Neurosurgery Coding Alert

Question: The surgeon performed a steroid injection procedure for the patient’s sacroiliac joint, but he did not use CT or fluoroscopy imaging. I can’t decide if I should report 27096 or 20552 for this procedure. Can you please help me?

Florida Subscriber

Answer: You would report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) because the surgeon did not use CT or fluoroscopy imaging. You should report 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed) only with CT or fluoroscopic imaging confirmation of intra-articular needle positioning.

Don’t miss: Trigger point codes are grouped to reflect the total number of muscles treated, not how many injections the surgeon performs. When the surgeon treats one or two muscles with injections, regardless of the number of injections, you should report 20552. When the surgeon performs trigger points on three or more muscles, you should report 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscles).

Takeaway: Report 20552 for trigger point injections of one or two muscles. For more than two muscles, report 20553.