Medicare data analysis indicates that a large percentage of claims submitted to Pinnacle Business Solutions (PBI) for sacroiliac (SI) joint injections with arthrography are reported using CPT® 27096 Injection procedure for sacroiliac joint, arthrography, and/or anesthetic/steroid without evidence of fluoroscopic guidance. Not only does this equate to a loss of as much as $78 per procedure, it sets up such claims for almost certain denial.

Simply by following CPT® and carrier guidelines, your practice can ensure proper claims payment for SI joint injections.

PBI instructs you on their website to report CPT® 27096 only if SI joint injections with arthrography are performed with fluoroscopic guidance. If fluoroscopy is not used, CPT® 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) is more appropriate.

To report guidance, use CPT® 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedure (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction for needle localization of a basic therapeutic SI joint injection; or report CPT® 73542 Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation for a more diagnostic SI joint injection and arthrogram (CPT® Assistant, July 2008). If billing 73542, radiographic hard copies of the arthrograms need to be obtained in multiple views and a separate radiologic interpretation and report need to be dictated.

National non-facility Medicare payment rates for CPT® codes 77003 and 73542 are $59.15 and $78.63, respectively. Note that CPT® 73542 includes 77003, so it would not be appropriate to bill for both.

On a final note, if bilateral SI joint injections with arthrography are performed with fluoroscopic guidance, report 27096 with modifier 50 Bilateral procedure.

8 Responses to “CPT® 27096 Requires Fluoroscopic Guidance”

1. Marvel J Hammer Says:
   January 20th, 2010 at 2:20 pm

   Actually, CPT code 27096 does not require use of fluoroscopic guidance specifically, rather physicians must use some form of image guidance in order to report the code. The injection can not be performed “blind” / “anatomically guided” and compliantly be reported as 27096.

   Though fluroscopy (77003) is the most common method for image guidance for SI joint injections, there are some patients that may require use of CT needle guidance (77012) in place of fluoroscopy. Use of CT needle guidance for an SI joint injection also would meet the criteria for compliantly reporting 27096.

2. Debra Griffin Says:
   January 21st, 2010 at 9:35 am

   Per CPT notes under 77003 for sacroiliac joint arthrography see 27096, 73542. The fluoro is only separately reported if a formal arthrography is NOT done. 77003 and 73542 should not be reported together.

3. Steve Says:
   February 19th, 2010 at 7:58 am

   Does this code include ultrasound guidence or would it be more appropriate to use 20610 (a large joint injection) with code 76942 (ultrasound guidence)?

4. Lu Sumner Says:
   March 15th, 2011 at 12:51 pm

   Confirm then Code; often when physicians are using 27096 and w/o flouroscopy, the injection that is actually being performed is to a trigger point, 20552, rather than in the SI joint. Usually the piriformis muscle is the site mostly related to a SI joint injection indication, so always confirm with the progress notes or the physician the specific site of injection.

5. Lisa Says:
   March 31st, 2011 at 11:05 am

   Can you use modifier RT and Left with the 27096 instead of modifier 50. We have seen where some payers won’t accept modifier 50.

6. Makailee Says:
   May 2nd, 2011 at 1:53 pm

   Hey, good to find someone who aegres with me. GMTA.

7. Marcella Stroman Says:
   May 18th, 2011 at 9:54 am

   When billing for the 73542 cpt should the modifier 26 be appended to the code?

8. Cynthia Says:
   January 30th, 2012 at 3:52 pm

   Medicare is not allowing 77003 to be billed with 27096 anymore; they are saying “Not covered when performed during the same session/date as a previously processed service for this patient.” This is new this year and a call to their provider “help” line yielded little help, only stating we should use an “unbundling” modifier. We already use 26, that has worked just fine.
   Any suggestions? comments? Anyone else having this issue?

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