Internal Medicine Coding Alert

Question: Which CPT® code applies to a sacroiliac joint injection? Would we bill it twice for a bilateral injection?

North Carolina Subscriber

Answer: You have two choices for sacroiliac (SI) joint injection coding: 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) or 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).

Difference: Coding notes associated with 27096 state that the physician must use imaging confirmation of intra-articular needle position. If you don't have image guidance and confirmation, report 20610.

For either code, append modifier 50 (Bilateral procedure) to indicate a bilateral injection unless the payer has guidelines specifying otherwise.