Date: 2015-11-01
Contact: CMS Local Coverage Determination (LCD) #L34443
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.
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Editor: Philip Blann (pblann@anesthesiabilling.com).
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