August 3, 2009

A number of pain medicine practices have recently found themselves targeted for audits by Medicare contractors. Audit letters from contractors including NGS and WPS have focused on medical necessity issues in connection with nerve blocks, epidural injections and other services administered in private office settings for chronic pain management. This activity serves to remind us all of the importance of documenting medical necessity for interventional pain procedures.

Documenting Medical Necessity

“Medical necessity” is a requirement for any service billed to Medicare and implicitly or explicitly to private payers as well. Prior to reviewing any underlying medical record, questions of medical necessity can arise, at the payer level, based on data analysis. One trigger is significant variation in the number of procedures submitted by comparable providers or in the diagnoses for which the procedure of interest is performed. Rapid growth trends likewise will often attract payer attention. Interventional pain medicine is a dynamic specialty, to say the least. Many new technologies – and CPT™ codes – have appeared over the last decade. These are among the factors responsible for increasing scrutiny of the medical necessity for chronic pain procedures.

Medicare carriers announce their medical necessity criteria through medical policies known as “Local Coverage Determinations.” Most of the MAC contractors and before them, the local carriers, have in place multiple LCDs involving specific pain medicine procedures, by CPT code. Your own MAC contractor’s LCDs are the single most important source of information on how you should document medical necessity.

A freshly revised and comprehensive LCD on pain management was issued by NGS, one of the contractors who has sent audit letters, with an effective date of June 6, 2009. This LCD is only applicable to those providers who are in a jurisdiction governed by NGS but it provides an excellent example. If your contractor doesn’t have a different written policy on what it expects to see in the documentation of medical necessity in your medical records for chronic pain services, you might consider the NGS LCD as guidance on what the other contractors may expect to see in terms of the detail of documentation.

In general, according to the NGS LCD, “the patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.” The LCD provides detailed guidance on documentation for specific procedures, for example:

For interlaminar or caudal epidural and/or intrathecal injections including those treating spasticity, transforaminal epidural injections, paravertebral joint/nerve injections and denervation, and sacroiliac joint injections the following lists general requirements:

• Complete initial evaluation including history and physical examination;
• Physiological and functional assessment, as necessary and feasible;
• Description of indications and medical necessity as follows:
  • Suspected organic problem;
  • Pain and disability of moderate-to-severe degree;
  • No evidence of contraindications, such as severe spinal stenosis resulting intraspinal obstruction, infection or predominantly psychogenic pain;
  • Nonresponsiveness to conservative modalities of treatment;
  • Responsiveness to prior interventions with improvement in physical and functional status for repeat blocks or other interventions
  • Repeating interventions only upon return of pain and deterioration in functional status.
• Assessment of this procedure outcome depends on the patient’s responses; therefore documentation should include:
  • Whether the injection/block was a diagnostic or therapeutic injection
  • Pre-and post-procedure evaluation of patient
  • Patient education
  • Subjective and objective responses from the patient regarding pain, including assessment of the patient's pain level and ability to perform previously painful maneuvers after receiving an injection at time intervals appropriate to the duration of action of the substance injected.
• Significant pain relief is defined as greater than or equal to (> /=) 80%-90% initially with the ability to perform previously painful maneuvers, and persistent pain relief is defined as a minimum of six (6) weeks of >/= 50% relief with the continued ability to perform previously painful maneuvers.
• The standard of care for all transforaminal epidural for chronic pain, paravertebral joint/nerve injections and denervations and sacroiliac (SI) joint injections requires that these procedures be performed under fluoroscopic- or CT-guided imaging. An image (plain radiograph with conventional film or specialized paper) or digital image documenting the needle position must be obtained whenever a substance is injected. A hard or digital copy of the needle placement should be retained to document accurate intra-articular placement.The medically necessary reason for the use of CT rather than fluoroscopy must be recorded.
• Claims billed for denervation procedures performed more frequently than once every six months at the same target level must be supported by documentation describing the unusual clinical circumstances and response to prior therapy(ies).

