Sacroiliac Joint Injections (L31359)
Contractor Information
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Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L31359 LCD Title Sacroiliac Joint Injections Contractor's Determination Number MS-009 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 02/15/2011 Original Determination Ending Date Revision Effective Date For services performed on or after 01/01/2012 Revision Ending Date |
CMS National Coverage Policy
Indications and Limitations of Coverage 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 code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
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 code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) 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:
CPT/HCPCS 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.
| 20610 | ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) |
| 27096 | INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED |
| 64999 | UNLISTED PROCEDURE, NERVOUS SYSTEM |
| G0260 | INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY |
ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.
For Procedure Code 27096, G0260
Diagnosis codes do not apply to codes 64999, 20610
For Procedure Code 27096, G0260
Diagnosis codes do not apply to codes 64999, 20610
| 715.15 | OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH |
| 715.18 | OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES |
| 715.25 | OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH |
| 715.28 | OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES |
| 715.35 | OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH |
| 715.38 | OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING OTHER SPECIFIED SITES |
| 715.95 | OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING PELVIC REGION AND THIGH |
| 715.98 | OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES |
| 716.15 | TRAUMATIC ARTHROPATHY INVOLVING PELVIC REGION AND THIGH |
| 716.55 | UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING PELVIC REGION AND THIGH |
| 716.58 | UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING OTHER SPECIFIED SITES |
| 716.95 | UNSPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH |
| 716.98 | UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES |
| 719.45 | PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH |
| 719.48 | PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES |
| 720.0 | ANKYLOSING SPONDYLITIS |
| 720.2 | SACROILIITIS NOT ELSEWHERE CLASSIFIED |
| 721.3 | LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY |
| 724.02 | SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION |
| 724.2 | LUMBAGO |
| 724.3 | SCIATICA |
| 724.4 | THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED |
| 724.6 | DISORDERS OF SACRUM |
| 724.79 | OTHER DISORDERS OF COCCYX |
| 726.5 | ENTHESOPATHY OF HIP REGION |
| 739.4 | NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED |
| 739.5 | NONALLOPATHIC LESIONS OF PELVIC REGION NOT ELSEWHERE CLASSIFIED |
| 756.11 | CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION |
| 846.1 | SACROILIAC (LIGAMENT) SPRAIN |
| 846.8 | OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
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.
Appendices
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
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.
From First Coast Options LCD
Aeschbach, A. & Mekhail, N.A. (2000). Common nerve blocks in chronic pain management. Regional Anesthesia, 18 (2). Retrieved June 20, 2002 from the World Wide Web: www.mdconsult.com
American Medical Association (2001). CPT 2002 changes: An insider s view. Chicago: American Medical Association.
Cardone, D.A. & Tallia, A.F. (2002). Joint and soft tissue injection. American Family Physician. Retrieved July 24, 2002 from the World Wide Web: www.aafp.org.
Dussault, R.G., Kaplan, P.A., & Anderson, M.W. (2000). Fluoroscopy-guided sacroiliac joint injections. Radiology; 214: 273-277. Retrieved July 8, 2002 from the World Wide Web: www.radiology.rsnajnls.org.
Tollison, C.D., Satterthwaite, J.R., & Tollison, J.W. (2002). Practical pain management, 3rd ed., (8), 91-97. Philadelphia: Lippincott.
Waldman, S.D. (2000). Atlas of pain management injection techniques, (65), 225-227. Philadelphia, W.B. Saunders.
Additional:
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.
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
Other Contractors LCDs
Advisory Committee Meeting Notes
Aeschbach, A. & Mekhail, N.A. (2000). Common nerve blocks in chronic pain management. Regional Anesthesia, 18 (2). Retrieved June 20, 2002 from the World Wide Web: www.mdconsult.com
American Medical Association (2001). CPT 2002 changes: An insider s view. Chicago: American Medical Association.
Cardone, D.A. & Tallia, A.F. (2002). Joint and soft tissue injection. American Family Physician. Retrieved July 24, 2002 from the World Wide Web: www.aafp.org.
Dussault, R.G., Kaplan, P.A., & Anderson, M.W. (2000). Fluoroscopy-guided sacroiliac joint injections. Radiology; 214: 273-277. Retrieved July 8, 2002 from the World Wide Web: www.radiology.rsnajnls.org.
Tollison, C.D., Satterthwaite, J.R., & Tollison, J.W. (2002). Practical pain management, 3rd ed., (8), 91-97. Philadelphia: Lippincott.
Waldman, S.D. (2000). Atlas of pain management injection techniques, (65), 225-227. Philadelphia, W.B. Saunders.
Additional:
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.
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
Other Contractors LCDs
Meeting Date:
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
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
10/07/2010
End Date of Comment Period
11/21/2010
Start Date of Notice Period
01/01/2011
Revision History Number
09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
20610 descriptor was changed in Group 1
73542 descriptor was changed in Group 1
77003 descriptor was changed in Group 1
01/01/2011 - Release Draft LCD to Final
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
27096 descriptor was changed in Group 1
77003 descriptor was changed in Group 1
11/21/2011 - The following CPT/HCPCS codes were deleted:
73542 was deleted from Group 1
01/01/2012 CPT 2012 code updates, deleted code 73542, description changed for code 27096, removed codes 77003, 77012 and reference to them.
Reason for Change
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
20610 descriptor was changed in Group 1
73542 descriptor was changed in Group 1
77003 descriptor was changed in Group 1
01/01/2011 - Release Draft LCD to Final
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
27096 descriptor was changed in Group 1
77003 descriptor was changed in Group 1
11/21/2011 - The following CPT/HCPCS codes were deleted:
73542 was deleted from Group 1
01/01/2012 CPT 2012 code updates, deleted code 73542, description changed for code 27096, removed codes 77003, 77012 and reference to them.
11/28/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
Billing & Coding Guideline 01/01/12 (PDF - 10 KB)
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