New CMS Palmetto LCD for SI joint pain

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Orin

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How're y'all in the southeast handling this? Effective 3/19/23. We discussed this briefly in Sacral RF reimbursement but looks like it is now moving through mostly unchanged.


- No more SI joint RFAs
- Must do a "diagnostic" injection with 75% relief before doing "therapeutic" injections that have 50% relief
- Maximum of 2 diagnostics and 4 therapeutic sessions (unilateral or bilateral events) over rolling 12 months
- Shouldn't routinely be doing SIJI beyond 12 months for most people

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How're y'all in the southeast handling this? Effective 3/19/23. We discussed this briefly in Sacral RF reimbursement but looks like it is now moving through mostly unchanged.


- No more SI joint RFAs
- Must do a "diagnostic" injection with 75% relief before doing "therapeutic" injections that have 50% relief
- Maximum of 2 diagnostics and 4 therapeutic sessions (unilateral or bilateral events) over rolling 12 months
- Shouldn't routinely be doing SIJI beyond 12 months for most people
I think my only question is- is there a diagnostic modifier? How will they know otherwise if I’m doing 5 therapeutic sessions vs 4 + one diagnostic?
 
I think my only question is- is there a diagnostic modifier? How will they know otherwise if I’m doing 5 therapeutic sessions vs 4 + one diagnostic?
Didn't see it described. The CPT code is the same so a modifier would make sense, but they may just look at the documentation itself to verify.

Technically your first diagnostic can have steroid in it, but then the steroid needs to provide >75% relief for the expected duration of the steroid's effects.

My bad: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=59192&ver=5
KX modifier requirements:



The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first 1 or 2 required to confirm the diagnosis after beginning treatment are not reasonable and necessary.
 
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Sounds like a problem for the people who do the billing and how to modify our notes to match the requirements. We will not do anything differently. Back office has to append Dx or Tx to note and bill correctly.
 
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Didn't see it described. The CPT code is the same so a modifier would make sense, but they may just look at the documentation itself to verify.

Technically your first diagnostic can have steroid in it, but then the steroid needs to provide >75% relief for the expected duration of the steroid's effects.

My bad: Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59192)
KX modifier requirements:



The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first 1 or 2 required to confirm the diagnosis after beginning treatment are not reasonable and necessary.

Oh wonderful- I want there to be steroid - thanks so much for that- I just could not see anywhere that said what the definition of a diagnostic injection could have in the syringe!
 
Who are the idiots writing these rules. It’s literally a new dumb rule every year
 
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What is the rationale behind doing a “diagnostic” SI joint injection prior to a therapeutic? Someone somewhere thought this was a good idea. Is CMS trying to encourage our specialty to perform more fusions of the SI joint? Why else do a diagnostic injection if you can’t perform RFA? It would be interesting to hear the thought process that went into this.
 
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And more radiation for us
 
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No more than 2 diagnostic joint sessions (CPT® codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.

No more than 4 therapeutic SIJI sessions (CPT® codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.

For the diagnostic SI joint injections: If a patient has left SI joint pain and you do 2 blocks then patient comes back 6 months later with right SI joint pain you cant treat because you used your "2 diagnostic joint sessions" for the left side already?
 
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These rules always apply unilaterally.
 
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No more than 2 diagnostic joint sessions (CPT® codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.

No more than 4 therapeutic SIJI sessions (CPT® codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.

For the diagnostic SI joint injections: If a patient has left SI joint pain and you do 2 blocks then patient comes back 6 months later with right SI joint pain you cant treat because you used your "2 diagnostic joint sessions" for the left side already?
DO we have to do TWO diagnostic SI joint blocks TWO weeks apart like lumbar MBB before SI JOINT INJECTIONS?
 
I dont believe you need to do 2 diagnostic blocks. i didn't see that anywhere. did i miss something?
 

  1. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the day of the SIJ injection, post-intervention on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.”
I’m interpreting this as you can use both local and steroid for diagnostic SIJ injections. So basically call the first injection “diagnostic” and subsequent injections “therapeutic” and you really shouldn’t have the problem of running out of diagnostic injection “encounters.”

Correct me if I’m wrong
 
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If you use steroid in the diagnostic block, I'm reading as it needs to have 75% relief for the duration of the steroid? Do I define duration of the steroid?
 
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DO we have to do TWO diagnostic SI joint blocks TWO weeks apart like lumbar MBB before SI JOINT INJECTIONS?
That's exactly how I am reading it. Doesn't mk any sense.

I have heard people are still doing "diagnostic" but putting steroids. However, eating the cost of steroids which is unfair to private docs.

What's worrisome is tht they are essentially pushing SI fusion. Can't tell you how many people I have treated tht get their total 1 or 2 therapeutic si injections a year, do PT, maybe an occasional. Nsaid..now what..fusion?
 
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That's exactly how I am reading it. Doesn't mk any sense.

I have heard people are still doing "diagnostic" but putting steroids. However, eating the cost of steroids which is unfair to private docs.

What's worrisome is tht they are essentially pushing SI fusion. Can't tell you how many people I have treated tht get their total 1 or 2 therapeutic si injections a year, do PT, maybe an occasional. Nsaid..now what..fusion?
PRP
 
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