For epidural injections the following lists specific requirements:

• Nonresponsiveness to conservative modalities of treatment except in acute situations such as acute disc herniation with disabling and debilitating pain, herpes zoster and postherpetic neuralgia, reflex sympathetic dystrophy, and intractable pain secondary to carcinoma; and/or
• The patient is a candidate for surgery, but surgery is unacceptable to the patient or the patient is a poor surgical risk; and/or
• The epidural injection is being performed as a therapeutic adjunct to a conservative therapy program, to provide temporary relief and in order to facilitate a more aggressive rehabilitative program; and/or
• Repeated interventions are only acceptable with the return of pain and deterioration in functional status.
• Baclofen injections should document significant spasticity, not relieved by oral medications or other modalities.

All of these requirements should be documented in the medical record, to support the diagnosis code(s) on the claim form – if you are in a NGS jurisdiction.

An article in the July 2009 issue of Pain Physician, Description of Documentation in the Management of Chronic Spinal Pain, provides additional guidance in the area of documentation. Given the importance of this subject matter, we encourage pain physicians to pay careful attention to documentation and to take appropriate measures to enhance compliance in the area of medical necessity and documentation.

Other Pain Medicine Fraud & Abuse Targets

A July 2009 report on ultrasound F&A issued by the Office of the Inspector General (OIG) within the federal Department of Health and Human Services reminds us of the enforcement interest in the reporting of ultrasound services performed in private office settings. This analysis excluded medical necessity issues, focusing just on threefold geographic variations in utilization and obvious markers of fraud such as the lack of a physician’s order for the ultrasound service and five or more services provided to a single patient in a single day. Although the brief report does not mention pain medicine or any other specialty, it should be considered together with the OIG’s 2008 and 2009 Work Plans. Both Work Plans listed ultrasound guidance for peripheral nerve blocks among the procedures that the OIG would be watching in the year ahead. Practices in Florida, New York and New Jersey should be especially rigorous in their documentation, since those are the states with the highest utilization rates.

In September 2008, the OIG also published a special report on Medicare Payments for Facet Joint Injection Services. The OIG’s analysis of 2006 claims data showed $96 million in improper payments and placed facet joint injections solidly in Medicare auditors’ sight lines.

Healthcare Reform – Contact Your Senators and Congressional Representatives

ABC is very pleased with the response to our postcard campaign: clients and non-clients have requested nearly 30,000 of our pre-printed postcards urging their individual federal legislators, and the White House, to prevent any future “public option” health plan from basing provider payments on Medicare rates. We offered postcard packages, including addresses for signing anesthesiologists’ individual Senators and Congressmen, through the MGMA-Anesthesia Administration Assembly (AAA) online discussion group. If you have not yet asked for a set of postcards, you are welcome to do so by sending a message to info@anesthesiallc.com; please include the 9-digit zip codes for the anesthesiologists who will sign the cards if you want us to provide you with their representatives’ addresses.

If you have already asked for a set, please note that we are going to begin sending packets out this week.

As you know, the House Energy and Commerce Committee finally approved a compromise bill late last Friday evening. This means that all three House Committees have substituted direct negotiations between public plans and providers for fixed payments based on the Medicare Fee Schedule. That vital change, however, is not a done deal. The Congressional Progressive Caucus, for one, has declared “unacceptable” any legislative proposal “that does not provide, at minimum, for a public option with reimbursement rates based on Medicare rates.” As the deal-making continues in Washington, it is important for all anesthesia providers and their allies to continue to make your voices heard. Last Thursday, I faxed my first letter to my own Congressman, John Dingell, who introduced the American Affordable Health Choices Act of 2009 (H.R. 3200). I plan to bring anesthesia specialty concerns to Mr. Dingell’s attention in person while he is in his home district during this month’s Congressional recess. I urge everyone to do the same -- perhaps your representative has scheduled a town hall meeting that you could attend? -- and not let this opportunity pass us by.

As always, we welcome your feedback. If you have a question about this topic or if you have another topic you would like discussed, please let us know.

With best wishes,

Tony Mira
President and CEO