Sacroiliac Joint Injections and Procedures
Table of Contents
Sacroiliac Joint Injections and Procedures
There is a new LCD, L39455 – Sacroiliac Joint Injections and Procedures, as well as the coinciding Billing and Coding Article (A59233) which reflects multiple changes to current policy including an expansion of the Indications and Limitations, an addition of frequency guidelines, as well as changes to payable diagnoses.
The LCD, L39455 – Sacroiliac Joint Injections and Procedures, is effective for services performed on or after 3/19/2023. You may view both the LCD and article on the CMS’ Medicare Coverage Database.
The information below will assist with understanding the changes further.
The following was prepared by Meredith Loveless, MD., FACOG of CGS Jurisdiction 15 to explain the new LCD Sacroiliac Joint Injections and Procedures based on the Multi-MAC SME Panel on Sacroiliac Joint Injections meeting that was held on 3/10/2022.
SIJI will be considered medically reasonable and necessary when all of the following requirements are met:
- Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints between the upper level of the iliac crests and the gluteal fold and
- Low back pain duration of at least three months and
- Low back pain below L5 without radiculopathy and
- Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foramina) stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis or pain related to spinal instrumentation) and
- At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests and
- Low back pain persists despite a minimum of four weeks of conservative therapies.
Diagnostic SIJI
Diagnostic SIJI are considered reasonable and necessary for patients who meet all the following criteria:
- The patient must meet the above criteria for Covered Indications for SIJI and
- The SI joint injections must be performed under CT or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance and
- SI joint injection are not performed with other musculoskeletal injections in the lumbosacral spine and
- The documentation should show direct causal benefit from the SI joint injection and not from other musculoskeletal injections or treatments and,
- The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as 75% sustained and constant pain relief for the duration of the local anesthetic and 75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the same pain scale at baseline. The measurements of pain must be taken pre-injection on the day of the SIJ injection, post-intervention on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.
Diagnostic SIJI Limitations
- No more than two diagnostic joint sessions, unilateral or bilateral. To clarify, two unilateral sessions, if performed on one side at one session and on the opposite side at a different session, would meet the limitation of two diagnostic sessions.
- HCPCS modifier KX requirements:
- The KX modifier should be appended to the line for all diagnostic injections.
- The KX modifier will only be used for the initial diagnostic injections.
- Repeat diagnostic injections beyond the first one or two SIJI required to confirm the diagnosis, are not reasonable and necessary.
- No more than two diagnostic joint sessions (CPT codes 27096 and/or 64451), unilateral or bilateral, regardless of the code billed.
Therapeutic SIJI
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet all the following criteria:
- The patient must meet the above criteria of Covered Indications for SIJI and
- The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as 75% sustained and constant pain relief for the duration of the local anesthetic and 75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the same pain scale at baseline. The measurements of pain were taken pre-injection on the day of the diagnostic SIJ injection, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJ injection to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used and
- Subsequent therapeutic SIJI are considered medically reasonable and necessary when the subsequent SIJI are provided at the same anatomic site as therapeutic SIJI, and the therapeutic SIJI produced at least consistent 50% pain relief or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs for at least three months from the proximate therapeutic SIJI procedure and compared to baseline measurements for ADLS and painful movements or pain relief using the same pain scale and
- The SI joint injections must be performed under CT or fluoroscopy image guidance with contrast.
Therapeutic SIJI Limitations
No more than four therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on one side first and then on the opposite side at a different session would qualify as two sessions for the limitation of four therapeutic SIJ sessions per rolling 12 months.
- Only one spinal region may be treated per session (date of service).
- Sacroiliac joint injections may be performed unilateral or bilateral in the same session.
- No more than four therapeutic SIJI sessions (CPT codes 27096 and/or 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.
SIJ Denervation
SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and necessary.
Requirements
- The SIJI must be performed under CT or fluoroscopy image guidance with contrast.
- Unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered.
- The SIJ procedure(s) should be performed in conjunction with conservative treatments.
- Patient should be part of an ongoing and be actively participating in a rehabilitation program, home exercise program or functional restoration program.
- SIJ primary index pain must be measured prior to the injection at the beginning of the session.
- The post procedure pain level must be measured after the SIJ injection at the conclusion of the session.
Pain Scales
Pain assessment:
- Baseline and after each diagnostic procedure
- Same pain scale for each assessment
- Must be documented in the medical record
- Acceptable scales include but are not limited to:
- Pain assessment:
- Verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS)
- Functional assessment:
- Pain Disability Assessment Scale (PDAS) Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS) and the PROMIS profile domains.
- Pain assessment:
Requirements
- When documenting the percentage of pain relief from the primary (index) pain compared to the post-injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of the duration of pain relief.
- The documentation should include a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection and the specific dates the measurements were obtained using the same pain scale used at baseline.
- When documenting the ability to perform previously painful movements and ADLs it is insufficient to provide a vague or nonspecific statement regarding the improvement of previously painful movements and ADLs.
- The documentation should include a functional assessment to show clinically meaningful improvement with painful movements and ADLs, if this metric is used to justify the efficacy of the SIJI procedure. Providers should use established and measurable goals and objective scales to assess functionality and ADLs measures.
