No, these are two different sessions. A session is a time period, which includes all procedures that are performed during the same day. Since this scenario describes injections performed on different days this will count as two sessions. This counts as 2/4 therapeutic SIJI sessions reimbursed per rolling 12 months.

Bilateral SIJIs procedures reported with 27096 or 64451 should be reported with modifier 50. For services performed in the ASC (specialty 49), do not bill on one claim line using modifier 50. For ASC facility claims (specialty 49), report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.

At baseline, a standardized pain or functional scale (provider can choose which one) must be used to measure pain prior to intervention. This can be done at the initial office visit or immediately before the injection.

Pain must be reassessed at follow-up using the same scale. In order to qualify for repeat injection documentation of at least 50% improvement from the baseline pain scale to the post treatment pain scale is required.

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.

The policy requires a period of four weeks of conservative therapy before proceeding with intervention. The patient should be informed that it is expected and required for coverage that aspects of conservative therapy determined to be most beneficial for the patient will be continued in conjunction with SIJIs as part of the treatment program. The patient and provider can determine the choice of conservative treatments and document this in the medical record.

Conservative treatment is defined in the policy as an appropriate combination of medication (for example, NSAIDs, analgesics, etc.) in addition to physical therapy, spinal manipulation therapy, CBT, home exercise program, or other interventions based on the individual’s specific presentation, physical findings and imaging results.

There are two factors to determine if CRNAs are eligible for payment:

• Must be within the Scope of Practice for CRNAs in their state to perform the procedures.
• Patient safety and quality of care mandate that healthcare professionals who perform SIJ procedures to be 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. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner should be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure, and utilization of the required associated imaging modalities.

No, if SIJIs are injected with biologicals or other substances not designated for this use, the entire claim will deny per CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 180.

See Response to Comment Article:

• The medical literature is insufficient to determine patient selection criteria, administration techniques, assessment criteria, frequency of treatment and long term outcomes.
• Sacroiliac joint radiofrequency ablation procedures require additional investigation to provide clarity to meet the requirements of reasonable and necessary

Use of moderate or deep sedation, general anesthesia and MAC is not covered. Minimal sedation anxiolysis, where patient can respond normally to verbal commends is permitted. “Twilight” sedation is not part of the ASA continuum of the depth of sedation, so the specific depth of sedation (if used) must be reported in the medical record. Vernacular terms for sedation are not sufficient documentation to describe the continuum of the depth of sedation.

According to ASA guidelines, progressing depth of sedation beyond minimal sedation is moderate or “conscious” sedation. Therefore, conscious sedation is defined as moderate sedation in the policy.

No, radiographically degeneration can occur throughout the entire spine as a result of aging and natural process. The objective of this policy is to identify the pain source and focus intervention to the specific pain generators. If pain is present throughout entire spine complex regional pain syndrome or other etiologies may be considered.

No, not currently.

Timing is rolling 12 months (not calendar year). No more than four SIJIs sessions may be reported in a rolling 12-month period. The exception is during the diagnosis period where two diagnostic injections can be performed if identified with KX modifier.

If additional studies are conducted and published in peer-reviewed journals, they can be submitted as part of the LCD reconsideration process.

The duration for diagnostic injection is not defined in the policy. Rather the policy requires response rate that aligns with the injectant used as follows:

“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 policy allows diagnostic and therapeutic injections if criteria is met for the Sacroiliac joint which is defined within the policy as: Sacroiliac Joint Complex- the articular portion of the joint, including bone, articular cartilage and joint capsule and the posterior extraocular structures which include the overlying dorsal ligaments, regional muscles and tendons.

However, injection of the posterior ligaments, rather than the dorsal ligaments that are considered part of the SIJ complex, might complicate the assessment of the response to intervention and should not be separately performed.

A minimum time duration between injections is not defined in the policy. It is expected the injection would not be repeated until the expected duration of effect from injectant used is complete. There is a limit of two diagnostic joint sessions- this is not per rolling 12 months. This is not expected to be repeated as it is diagnostic.

There is a limit of four therapeutic SIJI in a rolling 12 months. The duration between these sessions is based on the clinical needs of the patient and that they achieve the required response from each injection.

The provider performing the procedure is responsible for ensuring they have evaluated the patient themselves and that the patient meets the criteria for SIJIs as outlined per LCD. This must be documented in the medical record.

There are no specific mandates on how this pain measurement is obtained. The LCD is seeking real time information of response rather than historical verbal information. There are several ways this can be obtained. A pain scale is a simple and efficient way to collect this information post procedure. A follow up phone call can check on how the patient is doing (any complications) and provide opportunity to get this information. An electronic submission of the information via a portal or encrypted email which would “time stamp” the communication could be done.

Yes, if there is documentation that the provider performing the injection has reviewed the notes of the physician performing the procedure and the criteria for the procedure has been met per LCD requirements.

No, as long as the medical record (prior to 3/19/2023) indicates they meet the Covered Indications and there is documentation they have had a 75% or more response to previous diagnostic injections (as outlined in LCD) there is no need to repeat the diagnostic injections.

