Anesthesia Coding Alert

Medical Coding and billing - Physicians often perform sacroiliac (SI) joint injections to help diagnose or cure SI joint pain. You have to know whether the physician performed the injection to diagnose SI joint dysfunction or to treat joint pain if you want to code the service correctly.

Step 1: Understand SI Joint Anatomy and Pain

The sacroiliac joint lies next to the spine and connects the sacrum (the triangular bone at the base of the pelvis) to the pelvis (iliac crest). The SI joint is small but very strong; it acts as a shock absorber between upper and lower body forces and is mainly used for stability rather than motion. However, a small bit of motion does occur at the joint, which can lead to pain if the joint becomes locked in position.
 
Long, large ligaments provide additional stability around the SI joint. These ligaments connect to a variety of muscles including the piriformis, gluteus maximus and minimus, erector spinae, latissimus dorsi and more. Any of these muscles can be involved with a painful SI joint.
 
The SI joint itself is pain-sensitive because it has many free nerve endings within it. Having so many nerve endings and associated ligaments and muscles means that the physician can't always determine a definite cause of most SI joint pain. Many physicians believe that the culprit may be a change in the joint's normal motion - this source of pain can be caused by either too much movement (hypermobility or instability) or too little movement (hypomobility or fixation). Falls, sprains, sports injuries, tailbone injuries, and obesity often contribute to SI joint pain.
 
The patient generally feels pain on one side of the low back or buttocks, and sometimes down into the leg. Pain usually remains above the knee but extends to the ankle or foot in some cases.

Step 2: Code the Diagnosis Correctly

Common symptoms of SI joint dysfunction include tailbone pain and pain radiating down the leg or into the hip or groin. Even everyday activities become painful when the SI joint is affected, says Tonia Raley, CPC, claims processing manager with Medical Information Management Solutions in Phoenix. The patient often has aching and stiffness in the lower back, and activities such as sitting, climbing stairs, driving and walking can aggravate the pain. Muscle spasms of the back are also common.
 
Sometimes pain is immediate and keeps the patient from sleeping, walking or doing other normal activities. Patients in this situation are seen immediately so the physician can make a diagnosis and begin treatment. Other patients aren't diagnosed and treated until later because they have increased pain over long periods of time or sudden flares of pain during extra activities.
 
SI joint dysfunction symptoms often mimic those of other common conditions such as disc herniation or displacement (codes 722.xx related to Intervertebral disc disorders), sacroiliitis (720.2, Sacroiliitis, not elsewhere classified) and radiculopathy (729.2). That's part of the reason why pinpointing the problem and its cause can be so difficult.
 
As with any condition, the patient must have an acceptable diagnosis before most carriers will pay for SI joint dysfunction treatment. Some commonly accepted diagnoses are:

• 720.2 - Sacroiliitis, not elsewhere classified
• 724.6 - Disorders of sacrum
• 846.1 - Sprains and strains of sacroiliac region; sacroiliac ligament
• 846.8 - ... other specified sites of sacroiliac region
• 846.9 - ... unspecified site of sacroiliac region.

  Check your local carrier's guidelines regarding acceptable diagnoses.

  Step 3: Code the Diagnostic Test Correctly

  Physicians often rely on physical examinations and/or joint injections to diagnose SI joint dysfunction. During the physical exam, the physician may move the joint to determine whether it is causing pain.
   
  "The patient lies face up on an examining table and rests the leg of the affected side on a stool," Raley says. "The SI joint lies on the edge of the table so there's no support for the hip joint. Pressing down on the iliac crest may reproduce the patient's pain and help the physician diagnose the problem."
   
  "The physician can usually diagnose the patient with SI joint pain by the physical exam," says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C. Code these tests with the appropriate E/M code (99201-99205 for new patients, 99211-99215 for established patients, or 99241-99245 for office consultations with a new or established patient).
   
  Other orthopedic tests can be used to attempt to reproduce the symptoms associated with SI joint dysfunction. These include diagnostic studies, EMG studies, pin pricks, and range-of-motion tests. Several positive tests that reproduce pain at the sacroiliac joint increase the probability of SI joint dysfunction.
   
