Coding
Appropriate Use of SI Joint Arthrodesis CPT Codes (27278, 27279, 27280 & 22899)
Hemant Kalia, MD, MPH, FIPP, FAAPMR Wyoming County Community Hospital Warsaw, NY
David R. O'Brien, MD Atrium Wake Forest Baptist Medical Center, Department of Orthopaedics and Rehabilitation Winston-Salem, NC
David B. Cohen, MD, MPH Johns Hopkins University, Department of Orthopedic Surgery Baltimore, MD
The landscape of proper coding for sacroiliac (SI) joint fusions has evolved significantly over the past couple years. Multiple products have come into the market that are placed into the SI joint through a posterior approach that are designed to fuse and/or “stabilize” the SI joint. In May 2022, the CPT Editorial Panel announced the creation of a new Category III code (0775T) for these types of procedures. In January 2024, code 0775T was deleted and replaced with a new Category I code, 27278. NASS urges members to read and abide by their local Medicare Administrative Contractor (MAC) Local Coverage Determinant (LCD) policies. Here is an analysis of the appropriate use of SI joint arthrodesis CPT codes 27278, 27279, and 27280, as evaluated by the NASS Coding Committee.
As per the CMS National Coverage Policy guidance, surgical fusion of SI joint can be deemed medically necessary if ALL of the following criteria have been met.1 Indications of Coverage
- Patient has moderate to severe pain with functional impairment and pain persists despite a minimum six months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ, and hip, including a home exercise program.
- Patient’s report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIJ, and consistent with SIJ pain.
- A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus (Fortin’s point, ie, at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or PSIS) in the absence of tenderness of similar severity elsewhere (eg, greater trochanter, lumbar spine, coccyx) and that other obvious sources for their pain do not exist.
- Positive response to a cluster of three provocative tests (eg, thigh thrust test, compression test, Gaenslen’s test, distraction test, Patrick’s sign, posterior provocation test).
- Absence of generalized pain behavior (eg, somatoform disorder) or generalized pain disorders (eg, fibromyalgia).
- Diagnostic imaging studies that include ALL of the following:
- Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions (eg, tumor, infection), fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion.
- Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology.
- Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that can be causing low back or buttock pain.
- At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits each with a different duration of action), and the ability to perform previously painful maneuvers, following an image-guided, contrast-enhanced intra-articular SIJ injection.
- A trial of at least one therapeutic intra-articular SIJ injection (ie, corticosteroid injection).
The following three CPT codes elucidate the surgical approach and type of instrumentation or fixation device used for successful arthrodesis.
1. NEW CPT Code 27278: Arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s])
New Category I code 27278 describes percutaneous placement of an intra-articular stabilization device or implant into the sacroiliac joint using a minimally invasive technique that does not transfix the SI joint. These procedures are typically performed using a dorsal or posterior approach. This code is inclusive of all image guidance. The site of service for this procedure has been expanded to allow for billing when performed in an office setting.
2. CPT Code 27279: Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device
For clarity, Code 27279 requires the use of a transfixing device per the code descriptor. Although, CPT does not define the term “transfixing device”, the clinical example for code 27279 in CPT Changes 2015 states that “the implant needs to be within the osseous confines of the sacrum and ilium” and more specifically, an implant is advanced “across the ilium, across the SI joint, and into the sacrum.” The code specifies “indirect visualization” which means that the surgeon or proceduralist is able to visualize the joint anatomy through radiographic or other indirect interpretation of imaging data. This interpretation of imaging is bundled into a single code. For all bilateral procedures modifier 50 should be used.
3. CPT Code 27280: Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed.
These open procedures can be performed through either an anterior, posterior or trans-ileal approach to the SI joint. Direct visualization of the joint, preparation of the joint for arthrodesis, grafting and stabilization of the joint are considered key portions of the procedure.
CPT Code 22899 [UNLISTED Procedure for Pelvis/Hip Joint]
When performing a percutaneous SI joint “arthrodesis or stabilization” or hybrid of both that does not fit clearly into CPT codes 27278 nor 27279, NASS recommends use of the unlisted code, 22899 (unlisted procedure spine) When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide adequate description of the nature, extent, and need for the procedure time, effort, and equipment necessary to provide the service.
Key Take Home Points
1
SI Joint Arthodesis CPT Codes, whether open or minimally invasive, have significant appropriate use criteria and are not indicated for use in cases of spinal deformities and degenerative spinal conditions.
2
If the SI joint is only indirectly visualized using imaging modalities, then it is a minimally invasive procedure coded by 27278, 27279, or 22899.
3
New Code 27278 places a device interposed within the SI Joint that may engage the sacrum and ileum.
4
Code 27279 includes placement of a device that transfixes across the joint.