RFA has been added to this new LCD effective 3/19/2023, it is currently in the Pain Management LCD L33622 as noncovered.

For services performed in the hospital outpatient department (TOB 13x) or an ASC:

• 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

ASC and OPPS hospital based outpatient departments should report HCPCS code G0260 for SJIs. G0260 should be reported with an imaging code specific to the imaging modality employed. Report CPT 77002 for fluoroscopic guidance or CPT 77012 for CT guidance in the ASC and the hospital outpatient department. Injections of the nerves innervating the sacroiliac joint should be reported with CPT 64451. CPT 64451 includes imaging guidance. Imaging codes should not be reported with CPT 64451.

Physician services in an ASC setting should report codes as noted above in the section on professional services performed by the physician.
 

The KX modifier is used for diagnostic injections only regardless of the setting.

Outpatient hospitals should use the same codes and following the same billing convention as professional provider billing on a CMS-1500. They should use 27096 or 64451. ASCs (facility claim only) may not use 27096 so they should use G0260 along with an imaging code (77002 or 77012).

Dual (two) diagnostic injections (identified with KX modifier) can be performed at diagnosis. After diagnosis, a maximum of four therapeutic SIJI can be performed in a rolling 12 months. Therefore, there is a maximum of six injections in first 12 months. If injections continue beyond 12 months there is a maximum of four in a rolling 12 months. Additional injections with the KX modifiers will not be accepted after the initial two diagnostic injections.

If there is an extended time, two years or more, since the last SIJI and/or there is a question as to the source of the recurrent pain then diagnostic procedures may be repeated. Rationale for repeating diagnostic injections must be included in the medical record.

CPT 64550 and 20551 are not part of this policy.

If the procedure is elective delay until contrast is available is recommended. If the procedure is not considered elective and contrast is not available, the documentation should support why they needed to proceed with procedure in midst of shortage (medical necessity) and what steps were taken to improve safety.

Diagnostic injections are typically performed with local anesthetic and contrast. Response to the injection can be determined shortly after to the procedure given the rapid onset of local anesthetics which cannot be achieved with steroids. There is risk of including steroids in diagnostic injections as if the injections are negative, it may expose joint to steroids unnecessarily. There is a lack of consensus in the literature on the optimal injectant for diagnostic injections. Some providers advocate allowing steroids in the second diagnostic injection so it can provide both diagnostic and therapeutic benefits as well. The duration between injections should be reflective of expected duration of response to the injectant used. That means if steroids are added to second diagnostic injection it should be expected to last about three months.

If refers to the anti-inflammatory properties of corticosteroids used in the procedures.

If the steroid is used during a diagnostic injection (signified by the KX modifier), then that does not count towards the rolling 12-month limit. KX modifier should not be used for a therapeutic injection. However, if steroids are used in a diagnostic/therapeutic injection the duration between injections should be reflective of expected duration of response to the injectant used. That means if steroids are added to a second diagnostic injection it should be expected to last about 12 weeks.

The objective of the diagnostic injections is to confirm the suspected diagnosis of sacroiliac joint complex pain and identify patients who may benefit from therapeutic SIJIs. This LCD does not cover fusion or the role of SIJI injections for identification of surgical candidates. If a diagnostic injection includes anesthetic and corticosteroid the duration of the effect should be consistent with that of the corticosteroid used and typically last about 12 weeks. Therefore, injections should not be repeated during this time frame.

Yes, the LCD states: 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. If the injection fails to meet that criteria it would not be expected to be repeated. If there is rationale for repeated injection such as a long duration between initial evaluation or changes in symptoms/ location the rationale must be documented in the medical record.

The medical record should indicate that the procedure was performed under fluoroscopy or CT guidance (as appropriate). A separate report is not needed. Documentation requirements per Billing & Coding article require films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.

The duration between injections should be consistent pain relief for the duration of the local anesthetic and/or steroid used. Assuming local anesthetic is used the duration between diagnostic injections is typically two weeks. In order to qualify for a repeat therapeutic injection, it is expected to have at least a 50% improvement in pain relief or function for at least three months therefore it would not be expected to repeat the injection at an interval shorter than three months. Exceptional circumstances that necessitate an earlier injection should be documented in the medical record.

If there has been an extended period of time from the initial diagnostic injections (e.g. two+ years) or there is a change in the symptoms that suggest there may be a different etiology repeat diagnostic injections may be utilized with documentation in the record as to why repeat injections are considered medically necessary.

The policy allows a maximum of (two) diagnostic joint sessions, unilateral or bilateral. 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.

Diagnostic accuracy is improved with dual injections. However a single block may be sufficient because the next step in the algorithm would be therapeutic injection which could also be a confirmatory injection, therefore the policy allows this option. The confirmatory/therapeutic injection must meet the criteria for improvement as outlined in the policy before a subsequent injection can be considered.

LCD L39455 Sacroiliac Joint Injections and Procedures will be effective 3/19/2023.

RFA is not considered reasonable and necessary. Therefore, it is a noncovered service.