Advanced Search

Anesthesia Coding Alert

Pain Management Focus:

Protect Yourself From SI Joint Injection Downcoding

Published on Wed Jun 15, 2005

Home in on 4 areas to keep carriers from slashing justifiable payment

Sacroiliac (SI) joint injections are common fare for pain management practitioners, but some groups receive less reimbursement than expected because carriers downcode the claims. Before you fall victim to the same scenario, be sure your claims include all the necessary components for optimal reimbursement.

Ensure an Appropriate Diagnosis

Patients receiving SI joint injections can be searching for relief from a variety of conditions. Some of the most common ones include:

  • Arthritis (714.xx, Rheumatoid arthritis and other inflammatory polyarthropathies; 715.xx, Osteoarthritis and allied disorders; and 716.xx, Other and unspecified arthropathies)

  • Lupus (710.0, Systemic lupus erythematosus)

  • Sacroiliitis (720.0, Ankylosing spondylitis)

  • Inflammatory spondylopathies (720.89, Other inflammatory spondylopathies; other)

  • Other symptoms referable to back (724.8).

    Physicians usually try different combinations of medications or physical therapy to help treat these conditions. When these methods fail to provide pain relief, SI joint injections may be the next step. Coders such as Eileen Lorenco, RHIT, CS, CPC, a coder with Lahey Clinic in Burlington, Mass., say they have never seen LMRPs for SI joint injections. If you don't have an LMRP to work from, contact the carrier for information regarding their diagnosis policy.

    Confirmation Is the Key

    The SI joint is difficult to inject and requires precise needle placement plus confirmation of correct placement before the actual injection. "Without guidance, the physician can't be sure the pain medication has reached the correct spot," Lorenco says. "Another consideration is that patients who are obese or who have unusual anatomy or scar tissue might be impossible to inject without confirmation."

    The physician has two options for guidance and confirmation: fluoroscopy and arthrography. One of these always accompanies an SI joint injection. Fluoroscopy  is often the rule and not the exception for some physicians, says Cindy Clark, anesthesia coding supervisor for Anesthesiology Consultants in Savannah, Ga.

    Although arthrography isn't usually routine, it can be more appropriate in situations that stress diagnosis:  

  • To determine the cause of SI joint pain or the extent of damage - The physician injects dye or contrast to outline the joint and visualize where the problems lie. If the arthrography confirms a finding, the physician administers the injection.
     
  • To evaluate the patient's anatomy - If the patient has a history of past spinal surgeries or trauma, he might have scarring in that area. Using arthrography to visualize the damaged area allows the physician to work around them during the procedure. The physician might also use arthrography to evaluate the anatomy of a patient he has never treated.

    The physician can also use fluoroscopy as a diagnostic tool, but Lorenco says it's more commonly used as a localization tool.

    "The doctor might choose to use fluoroscopy with an SI joint injection if he has already determined the cause of pain, or is already familiar with the patient's anatomy and needs no further diagnostic information," she says. "At that stage of the game he only needs to guide the needle placement."

    Code All the Components

    Once you know which confirmation technique the physician used, you're ready to code the procedure.

    Begin by reporting the actual injection with 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid), which has 7 base units.
     
    Note: Code 27096 is a unilateral procedure. If the physician administers bilateral injections, designate this by appending modifier -50 (Bilateral procedure) or the left/right modifiers -LT (Left side) or -RT (Right side) to designate the side treated. Check the carrier's guidelines to determine which modifiers to report.

    Fluoro reporting: If the physician used fluoroscopic guidance prior to the injection, also report 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).

    Arthrogram option: If the physician performed an arthrogram instead of fluoroscopy, report 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation). Keep two important factors in mind before using this code:   

  • You must have a formal radiological report before submitting 73542. If the physician does not perform and record a formal report, you must report 76005 instead. "I want to see more than, 'The joint was injected with contrast and the joint space was outlined,' " Lorenco says. "I want to see something in the report about the arthrogram's findings even if they are negative. I also ask the doctors to document medical necessity for performing the arthrogram. If I see those things, then I feel that it's OK to bill 73542. If I don't see all that, then we report 76005."
      
  • If the procedure takes place in an ASC and you're billing for the facility, report HCPCS code G0260 (Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography). Guidelines for reporting - and being paid for - SI joint injections in an ASC have changed during the past few years. Medicare added 27096 to the ASC approved list on Jan. 16, 2004. The physician bills with 27096 and the facility bills using G0260, with both paid at the facility rate.

    Whichever technique you report, append modifier -26 (Professional component) to 76005 or 73542 unless you are able to charge for the equipment.

    Reporting 76005 rather than 73542 doesn't affect the bottom line much in most groups, especially for groups dealing only with physician fees and not facility components. Code 76005 has 2 base units and 73542 has 3 base units, but those single-unit differences can add up over time. And the difference will be greater if you're billing globally or for the technical portion, Lorenco says. You could be looking at a difference in the $40 range in those cases, depending on your practice.

    The final part of the coding equation lies in the contrast agent. If the physician uses low osmolar contrast agents such as Omnipaque for the contrast agent, you can bill for it using new codes Q9945, Q9946, Q9947, Q9948, Q9949, Q9950 and Q9951. Heads up: These Q codes replaced A4644, A4645 and A4646 for Medicare claims, effective April 1, 2005. (For a quick reference chart outlining payment limits for the new Q codes, contact editor Leigh DeLozier at leighdelozier@bellsouth.net.)

    Avoid Downcoding With This Strategy

    Whether the physician opts for fluoroscopic guidance or an arthrogram prior to the injection, it's an integral part of the procedure. If you report the SI joint injection alone - without a code for fluoroscopy or an arthrogram - most carriers will downcode your claim to a large joint injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). And this definitely affects your bottom line, whether the physician performs the injection in a facility or nonfacility setting:  

  • Code 20610 - 1.84 RBRVS units for nonfacility and 1.31 units for facility
     
  • Code 27096 - 5.85 RBRVS units for nonfacility and 1.83 units for facility.

    Real-world solution: Proper documentation can be one of the biggest challenges when reporting SI joint injections, Clark says. She has helped stress its importance by sitting down with her office manager and one of their physicians to show lost revenue from incomplete documentation. Seeing the information in black and white can sometimes help get documentation back on track.

    Lorenco's group also stresses discussion and education, plus uses some tools to help promote thorough documentation. Their pain center has a surgical billing form listing the group's most common procedures. Coders review these forms when the physicians turn them in and check them against the operative report before submitting the case to the billing department. "We know what the doctors usually do and would query them if we suspected something was omitted from the billing slip or from the operative notes," Lorenco says.

    Bottom line: Communication with the pain clinic staff and physicians goes a long way toward correctly reporting SI joint injections. Whether you're encouraging documentation, getting the correct diagnosis codes or learning more about the procedure itself, each piece helps make the distinction between 73542 and 76005 less fuzzy and your coding clearer.

    • Other Articles in this issue of

    Anesthesia Coding Alert

    View All