MORE FACET JOINT INJECTION PAIN
May 23, 2011
Anesthesia and pain medicine practice managers who keep up with the National Correct Coding Initiative (NCCI or CCI) already know of an important change that went into effect on April 1, 2011: facet joint injections (CPT® codes 64490-64495) are now bundled with sacroiliac joint injections (27096). There are no exceptions. The change also applies to vertebroplasty, kyphoplasty, and IDET.
For readers less fluent in how the NCCI works, it is a software compilation of claims “edits” that result in denials for component procedures that are billed with a comprehensive service on the same day, for the same patient. The system of edits is maintained and updated quarterly by Correct Coding Solutions under contract to CMS. According to convention, comprehensive codes are in Column 1 and the component codes are in Column 2. Other edits prevent billing mutually exclusive procedures in the same session.
If the edit has a modifier indicator of "1," the software will allow an override if it encounters the appropriate coding modifier, such as “-50” for a bilateral procedure. A CCI indicator of "0" means that the edit is absolute and that the software will ignore coding modifiers that would otherwise generate a payment.
The April release of the CCI (Version 17.1) thus introduced the following edits relating to pain management procedures, all with indicator “0” precluding overrides:
The change from an indicator of “1” to “0” appears to be the latest restriction on payment for sacroiliac and facet joint injections. The recent history of restrictions goes back to 2008, when the HHS Office of the Inspector General (OIG) published a report stating that 63 percent of all claims for facet joint injections submitted to Medicare in 2006 were coded incorrectly, and that the miscoding resulted in Medicare’s overpaying approximately $96 million.
In its March 2010 Compendium of Unimplemented Office of Inspector General Recommendations, the OIG indicated that CMS’ reaction to the 2008 report had been unsatisfactory. The OIG recommended that CMS “act to resolve the undocumented, medically unnecessary, and miscoded services that we found.” The Compendium pointed to the “lack of consensus in the medical community about the frequency with which injections may be administered, which is a barrier to creating frequency limits in local coverage determinations (LCD),” as well as to unclear billing instructions on bilateral services.
Consensus or not, Medicare Administrative Contractors (MACs) had been adopting LCDs on facet joint injections prior to the issuance of the OIG Compendium. Indeed, in early 2009, the MAC for a number of Western states, Noridian Administrative Services, had proposed a policy to stop paying for facet injections and ablations altogether. Following a concerted educational campaign on the part of twelve physician organizations led by the American Society of Anesthesiologists, Noridian last year issued an LCD for Lumbar Facet Blockade, effective November 16, 2010, containing the following requirements regarding medical necessity:
- A maximum of four (4) facet joint injection sessions (inclusive of medial branch blocks (MBB), intraarticular injections (IA), or facet cyst rupture) may be performed per year in the lumbar spine. A session is defined as all injections performed on one single date of service. (A maximum of two (2) facet joint thermal RF, and no other denervation treatment sessions are allowed per year in the lumbar spine. …
- Performance of more than one type of injection for pain treatment, such as epidural, sacroiliac joint injections or lumbar sympathetic injections, on the same day as facet joint interventions is not considered medically necessary. Performance of more than one type of block on the same day (with the exceptions listed below) makes it impossible to determine which injection resulted in pain relief.
Only one of these procedures is allowed on a given day with the following two exceptions with associated requirements:
- Pain relief is incomplete following an adequately evaluated nonfacet injection, and any potential residual effects from the first injection may be reliably known to have dissipated.
- Multiple anatomic pain generators are present, and diagnoses have been clearly documented, in a patient on anticoagulants and whose anticoagulation therapy must be discontinued prior to block.
To the same effect, but with less detail, is the LCD for Paravertebral Facet Joint Block and Facet Joint Denervation adopted by Wisconsin Physicians Service Insurance Corporation. CareSource, a private payer, will implement a policy requiring prior authorization for more than six facet joint injections in a 12-month period, effective July 1, 2011. Other carriers, both Medicare and commercial, have coverage policies in place and every pain medicine practice should keep current with the policies of all the payers with which it is contracted. Active, draft and retired LCDs are available, by state and MAC, at http://www.cms.gov/medicare-coverage-database/.
The NCCI edit that now bundles facet joint injections with SI joint injections represents a sledgehammer approach to the issue – but it stands, at least for the time being. We will continue to watch for developments on behalf of all our readers.
With best wishes,
President and CEO