Did you know that joint fusions are one of the most performed orthopedic surgeries in the healthcare industry? According to a 2023 study, around 12,978 sacroiliac joint fusion procedures were performed on Medicare beneficiaries, and 76.5% of those procedures were minimally invasive. But still, orthopedists are losing money. Why? Because the claim denial rate remains high for orthopedics (18%).
Incorrect coding is one of the main reasons for claim denials. That’s why today, we have centered our guide on CPT code 27279 to help you master coding accuracy and get paid for your services. Ready to read?
CPT Code 27279 – Description
The Current Procedural Terminology (CPT) code 27279 is from the code range covering ‘Arthrodesis Procedures on the Pelvis and Hip Joint’ as maintained by the American Medical Association (AMA). The code reports surgical fusion of the sacroiliac joint (arthrodesis) under image guidance to reduce pain and enhance stability. It is a minimally invasive procedure and uses the percutaneous approach to improve function and mobility in patients suffering from sacroiliac (SI) joint dysfunction.
During the procedure, the orthopedic surgeon incises the side of the patient’s buttock (the incision is usually 2-3 cm long) and inserts a fixation device, passing through the ilium, across the sacroiliac joint, and into the sacrum. A bone graft obtained from another part of the patient’s body is also placed on the affected area for immobilization. The entire procedure is performed under image guidance for precision. After the implantation, the surgeon irrigates the surgical site with a saline solution to remove debris and uses sutures to seal the incision.
Medicare covers CPT code 27279. The current physician reimbursement rate for arthrodesis of the sacroiliac joint is between $707.31 and $1,070.35, depending on the MAC locality and facility.
Scenarios Where CPT Code 27279 is Applicable
Now that we understand what the procedure entails, let’s look at some clinical scenarios where CPT code 27279 is accurately applicable.
To Treat Sacroiliac Joint Dysfunction
According to a USA cross-sectional survey, the National Health Measurement Study (NHMS), approximately 10 million Americans experience sacroiliac joint pain, especially in their lower back. The primary reason for this pain is sacroiliac (SI) joint dysfunction, which occurs when firm bone joints at the base of the spine do not move properly. It affects the lower back, buttocks, and upper leg, resulting in persistent pain and discomfort (while sitting, walking, and standing).
In an article published by the AAFP Foundation, it was found that 25% of adults in the USA have SI joint dysfunction, and its prevalence is higher in women compared to men.
So, let’s imagine that after childbirth and weight gain, a 38-year-old woman developed SI joint dysfunction. After months of alternative treatments like physical therapy, pain medication, and brace wearing, her orthopedist recommends an arthrodesis of the sacroiliac joint with bone grafting for permanent relief.
The orthopedist surgeon performs the minimally invasive procedure and bills the patient’s insurance payer with CPT code 27279.
To Reduce Sacroiliac Joint Inflammation
Sacroiliac joint inflammation, or sacroiliitis, is similar to SI joint dysfunction and mainly results from osteoarthritis (a type of arthritis affecting the bone joints). The condition is more common in people aged 50 and above. It causes body pain and stiffness, limiting the patient’s movement and sleep.
Assume that a 65-year-old man with osteoarthritis visits his orthopedist complaining of severe pain in his lower back, buttocks, and legs. He is unable to climb stairs, bend, or sleep in one position for a long time. His orthopedist conducts some physical exams and imaging tests, diagnosing him with bilateral sacroiliitis (inflammation in both sacroiliac joints). The patient is given pain medications and undergoes physical therapy and radiofrequency ablation (RFA) for pain management.
However, the condition persists, and after 6 months, the patient is recommended percutaneous sacroiliac joint arthrodesis with bone grafting for permanent pain reduction. The orthopedic surgeon performs the joint fusion procedure and reports CPT code 27279 on the claim form for reimbursement.
To Correct Posture While Sitting and Standing
Sitting or standing for long durations can worsen sacroiliac joint pain, especially if done with incorrect posture, like sitting cross-legged. People employed in professions that require prolonged sitting or standing are at a greater risk of SI joint dysfunction.
So, for our last example, let’s assume that a 40-year-old man with a corporate job visits his orthopedist for a follow-up appointment for his lower back pain. The patient spends nearly 10 hours a day sitting in front of his computer screen in an improper posture.
His orthopedist diagnoses abnormal movement in his right sacroiliac joint due to intense pressure on the right side of the hip and recommends joint fusion surgery to immobilize the joint. The orthopedist performs the surgery by implanting titanium plates (a transfixing device) and bone grafts and later bills the patient’s insurance payer with CPT code 27279.
Applicable Modifiers for CPT Code 27279
Modifiers are two-character codes that enhance coding specificity during medical billing. A few of the most applicable modifiers for CPT code 27279 are as follows.
Modifier 22
You can append modifier 22 next to CPT code 27279 when the procedure requires more time and effort than usual. This modifier indicates increased procedural services and can help you collect up to 25% on top of the standard reimbursement rate.
