Health Law Daily Wrap Up, AUDITS AND MONITORING—OIG REPORTS: Study found 72% of sacroiliac joint injections were improperly billed, (Aug 13, 2026)

By Erick Jorgenson

On the basis of the sample, the OIG estimated that Medicare improperly paid $15.2 million for 134,526 of 186,842 total sessions.

The HHS Office of Inspector General (OIG) reviewed a sample of 100 sessions of sacroiliac joint injections and found that 72 of those sessions did not comply with Medicare requirements. Further, the physicians’ billing did not meet Medicare guidance in 25 sessions between October 1, 2023, to September 30, 2024. The OIG recommended CMS to work with Medicare Administrative Contractors (MACs) to develop education specific to Medicare requirements, guidance for Medicare payments regarding sacroiliac joint injections, and some solutions to prevent further incorrect billing of the diagnostic injections as therapeutic injections. CMS concurred with the first two recommendations but did not concur with the third (OIG Report, OAS-25-09-021 (Aug. 3, 2026)).

Background. Medicare Part B covers spinal pain management services such as sacroiliac joint injections. In two previous audits, the OIG found more than 50% of sampled services did not comply with one or more Medicare requirements. CMS contracts with seven MACs to determine reimbursement amounts and pay claims as a safeguard against fraud and abuse. The MACs also provide education to providers and suppliers about Medicare billing requirements and new Local Coverage Determinations (LCDs).

Five MACs issued LCDs that list the Medicare requirements for sacroiliac joint injections related to (1) indications of pain, (2), imaging and pain assessment, (3) limitation of coverage, and (4) diagnostic and therapeutic injections. In addition, coverage is limited to two injections for diagnostic and four for therapeutic within a rolling 12-month period. Physicians must add the modifier “KX” to distinguish a diagnostic injection from a therapeutic injection in the claim line.

Findings. The audit found that 72 of 100 sessions did not comply with Medicare requirements. Furthermore, 41 sessions had more than one deficiency. The common deficiencies were indications of pain requirements not being met (47 instances), imaging and pain assessments not being met (45 instances), diagnostic and therapeutic injections requirements not being met (36 instances), and limitations of coverage not being met (8 instances). Additionally, 25 sessions did not meet Medicare billing guidance as they did not appropriately use the modifier “KX.”

Insufficient oversight. While CMS had oversight mechanisms to identify certain billing errors, it did not conduct additional oversight activities like educating physicians to ensure Medicare requirements and billing guidelines were being followed. Even though CMS relied on MACs to provide education to physicians, it did not direct MACs to conduct additional educational efforts, with limited material being provided by five MACs and two MACs not providing any LCDs. Moreover, some physicians that made errors stated the LCD requirements and LCD Reference Article billing guidance was too complex and stated that more consistent and additional training would have better helped their understanding.

Recommendations. The OIG recommended that CMS work with the five MACs to develop education specific to Medicare requirements, guidance for Medicare payments regarding sacroiliac joint injections such as developing additional education about the KX modifier. Furthermore, the OIG recommended that CMS use the results to adopt a national coverage determination (NCD) or work with the two MACs without an LCD and LCD Reference Article to develop those documents to reduce duplication of effort and promote consistency.

CMS response. CMS agreed with the first two recommendations but disagreed with the third. Regarding the third recommendation, CMS advised that Section 1869(f)(2)(B) of Title XVIII of the Social Security Act delegated the development of LCDs to MACs and the statute does not mandate uniformity across jurisdictions. Further, CMS stated that an NCD does not resolve issues of adjudications of claims inconsistent with claims. Since the implementation of an NCD would be done similarly to an LCD, CMS contended, adherence issues would continue. Finally, CMS advised that the education mechanisms that CMS is implementing with the first two recommendations precisely address the root causes of the problem being faced.

OIG response. The OIG disagreed with CMS’s comments regarding the third recommendation as the OIG believes greater consistency across all MAC jurisdictions would reduce improper payments and promote uniform application of Medicare coverage. The OIG conceded that statute provides MACs the discretion in developing LCDs but advised that the lack of LCDs in two of the MACs could result in different adjudication systems than the five MACs that have implemented LCDs and LCD Reference Articles. The OIG believes that the inconsistency would undermine uniform application of Medicare coverage criteria across all MACs. Quoting CMS’s response that “the coverage limitations [in LCDs and LCD Reference Articles] are intended to address inappropriate billing for pain management tied to overuse of spinal sacroiliac joint injections,” the OIG maintained its recommendations.

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