Anesthesia Coding Alert

Question: What diagnosis and procedure codes should I report for a sacroiliac joint injection treating sacroiliac arthropathy?

Virginia Subscriber

Answer: Start with diagnosis ICD-9 720.2 (Sacroiliitis, not elsewhere classified), and report 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) for the injection. You'll pair a fluoroscopy code with this injection code, depending on whether the physician only used it for radiological confirmation or if he performed other services as well.

For needle confirmation and guidance only -- not complete radiologic services -- report 27096 with 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).

If the physician also performed a formal arthrography (including reporting and recording it), report 27096 with 73542 (Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation) instead of 76005.