May 31, 2018

Question:
What CPT codes do I use to perform a right SI joint injection and then inject 4 spots along the left trapezius?  I use Fluoroscopy for guidance for the SI joint injection, but not for the trigger point.

Answer:
Use CPT code 27096-RT (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed) and CPT code 20552-59 or XS (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). CPT code 20552 is bundled if performed at the same anatomic location. In this case the trigger point was performed at a separate anatomic area. The 59 modifier tells the payor that the two procedures were performed at different anatomic areas.

*This response is based on the best information available as of 05/31/18.