Neurology & Pain Management Coding Alert

Question: Our pain management specialist administered a sacroiliac (SI) joint injection without any type of image guidance. How should we code this in an office setting?

Mississippi Subscriber

Answer: CPT® includes a parenthetical note directing providers to report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) if CT or fluoroscopic imaging is not used.

FYI: Some payers might have medical policies stating that they only cover trigger point injections for specific diagnoses, which often is not the conditions indicated for sacroiliac joint injections, i.e. 720.2 (Sacroiliitis, not elsewhere classified) or 724.6 (Disorders of sacrum). Linking one of these ICD-9 codes as the primary reason for the trigger point injection code may cause a denial for medical necessity.