September 29, 2008

Sixty-three percent (63%) of all the claims for facet joint injections submitted to Medicare in 2006 were coded incorrectly, according to a report issued by the HHS Office of the Inspector General (OIG) on September 17, 2008 (http://oig.hhs.gov/oei/reports/oei-05-07-00200.pdf). The report states that the miscoding resulted in Medicare’s overpaying approximately $96 million.

The publication of this report means that anesthesiologists and pain specialists should make sure that they follow Medicare requirements for billing for facet joint injections to the letter. As a result of the OIG’s recommendations, CMS plans to:

1. Help the Medicare carriers to develop more rigorous screening tools and policies (Local Coverage Determinations or “LCDs”). (Most carriers already have LCDs in place to address such issues as radiographic guidance, frequency of injections, etc.).
1. Twenty-seven percent (27%) of facet joint injection services were completely undocumented. Another 11 percent were insufficiently documented. Most of these were missing a description of the procedure performed; others were missing key details such as cervical level.
2. Eight percent (8%) of all claims in the sample did not contain patient histories, physical exam findings or radiographic studies to support the diagnosis and demonstrate medical necessity.
2. Clarify billing instructions for bilateral services. The OIG found that 60 percent of the overpaid services were cases in which the physician billed bilateral services as separate or as add-on injections.
3. Both the cervical facet joint injection code, CPT™ 64470 and the lumbar code, 64475, are for single level injections. Codes 64442 and 64476 are the respective add-ons for each additional level. Using multiple lines of the add-on codes instead of modifier 50, which designates bilateral services, yields a 50 percent overpayment.

We can expect that the OIG’s efforts have alerted private payers to the potential for preventing and recovering some payments for these procedures. Heightened caution is in order across the board – especially if the services are provided in private office settings, where more billing errors were found than in hospitals or ambulatory surgical centers.

Please see the OIG report (24 pages excluding appendices) for further details, and also for a succinct explanation of the relationship of the OIG, CMS and the carriers in combating Medicare “fraud and abuse.”

We are calling your attention to this risk area in the hopes of helping to prevent anesthesiology and pain medicine practices from attracting costly attention from the payers.