Local Coverage Determination (LCD): Sacroiliac Joint Injections (L34443) Contractor Information Contractor Name Wisconsin Physicians Service Insurance Corporation LCD Information Document Information LCD ID L34443 Original ICD-9 LCD ID L31359 LCD Title Sacroiliac Joint Injections Original Effective Date For services performed on or after 10/01/2015 AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights Revision Effective Date For services performed on or after 10/01/2015 Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date
reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Jurisdiction "8" Notice: Jurisdiction "8" comprises the states of Indiana and Michigan. WPS is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (7/16/2012-8/20/2012); and, is a consolidation of the previous legacy contractors policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination. ST Legacy A Contractor & Contract Legacy B Contractor & Contract J "8" MAC A Contractor & Contract J "8" MAC B Contractor & Contract J "8" Effective Date IN NGS: 00630 WPS: 08102 08/20/12 MI WPS: 00953 WPS: 08202 07/16/12 IN NGS: 00130 WPS: 08101 07/23/12 MI NGS: 00452 WPS: 08201 07/23/12 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion.
Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed. Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint, confirming accurate placement of the needle into the joint. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should only be reported when imaging confirmation of intra-articular needle positioning has been performed. Alternatively, many practitioners choose to use CT guidance as the imaging method of choice to guide the needle and confirm intra-articular positioning. CT guidance provides a more complete assessment of posterior osteophytes that can block access to the joint; additionally, because the SI joint is complex, the spatial information provided by CT can allow quicker, more accurate placement of the needle into the joint in more challenging cases. As such, some practitioners choose to use CT guidance on all patients. With CT guidance, injection of contrast into the joint is not necessary, injection of contrast could reduce the volume of medication that can be placed into the joint. Medicare will consider the injection procedure of the SI joint medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, Medicare will consider the injection procedure of the SI joint medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID s, etc.) have failed. Limitations Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary. Sacro-iliac joint/nerve denervation procedures are also considered investigational and not medically necessary. It is not appropriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) ); without ultrasound guidance or CPT code 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg. shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting for SI joint injections.
Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. CPT/HCPCS Codes Group 1 Paragraph: Group 1 Codes: ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR 20610 BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH 20611 ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, 27096 WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED 64999 UNLISTED PROCEDURE, NERVOUS SYSTEM INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF G0260 ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: For Procedure Code 27096, G0260 Diagnosis codes do not apply to codes 64999, 20610, 20611 Group 1Codes ICD-10 Code Description M08.1 Juvenile ankylosing spondylitis M12.551 Traumatic arthropathy, right hip M12.552 Traumatic arthropathy, left hip M16.0 Bilateral primary osteoarthritis of hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other bilateral secondary osteoarthritis of hip M16.7 Other unilateral secondary osteoarthritis of hip M25.551 Pain in right hip M25.552 Pain in left hip M25.751 Osteophyte, right hip M25.752 Osteophyte, left hip M43.27 Fusion of spine, lumbosacral region M43.28 Fusion of spine, sacral and sacrococcygeal region M45.7 Ankylosing spondylitis of lumbosacral region M45.8 Ankylosing spondylitis sacral and sacrococcygeal region M46.1 Sacroiliitis, not elsewhere classified M47.27 Other spondylosis with radiculopathy, lumbosacral region M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region M47.897 Other spondylosis, lumbosacral region M47.898 Other spondylosis, sacral and sacrococcygeal region M48.8X7 Other specified spondylopathies, lumbosacral region M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region
