At a recent ASCA industry focus group, experts weighed in on the topic of reimbursement and risk areas for today’s sacroiliac joint (SI joint) procedures performed in ASCs. Because appropriate coding consideration for SI joint fusion procedures includes code descriptors, clinical vignettes, surgical anatomy, technology used, and the approach or trajectory, it is important for ASCs to understand the differences in existing procedures to avoid possible miscoding.

Miscoding can expose healthcare providers and practices to legal liability under the False Claims Act. At a recent ASCA industry focus group, healthcare attorney Jennifer Weaver shared the example of government enforcement actions relating to miscoding of P-Stim electro-acupuncture devices, and highlighted certain similarities to the current SI joint procedure market. The miscoding of P-Stim procedures under the highly reimbursed code HCPCS L8679, which is meant for surgically implanted devices, resulted in multimillion-dollar False Claims Act settlements and crippling penalties for many physicians and their practices.

As Jennifer Weaver highlighted, a number of providers and practices billed for P-Stim devices, which are attached externally to a patient using needles and adhesive, under the higher reimbursement code for surgically-implanted devices. This led to government payors providing larger reimbursements to these providers and practices than they otherwise were entitled to. In 2020 – over ten years after P-Stim devices first were available in the U.S. – Medicare issued clarifying guidance for code HCPCS L8679. But previous miscoding was not given a free pass. Providers who miscoded P-Stim devices prior to the clarifying guidance still were found liable under the False Claims Act. Ms. Weaver cautioned that when providers are considering reimbursement billing, “If something seems too good to be true, it probably is.”

Commercial payors, as well as government payors, may also have means to audit, and claw back payments made to providers for miscoded procedures. Recently, payors have begun to limit coverage for certain SI joint fusion procedures to certain device types, as well as certain approaches and trajectories (e.g., transiliac-placed triangular implants).

Audit Expert: Jennifer Weaver, Esq.

Jennifer Weaver is Co-Chair of Waller’s Healthcare Industry Team and specializes in defending healthcare providers facing government investigations and enforcement actions brought by the Department of Justice and other federal and state agencies and regulators. Jennifer is an expert in helping providers appeal costly and potentially crippling Medicare audits conducted by Unified Program Integrity Contractors (UPICs).

Access Jennifer’s complete bio and experience in the area of health care providers’ risk exposure and mitigation strategies:

wallerlaw.com/our-people/78/jennifer-weaver

Background on SI joint fusion procedures

SI joint procedures encompass different surgical approaches with different final implant locations. On one hand, a number of SI joint fusion procedures involve the placement of implants across (“transfixing”) the SI joint using a lateral (or posterolateral) transiliac trajectory. On the other hand, some newer SI joint procedures place standalone bone allograft products or metallic devices interpositionally within the ligamentous portion of the SI joint via a posterior, or “dorsal,” approach.

In addition to the different trajectory and implant location, the two types of SI joint procedures vary greatly in terms of clinical support, nature of the procedure, and the time, effort and equipment needed to provide the procedure.

In 2015, CPT code 27279 was added by the AMA to describe procedures which use a “transfixing device” and a lateral, transiliac approach, where implants traverse three cortices of bone (“across the ilium, across the SI joint, and into the sacrum”). For several years following its introduction, CPT code 27279 was reported virtually exclusively by orthopedic surgeons and neurosurgeons. Between 2018 and 2020, however, there was significant growth in the number of CPT 27279 procedures being reported to Medicare, particularly those performed by non-surgeon physician specialties (e.g., pain management, anesthesia, physical medicine and rehabilitation). Likely, a significant proportion of the high growth rate of 27279 procedures seen since 2018, performed by non-surgeon specialties in ASCs and reported as 27279, were actually procedures intended to place structural bone allograft implant(s) interpositionally within the SI joint, i.e., not transfixing it or using metallic devices.

The AMA has now provided guidance that appropriate use of CPT 27279 is limited to a lateral, transiliac “transfixing device” SI joint procedure. Procedures that do not use transfixing devices in a lateral, transiliac approach, but which are presented to commercial and government payors as CPT 27279, may be subject to future scrutiny as having been potentially miscoded.

Audit risks and scrutiny for miscoding

Ignorance of the latest coding interpretations is no excuse for those providers selecting an inappropriate code. The differences in types of SI joint procedures are significant – including the clinical evidence in support of coverage, the nature of the devices and procedures, and the time, effort and equipment needed to provide the procedures. Physicians who miscoded P-Stim procedures were held accountable, even if they did not intend to miscode or make false claims to federal healthcare programs, e.g., Medicare, Medicaid and TRICARE. Physicians and practices are encouraged to carefully consider their billing codes in order to avoid a similar outcome.