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Anesthesia Coding Alert

What Coders Should Know:

Diagnosing and Treating Sacroiliac Joint Dysfunction

Published on Sat Jun 01, 2002

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Recent studies have estimated that 10 to 30 percent of those who suffer from chronic low back pain may have sacroiliac (SI) joint dysfunction. SI joint dysfunction often is related to a traumatic injury, such as falling and landing on the buttocks, or automobile accidents where the driver's leg is extended at the time of impact. Even simple twisting motions, such as shoveling snow or swinging a golf club, can result in SI joint sprain, which may eventually lead to SI joint dysfunction.

Symptoms usually include pain felt on one side of the lower back or buttocks. This pain can radiate downward toward the knee and, in rare cases, extend to the ankle or foot. Yet, SI joint dysfunction is difficult to diagnose because it mimics the symptoms of other conditions, such as disc herniation and radiculopathy. Perhaps as frustrating as diagnosing SI joint dysfunction, obtaining appropriate reimbursement for diagnosis and treatment presents its own challenges. The key for coders lies in knowing which diagnoses and treatments are medically necessary and reimbursable by Medicare and other insurers.

Diagnosing SI Joint Dysfunction

SI joint dysfunction is a chronic pain condition, meaning the patient must have persistent pain for three months or more. The physician may perform a thorough physical examination and order a magnetic resonance imaging (MRI) or other diagnostic scan to rule out the possibility of another condition, such as a slipped disc. The pain management physician also might perform a diagnostic SI joint injection of lidocaine, occasionally including a steroid solution to reduce inflammation. If the patient feels relief after the injection, the physician can infer that the sacroiliac joint is the source of the pain.

Cynthia Thompson, CPC, a consultant with Gates, Moore and Company, a healthcare consulting firm in Atlanta, says, Report CPT 27096 (Injection procedure for sacroiliac joint" arthrography and/or anesthetic/steroid) for the injection procedure and 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures ... including neurolytic agent destruction) for the fluoroscopic guidance. If injections are performed bilaterally append modifier -50 (Bilateral procedure) to 27096. Some carriers may prefer modifiers -LT (Left side) or -RT (Right side)."" Thompson also suggests that the pain management physician add modifier -26 (Professional component) to 76005 if the service is provided in a facility where the physician does not own the radiology equipment.

The local medical review policy (LMRP) for Empire Medicare Services New York state's Medicare carrier also states that the appropriate J code (i.e. J2000 for lidocaine) for the injected agent should be entered on the same claim for the same date of service. Sally J. Trew RN CPC of GSA Healthcare Group in Gibsonia Pa. president of the Greater Pittsburgh Chapter of the American Academy of Professional Coders says coders should check with their local Medicare carriers and private insurers concerning billing for injected agents. ""Some carriers may not reimburse for anesthetic agents administered as part of the procedure "" she says.

Trew also notes ""On occasion the pain management physician may provide supervision and interpretation of the arthrography. In these circumstances 73542 (Radiological examination sacroiliac joint arthrography radiological supervision and interpretation) should be used instead of 76005. Codes 73542 and 76005 cannot be billed together. A written radiology report must accompany claims reported with 73542. If there is no written report 76005 can be used for the fluoroscopic guidance of the sacroiliac injection procedure.""

LMRPs for many states list the following ICD-9 codes to support the medical necessity of SI joint injections:

  • 720.2 Sacroiliitis not elsewhere classified
  • 724.6 Disorders of sacrum (sacroiliac pain and chronic or old sacroiliac sprain)
  • 846.1 Sprains and strains of the sacroiliac ligament
  • 846.8 Sprains and strains of other specified sites of sacroiliac region
  • 846.9 Sprains and strains of unspecified site of sacroiliac region.

    These LMRPs also state ""It is not enough to link the procedure code to a correct payable ICD-9 diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid."" If SI joint dysfunction results from an accident or trauma Thompson and Trew advise using an E code as a secondary diagnosis to identify the source of the accident or trauma. ""For example if the problem is the result of a fall use the E880.x series code which best describes the nature of the injury as the secondary diagnosis code "" Thompson says.

    Treating SI Joint Dysfunction

    Treatment for SI joint dysfunction normally follows a conservative path incorporating nonsteroidal anti-inflammatory drugs (NSAIDs) physical therapy and exercise. For example the pain management physician may perform osteopathic manipulation to help alleviate SI joint pain using a variety of techniques. Coding is based on the number of body regions CPT 2002 lists 10 specific regions involved in the therapy. Most commonly 98925 (Osteopathic manipulative treatment [OMT]; one to two body regions involved) would be used.

    If conservative therapies fail to relieve the patient's pain the pain management physician may administer a course of SI joint injections. Again 27096 is used for the injection procedure with 76005 for the fluoroscopic guidance or 73542 if the pain management physician performs full arthrographic supervision and interpretation.

    A more radical treatment involves destruction of the nerves surrounding the SI joint either through neurolytic agents (such as phenol) cryotherapy or radiofrequency. Thompson says that the coding for these procedures depends on the location of the specific nerve or branch. ""One common scenario involves the paravertebral facet nerve. In this case the initial injection would be coded 64622 (Destruction by neurolytic agent paravertebral facet joint nerve; lumbar or sacral single level). Each additional level would be coded with +64623 ( lumbar or sacral each additional level [list separately in addition to code for primary procedure]).""

    Manipulation under joint anesthesia (MUJA) also may be beneficial when other treatments have failed. Code 22505 (Manipulation of spine requiring anesthesia any region) is used to report these procedures. Many LMRPs note however that the procedure should be performed only on select patients who have failed to respond to conservative therapies. ""Payment for the procedure is made on a case-by-case basis and substantial documentation is required to demonstrate the medical necessity of MUJA "" Thompson says.

    Another treatment option is transcutaneous electrical nerve stimulation (TENS). TENS is the application of electrical stimulation to skin electrodes that may be placed over painful paravertebral locations as well as over nerves proximal distal and contralateral to the site of pain. The electrical signals interfere with the transmission of painful stimuli sent to the brain producing an analgesic effect. The attending physician or an employee of the physician on the physician's order can use 64550 for the application of the surface (transcutaneous) neurostimulator. First Coast Service Options Florida's Medicare Part B carrier states that documentation maintained by the ordering/ performing physician must indicate the medical necessity for the application of TENS including history and physical office/progress notes and treatment records.

    The patient can perform TENS therapy at home. The pain management provider can bill for training the patient regarding the safe and effective use of the stimulator with 97032 (Application of a modality to one or more areas; electrical stimulation [manual] each 15 minutes).

    Some Treatments Not Covered by Insurers

    In rare cases the patient may elect to have surgery to fuse the sacroiliac joint. Medicare and many commercial carriers consider this procedure controversial and will not provide reimbursement.

    An emerging treatment for SI joint dysfunction is prolotherapy which involves the injection of a proliferant solution into the damaged connective tissue. After the solution is injected it elicits an inflammatory response causing fibroblasts to migrate to the area and begin the healing process. These cells produce collagen which repairs and strengthens the damaged connective tissue and slowly tightens the hypermobile SI joint segment. Medicare and most private payers consider prolotherapy experimental and thus noncovered.

    ""There are many viable and potentially reimbursable procedures for diagnosing and treating SI joint dysfunction. It's important for pain management physicians coders and billers to know the LMRPs for their Medicare carriers and to become familiar with the claims submission requirements "" Thompson concludes.

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