Dealing with denied claims for sacroiliac (SI) joint injections is frustrating. You perform the procedure correctly, document the medical necessity, and yet, the claim gets rejected. The reason is that you are missing minute details that are essential. Don’t worry, we have created this guide to help you understand these details.
CPT code 27096 is among the most used codes for sacroiliac (SI) joint injections. So, we will discuss how you can use it effectively in your billing. Let’s start.
CPT Code 27096 – Description
CPT code 27096 is defined as:
“Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT), including arthrography when performed.”
Sounds hard? Let’s simplify it for you.
27096 is a pain management procedure code. It is used to bill a sacroiliac joint injection. During the procedure, an anesthetic agent or steroid drug is injected into the joint to relieve the pain. However, according to the guidelines, CPT code 27096 is specific to physicians and non-facility settings. You cannot use it for hospitals and facilities.
Key requirements for 27096:
- Image Guidance is Mandatory: You cannot bill 27096 if you do not use fluoroscopy or Computed Tomography (CT). The code description explicitly includes image guidance. Also, many billers use 27096 if ultrasound imaging is used. However, this is wrong and will result in a denial.
- Intra-articular Confirmation: You must document imaging confirmation of intra-articular needle positioning. This usually involves the injection of contrast medium (arthrography) to verify the flow within the joint space. Without this visual proof documented in the operative report, the service does not meet the definition of 27096.
Furthermore, CPT 27096 is a unilateral procedure. It represents an injection on one side only. If you treat both sides, you must adjust your coding strategy (more on that in the modifiers section).
Scenarios Where CPT Code 27096 is Applicable
Let’s try to make things clearer with a couple of real-world scenarios in which CPT code 27096 can be used:
Sacroiliitis
Suppose a female patient comes to the clinic with persistent lower back pain that worsens with prolonged sitting and climbing stairs. She experiences stiffness in her buttocks and hips, especially in the morning. The physician assesses the patient’s condition in detail and suspects inflammation of the sacroiliac joint, a condition known as sacroiliitis.
To provide temporary relief and confirm the diagnosis, the physician orders a therapeutic sacroiliac joint injection with fluoroscopic guidance. In this scenario, the billing department can use CPT code 27096 with diagnosis code M46.1.
Chronic SI Joint Dysfunction
For our second example, suppose a patient arrives at the clinic complaining of chronic, non-radicular pain in his right lower back. He has been experiencing this pain for the past 6 months, and conservative treatments like physical therapy and NSAIDs have failed to offer permanent relief.
When asked, he specifically points to the area just below the beltline and over Fortin’s point as the site of pain. He also tells the physician that the intensity of pain becomes sharp when he stands up from a sitting position, but when he walks, the pain becomes dull.
The physician performs Flexion, Abduction, and External Rotation (FABER) and Gaenslen’s tests, both of which give positive results for SI joint dysfunction. Hence, an SI joint injection is administered on the right side using fluoroscopic guidance and some contrast dye.
After that, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 27096 is used along with diagnosis code M53.3.
Applicable Modifiers for CPT Code 27096
The following are some commonly used modifiers with CPT code 27096:
| Modifier | Short Description | Usage |
|---|---|---|
| 50 | Bilateral procedure | Used when injecting both SI joints. Append to CPT 27096 to indicate bilateral procedure. Note: Some payers may prefer two line items with RT and LT modifiers instead. Check local payer contracts. |
| RT/LT | Right or left side | Used when treating only one side to specify which joint was treated. Prevents duplicate claim issues when treating the opposite side at a later date. |
| KX | Requirements met | Required by some payers (especially Medicare MACs) for therapeutic injections to attest that the service is medically necessary and meets all coverage policy requirements. |
CPT Code 27096 – Billing & Reimbursement Guidelines
Getting the code right is only half the battle. You must be aware of the following essential points before filing claims with 27096:
Facility vs. Non-Facility Coding
Where you perform the procedure changes the code you submit.
- Physicians (Office/Non-Facility): Use CPT 27096.
- Hospital Outpatient Departments (Facilities): Under the Outpatient Prospective Payment System (OPPS), facilities should typically report HCPCS code G0260 (injection procedure for sacroiliac joint; provision of anesthetic, steroid, and/or other therapeutic agent, with or without arthrography).
Documentation for Medical Necessity
Documentation is key to getting your claims reimbursed. Without proper and detailed documents, insurance payers cannot verify the medical necessity of the procedure, which leads to denials. For 27096, you must provide the following details:
- Each page of the patient’s file must be clear and readable, showing the patient’s full name and service dates. The treating physician or practitioner must sign all documentation legibly.
- Medical records must justify the ICD-10-CM diagnosis codes selected, and the CPT/HCPCS codes must accurately reflect the services provided.
- Records must demonstrate that non-invasive treatment options were attempted first, including medication management, with explanations provided if these treatments were not fully pursued.
- Procedure reports must explain why the nerve blocks were medically necessary and document the percentage of pain relief the patient experienced immediately after the injection.
- Imaging documentation showing final needle placement and contrast distribution (at least 2 views) must be kept and available for review if requested.
- The patient’s medical record must contain the provider’s clinical assessment related to the patient’s complaint, relevant health history, test and procedure results, signed and dated visit notes or operative reports (required for all Medicare services), and documentation establishing why the procedure was medically necessary.
Medicare Reimbursement Rate
According to the Medicare Physician Fee Schedule for 2026, the national average reimbursement rates for CPT code 27096 are:
- Facility setting (hospital outpatient/ASC): $73.82
- Non-facility setting (office): $175.69
However, these rates are different for each Medicare Administrative Contractor (MAC) locality. To find the exact reimbursement rate for your MAC locality, you can use the PFS Lookup Tool.
Wrapping Up
Finally, we have reached the end of this guide. Let’s recap the essential points.
- CPT code 27096 is used for sacroiliac (SI) joint injections performed with the help of imaging (fluoroscopy or CT).
- The code can only be used in non-facility settings.
- You must provide detailed documentation and append appropriate modifiers for proper reimbursement.
If you are having trouble with medical coding or want to outsource your non-clinical operations, you can always count on MediBillMD’s pain management billing services.
