Orthopedic Coding Alert

Question: One of our patients presented for a sacroiliac joint injection. The orthopedist drew the medication and was just about to stick the patient, but the patient refused the injection once she saw the needle. Can we still bill for the injection if we append the reduced services modifier (modifier -52)?

Iowa Subscriber

Answer: From Medicare's standpoint, you did not perform any service. You should not report the injection code (27096, Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid), because you
never actually injected the patient. And modifier -52 (Reduced services) would not be appropriate because you didn't actually perform a reduced service.
 
Because the orthopedist filled the syringe with the medication, you should report the J code for the appropriate drug. Some carriers may question why you reported a HCPCS code and not a CPT code representing the injection, so you should send a letter to your carrier explaining what happened. You may be able to avoid this if you are able to use the syringe on another patient. If another steroid-injection patient is in your waiting room and requires the same dosage as the patient who refused the injection, you can use the medication on the second patient and report it to his or her insurer instead.