June 6, 2019

Question:

A patient comes to our office for a sacroiliac joint injection and is also requesting a cervical trigger point injections as he woke with a stiff neck.  The physician evaluated the patient and performed a right SI joint injection and also injected 4 spots along the left trapezius.  Fluoroscopy is used for guidance for the SI joint injection with no imaging for the trigger point injection.  How would I code this?

Answer:

You would report 27096-RT (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed) for the SI Joint injection.  Imaging guidance is included and is not reported separately.  You would also report CPT code 20552-59 or XS (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)).  You must append either Modifier 59 (distinct procedural service) or XS (separate structure) to CPT code 20552.  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 or XS 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 06/06/19.