There has been a seismic change to the coding and reimbursement for sacroiliac (SI) joint procedures over the last few years – we’re “transfixed” on this hot topic. New and disruptive minimally invasive procedures and techniques have come onto the market since 2018- now, there are more than 40 different implants to choose from. As a result, new CPT coding became effective 1/1/23, and higher payment rates for certain SI joint procedures are available from Medicare to hospital outpatient departments and ASCs supporting them. Also, new provider types are now performing SI joint procedures historically done by only surgeons. All of this has resulted in increased scrutiny by MACs and private payors, the AMA has created new codes and definitions, and a RAC audit of medical necessity and documentation for CPT 27279.
The minimally invasive SI joint fusion procedure has typically used a lateral approach, from the side of the body, which “transfixes” the SI joint by advancing 2-3 metallic implants, sending them first across the ilium (hip) bone, across the SI joint, and into the sacrum bone at the bottom of the spine (e.g., Medtronic Rialto, Globus SI-LOK, SI-BONE iFuse). As of late 2018, a new procedure became popular which required providers to advance typically a single piece of bone allograft into the joint space, from a posterior approach (e.g., PainTEQ LinQ, CornerLoc). Nothing is transfixed in this procedure. At the same time, there were a couple of implants designed to “span” the joint from a posterior approach, by resting with one side of the implant in the ilium bone, and one side in the sacrum bone (e.g., Tenon Catamaran, SiLO TFX).
How is it Billed?
Numerous professional spine societies appealed to the AMA to create, or at least update, Current Procedural Terminology (CPT) coding to describe these new procedures. Effective 1/1/23, there are two codes to describe minimally invasive SI joint procedures:
• CPT 27279 describes the lateral “transfixing device” procedure.
• CPT 0775T describes the posterior “intra-articular” bone allograft procedure like PainTEQ LinQ and CornerLoc.[1] Beginning 1/1/24, the 0775T code will be replaced by 2X000, and Medicare is proposing to allow it in both facility and non-facility settings.[2]
Is it covered by Insurance?
Most insurance covers the lateral 27279 procedure; virtually none cover 0775T and therefore the likelihood for miscoding these other, non-covered procedure types is high. Please check your respective plan policies.
What should you look for?
• When auditing claims, review the device name/type – e.g., iFuse, vs. PainTEQ or CornerLoc, vs. Tenon Catamaran, etc.
• Look for outliers based on provider specialty as mostly surgeons have historically reported 27279. Mostly non-surgeon taxonomies like interventional pain, pain management, physical medicine, and anesthesia typically use the posterior technique. Many simply reported 27279 prior to 1/1/23.
If you are using the Healthcare Fraud Shield (HCFS) platform, HCFS has you covered. Our 1600+ library of alerts that is used in combination with our artificial intelligence includes the following alert:
[2570-20] – MISREPRESENTATION OF SERVICES, SACROILIAC JOINT PROCEDURES: This Alert identifies providers excessively billing a sacroiliac joint procedure via lateral, transiliac “transfixing device” approach when compared to their peers, as they may actually be performing a procedure that uses intra-articular placement of bone allograft products or devices typically placed via a posterior, or “dorsal,” approach. (PEER COMPARISON)
REFERENCES
[1] https://www.ama-assn.org/system/files/may-2022-cpt-summary-panel-actions.pdf
[2] https://www.ama-assn.org/system/files/cpt-panel-september-2022-agenda.pdf
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