CPT Code 27096: Sacroiliac Joint Injection, Unilateral

What is CPT code 27096?

CPT code 27096 describes a therapeutic injection procedure performed into the sacroiliac (SI) joint, typically used to relieve pain and inflammation. The injection is performed under imaging guidance, such as fluoroscopy or computed tomography (CT), to ensure accurate targeting of the joint. Healthcare providers, including pain management specialists, use this injection procedure primarily to treat conditions like sacroiliitis or SI joint dysfunction. The 27096 CPT code encompasses all components necessary for achieving effective pain relief and diagnostic clarity, including contrast for arthrography (if performed), image guidance, needle placement, and administration of anesthetic and corticosteroid medications.

What is a sacroiliac joint injection?

A sacroiliac (SI) joint injection is a minimally invasive procedure used to diagnose and treat pain originating from inflammation or dysfunction of the SI joint, located between the sacrum and ilium bones. By injecting anesthetic and corticosteroid medications directly into the joint, healthcare providers can confirm the joint as a source of pain and deliver significant pain relief and reduce inflammation.

CPT code 27096 documentation requirements

Comprehensive documentation ensures compliance and supports reimbursement from payers, such as Medicare and Medicaid services.

Clinical indication

Document the medical necessity clearly, specifying the indication for the SI joint injection, such as SI joint dysfunction or sacroiliitis, aligning with local coverage determinations (LCDs).

Imaging guidance details

Record the imaging modality used for guidance, typically fluoroscopy or CT. Retain fluoroscopic or CT images in the medical record as supportive documentation.

Injection technique and medications

Clearly document the injection procedure technique, medications administered (anesthetic, corticosteroid), and their dosages to justify the service fully by bringing clarity to the treatment provided.

Anatomical site and laterality

Include detailed notes specifying the anatomical site injected and clearly indicate laterality (right, left, or bilateral procedure), using the appropriate modifier if the injection was unilateral or bilateral.

Response to diagnostic injection

If performed diagnostically to confirm SI joint pain, document the patient’s immediate response to evaluate the effectiveness of the injection and guide further management.

CPT code 27096 billing guidelines

Accurate billing practices ensure correct reimbursement according to the Medicare Physician Fee Schedule (MPFS) and guidelines from Medicare Administrative Contractors (MAC).

Report once per session, per joint

Bill CPT code 27096 once per joint per session. If a bilateral procedure is performed, verify with the payer for specific billing guidelines.

Image guidance included

Do not separately bill imaging guidance codes (77003 or 77012), as CPT code 27096 includes image guidance for accurate needle placement.

Ultrasound guidance exclusion

Do not use CPT code 27096 for ultrasound-guided SI joint injections, as there is currently no CPT code that specifically supports ultrasound guidance for this procedure.

Medical necessity verification

Ensure documentation meets medical necessity criteria set by the Centers for Medicare & Medicaid Services (CMS) and aligns with local coverage determinations (LCDs) found on the Medicaid services CMS website or through your local Medicare Administrative Contractor.

Modifiers

• Modifier 50 – Bilateral procedure: Use this when injections are performed on both sacroiliac joints during the same session.
• Modifier LT – Left side: Apply this when the injection is performed on the left sacroiliac joint only.
• Modifier RT – Right side: Use this when the injection is performed on the right sacroiliac joint only.
• Modifier 59 – Distinct procedural service: This may be reported if the injection is performed separately from another procedure on the same day, such as in a different anatomical region or session.
• Modifier 76 – Repeat procedure by same physician: Use this when the same provider repeats the SI joint injection on the same day.
• Modifier 77 – Repeat procedure by another physician: Use this if a different provider repeats the injection on the same day.
• Modifier 22 – Increased procedural services: Report this if the injection required significantly more effort than usual, such as in patients with complex anatomy or technical difficulty.
• Modifier 24 – Unrelated evaluation and management service by the same physician: Use this when an E/M service unrelated to the SI joint injection is also provided on the same day.
• Modifier 52 – Reduced services: Apply this if the injection was intentionally limited or partially performed.
• Modifier 53 – Discontinued procedure: Report this if the procedure began but was discontinued due to unexpected circumstances, such as patient intolerance or complications.

Other relevant CPT codes

• 20552 – Trigger point injection (different anatomical site)
• 64483 – Transforaminal epidural injection (lumbar spine)
• 77003 – Fluoroscopic guidance (included in 27096, do not bill separately)
• 20610 – Major joint injection (hip joint)
• 62321 – Cervical or thoracic epidural injection