Modifier 50
Modifier 50 indicates that the procedure was performed bilaterally, meaning on both sides of the pelvis. You must append modifier 50 to CPT code 27279 if the sacroiliac joint fusion surgery was performed on the left and right joints during the same session.
Modifier 53
Can you still get paid for a surgical procedure that was abandoned midway due to unforeseen circumstances? Yes, you can! The solution is to append modifier 53 to the code if you had to discontinue the arthrodesis of the sacroiliac joint(s) due to the patient’s worsening condition. However, for this modifier to be relevant, the termination must occur after anesthesia administration.
Modifier LT
Modifiers RT and LT indicate laterality, helping the insurance payers identify the side of the body where the procedure was performed. So, you must append modifier LT to CPT code 27279 if the joint fusion surgery was only performed on the left side of the pelvis.
Modifier RT
Modifier RT will help you specify that the sacroiliac joint fusion surgery was only performed on the right side of the pelvis.
CPT Code 27279 – Billing & Reimbursement Guidelines
Your claims with CPT code 27279 can get approved on the first attempt if you follow the billing best practices. Below, we have discussed some coding, billing, and reimbursement guidelines specific to CPT 27279 to help you optimize your revenue cycle. Take a look!
Pair with the Appropriate Diagnostic Codes
Insurance payers need proof of medical necessity to process and approve your reimbursement claims. Reporting the correct ICD-10-CM diagnostic codes with CPT 27279 will help you explain why the medical intervention was needed. Therefore, you must pair CPT code 27279 with the most relevant diagnostic code, such as M46.1 for sacroiliitis or M99.04 for segmental and somatic dysfunction of the sacral region, to avoid claim denials.
Use Correct Place of Service Codes
Medicare considers ambulatory surgical centers, hospital outpatient departments, and office-based interventional suites as the appropriate settings for performing a minimally invasive arthrodesis of the sacroiliac joint(s). Therefore, you must report the correct Place of Service (POS) codes with CPT code 27279 to establish coding accuracy.
- POS 11 – Office
- POS 19 – Off-Campus, Outpatient Hospital
- POS 22 – On-Campus, Outpatient Hospital
- POS 24 – Ambulatory Surgical Centers (ASC)
Do Not Confuse CPT 27278 with 27279
Orthopedic billing specialists frequently get confused between CPT codes 27278 and 27279. So much so that Medicare had to release a detailed document highlighting the correct and distinct usage of the two CPT codes.
Remember that while CPT codes 27278 and 27279 both describe the surgical fusion (arthrodesis) of the sacroiliac joint via percutaneous approach, the two are distinct in the type of device used and its placement.
CPT code 27278 is reported when the provider implants an intra-articular device in the SI joint to engage the sacrum and ilium, whereas CPT code 27279 reports transfixing the ilium and sacrum bones to immobilize the SI joint. So, while 27278 is the initial procedure for treating SI joint pain, inflammation, and dysfunction, the procedure reported by CPT 27279 is absolute.
Provide Adequate Documentation
You must always maintain and submit accurate and comprehensive documentation to support the medical necessity of your services. It is key to warding off claim denials. Hence, your claim with CPT code 27279 should include documents like:
- Patient’s complete medical history
- Treatment plans
- Diagnostic test results/reports
- Clinical notes
- Surgical notes
- Referral letters
- Pre-authorization letters
Follow Payer-Specific Guidelines
Arthrodesis of the sacroiliac joint using transfixation and a bone graft is covered by Medicare, Medicaid, and most commercial insurance payers. However, the billing and reimbursement guidelines for CPT code 27279 vary across payers. To ensure clean claim submission, you must follow the payer-specific guidelines set forth for CPT 27279 by each.
It is best to review the Medicare Administrative Contractors’ (MACs) Local Coverage Determination (LCD) policy manuals and payer contracts to find the applicable billing rules for your practice and region.
Summary
Our ultimate guide comes with an ultimate solution to all your medical coding and billing problems. But before we unveil it, let’s quickly recap what we have learned so far. We explained that CPT code 27279 specifies a minimally invasive sacroiliac joint fusion surgery (arthrodesis) using a transfixing device and bone graft to treat lower back and pelvis pain. The procedure is performed under imaging guidance and has a global surgery period of 90 days.
We also discussed the code’s real-world applications, such as treating SI joint dysfunction, reducing sacroiliitis, and improving posture. You must append modifiers like 22, 50, 53, RT, and LT when necessary to enhance coding specificity. Lastly, remember to report the correct diagnostic and place of service codes, maintain detailed documentation, and follow payer-specific guidelines to avoid claim denials.
However, the best way to free yourself from the coding frenzy is to outsource everything to professionals. MediBillMD’s orthopedic billing services include accurate CPT coding, guaranteeing a 98% clean claim rate.