The documentation must have the radiographic films (i.e., fluoroscopy images) of the procedure in at least two views (i.e., the pre and post contrast injection views in the AP and oblique planes) to confirm intraarticular injection of contrast and the treatment agent(s) used.
Additional Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or nonphysician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.
- Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.
- The patient’s medical record should include, but is not limited to:
- The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
- Relevant medical history.
- Results of pertinent tests/procedures.
- Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
- Documentation to support the medical necessity of the procedure(s).
Limitations
- Injections performed without radiographic image guidance are not considered reasonable and necessary.
- A SIJI involves the use of an anesthetic, corticosteroid and contrast agent and does not include injections of biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other injectates.
- It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, trigger point injections, etc.) during the same session as SJIs injections and during the post-SJI injection efficacy assessment period.
- Use of Moderate or Deep Sedation, General Anesthesia and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for SIJ injections and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice.
- SIJIs to treat non-specific low back pain (LBP), axial spine pain primary above the level of L5, complex regional pain syndrome, widespread diffuse pain, chronic pain syndrome and pain from neuropathy are considered investigational and therefore are not considered medically reasonable and necessary.
- SIJIs used as part of a series of lumbar spine and musculoskeletal injections to treat nonspecific or chronic low back pain is not considered reasonable and necessary.
- In patients with implanted electrical devices, (i.e., spinal cord stimulation, peripheral nerve stimulation, cardiac devices, etc.) and intrathecal pump delivery devices, providers should follow manufacturer instructions and extra planning as indicated to ensure safety of the procedure.
- Patients with coexisting psychological conditions or depression related illness should be treated and stabilized prior to proceeding with interventional procedures. Multidisciplinary biopsychosocial rehabilitation principles should be provided to these patients.
- It generally would not be considered medically reasonable and necessary for treatment with SIJIs to extend beyond 12 months. Frequent continuation of SIJIs injections over 12 months may trigger a focused medical review. Use beyond twelve month requires the following:
- Pain is severe enough to cause a significant degree of functional disability or vocational disability and providers use established and measurable goals and objective scales to assess functionality and ADLs measures.
- SIJIs provides at least 50% sustained and consistent improvement of pain and/or 50% sustained and consistent objective improvement in function (using same scale as baseline) for at least three months.
- Rationale for the continuation of SIJIs including but not limited to patient who are high-risk surgical candidates, the patient does not desire surgery and/or the recurrence of pain in the same location was sustained and consistently relieved with the SIJIs for at least three months.
- The primary care provider should be notified regarding continuation of procedures and prolonged repeat steroid use to allow for systematic care delivery treatment surveillance and multidisciplinary biopsychosocial Rehabilitation (MBR).
- A subsequent diagnostic SIJI is not reasonable and necessary when the initial diagnostic block does not produce a positive response of ≥75% pain reduction.
- A subsequent therapeutic SIJI is not reasonable and necessary when the proximate SIJI did not provide at least a consistent 50% pain relief or at least a 50% consistent improvement in the ability to perform previously painful movements and ADLs for at least three months compared to baseline objective measurements for ADLS and painful movements or pain relief using the same pain scale.
Provider Qualifications
- The CMS IOM Publication 100-08, Medicare Program Integrity Manual states services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
- Patient safety and quality of care mandate that healthcare professionals who perform SIJ injections/procedures for chronic pain (not surgical anesthesia) are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program whose core curriculum includes the performance and management of the procedures addressed in this policy.
- Credentialing or privileges are required for procedures performed in inpatient and outpatient settings.
- All aspects of care must be within the provider's medical licensure and scope of practice.
Billing and Coding
- Sacroiliac joint injections may be performed unilateral or bilateral in the same session.
- Bilateral SIJIs procedures reported with CPT codes 27096 or 64451 should be reported with CPT modifier 50.
- For services performed in the ASC (specialty 49), do not bill on one claim line using CPT modifier 50. For ASC facility claims (specialty 49), report the applicable procedure code on two separate lines, with one unit each and append HCPCS modifiers RT and LT to each line.
- CPT code 27096 Injection procedure for sacroiliac joint, anesthetic/steroid with image guidance (fluoroscopy or CT) including arthrography when performed.
- CPT code 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography).
- ICD-10 codes
- M46.1 Sacroiliitis, not otherwise classified
- M46.1 Sacroiliac inflammation
- M47.818 Arthritis of the Sacroiliac Joint
- M43.28 Ankylosing of the Sacroiliac Joint
- M53.3 Disorder of the Sacroiliac Joint
- The following CPT codes are noncovered (this is not an inclusive list of noncovered codes)
- 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint with image guidance (i.e., fluoroscopy or computed tomography).
- CPT 27096 is not covered in ASC.
- For ASC facility claims only.
- G0260 injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography.
- Must be billed with fluoroscopy code (77002) or CT (77012).
- 77002 Fluoroscopic guidance for needle placement. (e.g., biopsy, aspiration, injection, localization device) (list separately in addition to code for primary procedure)
- 77012 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation.
- Providers who submit professional claims should use 27096 and/or 66451 as appropriate
- The KX modifier is used for diagnostic injections only regardless of the setting.
Reviewed 10/10/2023