The market for sacroiliac (SI) joint procedures is large and growing, and the site of care is rapidly shifting to ASCs. As this shift occurs, it is essential that ASC leaders understand the complex coding landscape and be prepared to code appropriately, since the risks of not doing so can be significant. Here are six key points about SI joint procedures in ASCs.
1. The SI joint procedure market is large and growing. According to a research report from Fact.MR, the global sacroiliac joint fusion market size is estimated at $620 million in 2022 and is projected to grow to $3.9 billion in a decade (2032), with an estimated compound annual growth rate of about 20 percent per year during this time.
2. In the United States, there has been a massive shift in the site of SI joint procedures. According to a 2022 article in ASC Focus, less than 5 percent of SI joint procedures under CPT code 27279 were performed in an ASC in 2015. In 2018, a rapid shift began. Currently, there are approximately 12,000 SI joint procedures performed each year and for 2021 it's estimated that more than 50 percent of these procedures were performed in ASCs.
3. CPT 27279 requires the use of a "transfixing device." According to the article, the American Medical Association added CPT code 27279 in 2015 to describe procedures that use a "transfixing device." The AMA has since clarified that to transfix the SI joint, implants must pass through the ilium and go across the SI joint and into the sacrum. This may be achieved via a lateral or posterolateral transiliac approach. There are more than 30 metallic devices cleared by the FDA that use a lateral transiliac "transfixing device" approach, with either a lateral trajectory or a posterolateral trajectory.
4. The AMA has added a Category III code to describe non-transfixing MIS SI joint procedures. In June 2022, the AMA CPT editorial panel posted a decision to add a Category III code ("t-code" 0775T) to describe non-transfixing MIS SI joint procedures, effective Jan. 1, 2023. These procedures include use of dorsally placed intraarticular or interpositional bone allograft products and devices. Prior to the AMA decision, these procedures previously were reported primarily via CPT 27279.
5. There are currently ways to describe MIS SI joint procedures not described under CPT 27279. To appropriately report non-transfixing SI joint procedures before 2023, ISASS and AAPC coding experts have stated that an unlisted CPT code (hip/pelvis 27299 or spine 22899) is appropriate to describe today's MIS SI joint procedures that are not described under 27279. There are approximately 12 bone allograft products and devices used in MIS non-transfixing procedures.
6. There are significant risks to ASCs associated with miscoding. It is important that ASCs understand proper coding for SI joint procedures and code them appropriately. The consequences for not coding properly can be significant, since highly reimbursed codes may be subject to government and private payer audits and related actions.
In a recent Becker's discussion, an audit expert and a healthcare attorney with experience assisting ASCs shared their thoughts on the risks associated with miscoding and why this area is such a ripe target for UPIC auditors.
With about 12,000 SI joint procedures performed each year — and with these procedures shifting to ASCs — SI joint procedures are an important opportunity and area of focus for many ASCs. It is important for ASCs to understand the dynamics and requirements in this market and to understand the constantly changing coding requirements. Those ASCs that understand the opportunity and the coding landscape will be well positioned for this opportunity, while ASCs that aren't focused on SI joint procedures and on the coding nuances will miss out on opportunities and could be exposed to audit and miscoding risks.