M53.2X7 Spinal instabilities, lumbosacral region M53.2X8 Spinal instabilities, sacral and sacrococcygeal region M53.3 Sacrococcygeal disorders, not elsewhere classified M53.86 Other specified dorsopathies, lumbar region M53.87 Other specified dorsopathies, lumbosacral region M53.88 Other specified dorsopathies, sacral and sacrococcygeal region M54.17 Radiculopathy, lumbosacral region M54.31 Sciatica, right side M54.32 Sciatica, left side M54.5 Low back pain M99.04 Segmental and somatic dysfunction of sacral region M99.05 Segmental and somatic dysfunction of pelvic region Q76.2 Congenital spondylolisthesis S33.6XXA Sprain of sacroiliac joint, initial encounter S33.6XXD Sprain of sacroiliac joint, subsequent encounter S33.6XXS Sprain of sacroiliac joint, sequela S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela Showing 1 to 50 of 50 entries in Group 1 ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: Group 1 Codes: Additional ICD-10 Information General Information Associated Information
Documentation Requirements Medical record documentation maintained by the performing provider must clearly indicate the medical necessity for billing a SI joint injection and that the SI joint injection was performed using imaging confirmation of intra-articular needle positioning. As stated in the Indications and Limitations of Coverage section, when SI joint injection is used for therapeutic purposes, the documentation must support other noninvasive treatments attempted. Utilization Guidelines The frequency at which a SI joint injection is performed is dependent on the clinical presentation of the patient. However, it is generally expected that the patient s response to the previous injection is important in deciding whether and when to proceed with additional injections for therapeutic indications. If the patient has achieved significant benefit after the first injection, a second injection would be appropriate for reoccurring symptoms. However, if the patient experiences no symptom relief or functional improvement after two (2) injections, medical literature supports that additional injections would not be expected, because the probability of a positive outcome is low. If therapeutic effect is achieved, a maximum of three (3) injections per year, per site, is recommended. It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity. Sources of Information and Basis for Decision Boswell MV, Trescot A M, Datta S, Schultz D, M., Hansen H C, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007 Jan;10(1):7-111. Cohen SP, Sacroiliac Joint Pain: A Comprehensive Review of Anatomy,Diagnosis, and Treatment Anesth Analg 2005;101:1440 53. Cohen SP, Hurley RW, Buckenmaier CC, Kurihara C, Morlando R, Dragovich A. Randomized Placebo-Controlled Study Evaluating Lateral Branch Radiofrequency Denervation for Sacroiliac Joint Pain Anesthesiology. 2008 August ; 109(2): 279 288. Dussault, R.G., Kaplan, P.A., & Anderson, M.W. (2000). Fluoroscopy-guided sacroiliac joint injections. Radiology; 214: 273-277. Manchikanti L, Boswell MV, Datta S, Fellows B, Abdi S, Singh V, Benyamin R, Falco F, Helm S, Hayek S, and Smith HS, Comprehensive Review of Therapeutic Interventions in Managing Chronic Spinal Pain Pain Physician 2009; 12:E123-E198. Muhlner SB, Review article: Radiofrequency neurotomy for the treatment of sacroiliac joint syndrome Curr Rev Musculoskelet Med (2009) 2:10 14. Rupert MP, Lee M, Manchikanti L, Datta S, and Cohen SP. Evaluation of Sacroiliac Joint
Interventions: A Systematic Appraisal of the Literature Pain Physician 2009; 12:399-418. Contractor Advisory Committee (CAC) Meeting Dates Wisconsin: 09/24/2010 Illinois: 09/22/2010 Michigan: 09/15/2010 Minnesota: 09/16/2010 J5 MAC IA, KS, MO, NE, 10/07/2010 Open Meeting 09/02/2010 Start Date of Comment Period 10/07/2010, End Date of Comment Period, 11/21/2010 Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 10/01/2015 R1 Revision History Revision History Explanation 01/01/2015 Annual review and CPT 2015 code updates, added code 20611 and description change for code 20610. Updated references list. Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes Associated Documents Attachments Billing and Coding Guidelines (PDF - 79 KB ) Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 12/18/2014 with effective dates 10/01/2015 - Updated on 03/04/2014 with effective dates 10/01/2015 -
Billing and Coding Guidelines LCD Title Sacroiliac Joint Injections General 1. Procedure code 27096 is to be used only with imaging confirmation of intra-articular needle positioning. 2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection. 3. It is not appropriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa); without ultrasound guidance or CPT code 20611 Arthrocentesis, aspiration and /or injection, major joint or bursa (eg. shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting for SI joint injections. 4. Procedure code 27096 represents a unilateral procedure. If bilateral SI joint arthrography is performed, 27096 should be reported with a 50 modifier. 5. CPT code G0260 should be billed by facilities paid by OPPS. 6. Use CPT code 64999 (Unlisted procedure, nervous system) for pulsed radiofrequency and the denervation procedures of the sacro-iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary. Sacro-iliac joint/nerve denervation procedures are also considered investigational and not medically necessary. Revision History 01/01/2015 annual review 2015 CPT code updates added code 20611 and description change for code 20610.