct Coding for this procedure



## NESmith (Dec 27, 2012)

Procedure : Sacral Iliac Joint Block Right, primary Ramus Nerve S1, S2, S3, and S4, Right Sacral Iliac Joint Arthrogram

After a brief [hysical examination, the properative diagnosis was confirmed;the risks and benefits of the procedure were clearly detailed and discussed with the patient, whom voluntarily agrees to proceed with the intervention. Written and verbal consents were obtained prior to initiating the procedure.A pause was perfomred and the surgical site was cofirmed with the Anesthesiologist, Surgeon and procedure room circulator.

Procedure in Detail: After performing a brief physical exam and reconfirming the surgical site, the patient was tken to the procedure suite and placed prone on the operating room table, non invasive monitors were placed, vital signs were verified. IV access was obtained and an intravenous balalnced salt solution was infused during th entire procedure. oxygen was provided through a nasal cannula at a rate of perminute. Sedation was provided under constant monitoring for ventilation, cardiovascular hemodynamics, and oxygenation. Medications used to provide sedation were propofol, intravenous. Documentation of the medication used for sedation was undertaken on separate charting.

Fluoroscopic evaluation of the sacral iliac region was undertaken. Identification of the appropriate affected side was noted with an AP image of the fluoroscopy machine. Image was then rotated laterally under constant imagimg until the anterior & posterior aspects of the sacral iliac joint was identified on the right. The inferior third of the joint was identified and appropriate skin markings were placed. identification of the S1 thru S4 sacral foramen were isdentified. Area was prepped and draped in a sterile fashion, followed by the infiltration of 1 cc of 1% lidocaine was injected inf the subcutaneous tissue using a 25 g 1 1/2 needle. A 22 ga spinal needle was placed with gentle manipulation under fluoroscopic guidance. Verification of needle plaacement in the sacral iliac joint was noted and a sacral iliac joint arthrogram was undertaken. A solution containing 2.5 cc's of 0.5% bupivacaine plus 05 mg of depomedrol solution was injected in the SI Joint. 
Placement of the needle were noted along the sacral foramen corresponding to the primary sacral ramus was also undertaken and 1 cc of the 0.5% bupivacaine & 05 mg of methylprenisolone was injected at the 2 o'clock position laterally to the corresponding formanen at each corresponding level, S1, S2, S3, and S4. This was performed in addition to the classic injection to the SI Joint along the inferior portion of the articulation.
The needle was then removed and the area was cleansed with a warm moist towel. Fluoroscopic images were obtained and saved on the machines hard drivw and a copy of which was placed on the patient's permanent office record. Patient was alert to verbal & tactile stimuli during the entire procedure.

CPT code 27096 was billed. I do not believe this is correct, so please help me with coding of this procedure.
Thank You as always for your help


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## OCD_coder (Dec 27, 2012)

Not sure why you would think it was incorrectly billed, can you elaborate on your thoughts?

27096  Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance including arthrography when performed (00 GFP days). 

Seems accurate from the CPT description.


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## dwaldman (Jan 2, 2013)

"Code 64450 is a component of Column 1 code 27096 but a modifier is allowed in order to differentiate between the services provided."

I was having trouble from the procedure note provided, being able to tell if 4 separate injections were provided for S1-S4 in addition to the SI joint block or one single injection. I noticed that 64450 is bundled into 27096. Would probably need to write NCCI with the procedure note to see if 59 would be appropriate. Below is from CPT Assistant, describing lateral branch nerve destruction with 64640. 



June 2012 page 15

Frequently Asked Questions:Surgery: Nervous System

Question: May code 64640 be reported for each individual peripheral neurolytic nerve destruction procedure performed at the L5, S1, S2, and S3 nerves? 

Answer: Yes. When performing individually separate nerve destruction, each peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, for peripheral nerve root neurolytic blocks (destruction) of L5, S1, S2, and S3, code 64640 should be reported four times. The coder should append modifier 59, Distinct Procedural Service, to the second and subsequent listings of code 64640 to separately identify these procedures.


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