Neurology & Pain Management Coding Alert

Question: An established 62-year-old patient presents with a seven-month history of chronic, dull, aching low back pain localized specifically over the right posterior sacroiliac (SI) joint, with pain radiating into the right buttock and posterior thigh. The patient reports pain during a Fortin finger test, pointing directly to the posterior superior iliac spine (PSIS). Physical examination reveals positive results on a cluster of sacroiliac provocative tests, including the right-sided Patrick’s sign (FABER), Gaenslen’s sign, and the compression test. The patient has failed six months of conservative management, including chiropractic care, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy.

To determine if the SI joint is the source of pain (diagnostic) or to provide pain relief (therapeutic), the physician performs a right-sided periarticular nerve block. Using fluoroscopic guidance, a needle is placed to target the nerves innervating the right SI joint (lateral branch nerves). The provider injects a mixture of 2 mL of 1% lidocaine and 40 mg of methylprednisolone sodium succinate. The procedure notes document the specific nerves targeted, the medication used, and the immediate reduction in pain post-injection, confirming the diagnosis. The provider counsels the patient on the aftereffects of the procedure and requests they contact the clinic if anything outside of the typical results occurs. The patient is to return in six weeks for reevaluation.

How should I report this encounter? Are the SI joint provocative tests separately reportable?

Revenue Cycle Insider Subscriber

Answer: You cannot report the SI joint tests separately; you should roll the work for those tests into the service level when deciding on an evaluation and management (E/M) code.

On your claim, you should:

• Report 64451 (Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)) for the injection
• Append modifier RT (Right side) to 64451 to indicate laterality if the payer requires it
• Report J1010 (Injection, methylprednisolone acetate, 1 mg) x 40 for the methylprednisolone supply
• Report the appropriate-level E/M code from the 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) set for the office visit
• Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure) to the E/M code to show that the SI injection and the E/M were separate, significantly identifiable services
• Append M53.3 (Sacrococcygeal disorders, not elsewhere classified) to 64451, J1010, and the E/M code to represent the patient’s SI joint issues.

Jessica Sullivan, CPC, COBGC, COSC, 
Consultant, Pinnacle Enterprise Consulting Services (PERCS)