Anesthesia Coding Alert

Question: Our pain physician performed a lumbar epidural steroid injection (LESI) and SI joint injection during the same session. He used fluoroscopy to help with needle placement. How do I report this encounter? 


Florida Subscriber
Answer: Begin by reporting the LESI with 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

Many providers use fluoroscopy or CT to verify needle placement within the SI joint. In this case, report fluoroscopy 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[s]; including neurolytic agent destruction).
 
Finally, code the SI joint injection with 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid). Append modifier 59 (Distinct procedural service) to indicate the SI joint injection was separate from the LESI.