  Another useful diagnostic test is a sacroiliac joint injection (sometimes called an arthrogram or sacroiliac joint block). The physician uses fluoroscopic guidance while inserting a needle into the SI joint to inject lidocaine. He or she may also inject a steroid solution to decrease joint inflammation and pain. If the injection relieves the patient's pain, the physician concludes that the SI joint is the pain source.
   
  Correct coding for this depends on whether the physician uses fluoroscopy or arthrography and whether he also performs the radiological supervision and interpretation with a formal report. Consider these possibilities:
   

• If the physician performs the SI joint injection under fluoroscopy or arthrography, report 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) for the injection itself. Be sure to report 27096 only with imaging confirmation of intra-articular needle positioning, Raley says.
   
• If the physician does not use fluoroscopy during the procedure, you can only code it as a large joint injection (20610*, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). Bukauskas-Vollmer recommends that you double- check the use of fluoroscopy since insurance companies will deny claims that are billed incorrectly.
   
• Report the radiological portion with 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation) if the pain-management physician completes a formal report of the procedure. Use 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) when the physician uses fluoroscopic guidance without formal arthrography. You cannot bill codes 73542 and 76005 together.
   
• Report J2000 (Injection, lidocaine HCl, 50 cc) for the appropriate amount of lidocaine injected. This includes Xylocaine HCl, Lidoject-1, Lidoject-2, Dilocaine, Caine-1, Caine-2, L-Caine, Nervocaine 1%, Nervocaine 2%, and Nulicaine.
   
  The physician can usually diagnose the patient with SI joint pain based on the physical exam, Bukauskas-Vollmer says. But she adds that the physician must also conduct a CT scan or MRI prior to performing any treatment or injections because most carriers require a confirmed diagnostic interpretation before authorizing any treatment or procedure. Code the CT scan with the appropriate choice from 72131-72133 (Computed tomography, lumbar spine) and the MRI with 72148-72149 (Magnetic resonance [e.g., proton] imaging, spinal canal and contents, lumbar) depending on whether the physician uses contrast.

  Step 4: Code Treatments Accurately

  Once the physician diagnoses SI joint dysfunction, the patient goes through a variety of conservative (non-surgical) treatments aimed at restoring normal motion to the joint. These often include:
   

• Sacroiliac joint injections: SI joint dysfunction differs from most other conditions in that injections to the joint can be used to diagnose the problem as well as treat it. You still report 27096 for the therapeutic SI joint injection as you did for the diagnostic.
   
• Trigger point injections: Trigger point injections to the surrounding area might help relieve pain. Code them depending on the number of muscles treated with either 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (... single or multiple trigger point[s], three or more muscles).
   
• Chiropractic manipulations: The pain management physician may refer the patient to a chiropractor for manipulative treatment. The code for this treatment is 98940 (Chiropractic manipulative treatment [CMT]; spinal, one to two regions). Many pain physicians are osteopaths and perform their own manipulations. They sometimes refer patients to a chiropractor for more complicated cases, especially if the patient has pelvic obliquity (pelvic misalignment).
   
• Physical therapy: The physician may treat SI joint dysfunction with a variety of physical therapy techniques. These can include 97010 (Application of a modality to one or more areas; hot or cold packs), 97035 (... ultrasound, each 15 minutes), 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes), and 98925-98929 (codes for the number of regions involved in Osteopathic manipulative treatment).
   
• Water therapy: Physicians sometimes prescribe aquatic therapy (97113, Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises) or whirlpool therapy (97022, Application of a modality to one or more areas; whirlpool) for these patients. Bukauskas-Vollmer says carriers don't always readily pay for these treatments, however.

  Step 5: Keep Up With SI Joint Changes

  Many physicians who are not board-certified in pain medicine claim to be performing SI joint injections "blindly," without using radiologic guidance. The American Medical Association (AMA) and the American Society of Pain Physicians (ASPP) have stated that physicians should only perform these injections under fluoroscopy or arthrography.
   
  As a result, Bukauskas-Vollmer says Medicare and other carriers now downcode an SI joint injection reported with 27096 to code 20610* (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) if it is not reported with either fluoroscopy code 76005 or supervision/interpretation code 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation). Be aware of this policy and code things correctly because this downcoding drops the physician's payment from 7 units for 27096 to 3 units for 20610.