Neurology & Pain Management Coding Alert

Question: Our physician documented that he performed a left SI joint injection under lateral fluoroscopic view. I plan to report procedure codes 62311 and 77003. Do I need to add a modifier 51 or 59 to the 77003? Our coding system allows both modifiers with the code. 

New Mexico Subscriber

Answer: CPT® actually has a code that’s more appropriate for SI joint injections under fluoroscopic guidance than 62311 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral [caudal]) with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]).  

Better option: The more appropriate coding choice is 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed). It describes your provider’s service more accurately and includes image guidance, so adding the separate fluoroscopy code would not be compliant. 

Other details: You should only report 27096 when your provider uses CT or fluoroscopic imaging to confirm intra-articular needle positioning. If he doesn’t use CT or fluoroscopy imaging, report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) instead. Also remember that 27096 is a unilateral procedure. For bilateral injections, append modifier 50 (Bilateral procedure).