Radiology Coding Alert

This code's unilateral/bilateral status is key to proper payment.

Your days of choosing between arthrography and fluoroscopic guidance codes for sacroiliac injections are over.

CPT® 2012 changes the definition of 27096 so that it includes fluoroscopic or CT guidance, effective Jan. 1, 2012:

• 2011: 27096, Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
• 2012: 27096, Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

Impact: You should no longer report a separate code for imaging guidance in addition to 27096.

For example, in 2011, you reported a sacroiliac (SI) joint arthrogram using 27096 and 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation).

In 2012, you should report only 27096 to capture both the injection procedure and the arthrography. In fact, CPT® 2012 deletes 73542 because the arthrography service is now included in the definition of 27096.

Your coding for an SI joint injection will see a similar change for 2012. In 2011, you reported a fluoro-guided injection using 27096 and 77003 (2011 definition: Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction).

In 2012, you should report only 27096 to capture both the injection procedure and the radiological guidance. In fact, CPT® 2012 removes "sacroiliac" from the definition of 77003: "Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)."

No Imaging? 20552 Appears in New Note

As a radiology coder, your physician will almost certainly use imaging guidance to perform the SI injection. Still, an apparent change in how to code services that don't involve CT or fluoro guidance is interesting to consider.

In cases where the physician performs the injection procedure without CT or fluoro, CPT® 2012 instructs you to report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]), says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Colo.

"Historically providers have reported 20610 [Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa)] for 'blind'/'anatomically guided' SI joint injection" where no image guidance is used, says Hammer.

She adds that the code choice was based on a Q&A from the April 2004 CPT® Assistant, which stated: "From a CPT® coding perspective, if an injection is administered into the SI joint without fluoroscopic imaging guidance, then it would be appropriate to report code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa), for the injection administered into the SI joint without fluoroscopic imaging guidance." As recently as July 2008, CPT® Assistant confirmed this instruction, stating: "If a sacroiliac injection is performed without imaging guidance, it is incorrect to use code 27096. In those cases, use code 20610."

RVU Drop Makes Bilateral Know-How Crucial

"One other point to note is the change in RVU [relative value unit] for code 27096," Hammer says. "The RVUs are substantially decreased in 2012, particularly if you factor in the 2011 RVU from the image guidance that will no longer be separately billed."

For office place of service in 2011, 27096 had 5.43 RVUs and 77003 (global) had 1.84 RVUs, for a total of 7.27 RVUs, Hammer says. For office place of service in 2012, 27096 has 5.05 RVUs. This is a drop of 2.22 RVUs. (These RVUs are based on information published by CMS at www.cms.gov/physicianfeesched/pfsrvf/itemdetail.asp?itemid=CMS1254038.)

To be sure you capture every legitimate dollar, heed the parenthetical instruction with 27096 that the code describes "a unilateral procedure. For bilateral procedure, use modifier 50 [Bilateral procedure]." Although Medicare pays less for the second side in a bilateral injection, you want to be sure you report bilateral injections accurately both to capture all possible reimbursement and to be sure your coding accurately reflects the services performed.

Example: Your pain management specialist administers bilateral SI injections with fluoro. Begin with 27096 for the SI injection. Because your specialist administered bilateral injections, you should report 27096-50, according to CPT® guidelines.

Caution: Some payers may require 27096 on two separate lines on the claim, with modifier LT (Left side) appended to one and modifier RT (Right side) appended to the other. If your payer's preference varies from CPT® guidelines, be sure to get that preference in writing.