SPECIAL ALERT: Anesthesia for Epidural Steroid Injections in Jeopardy
A few months ago, we published an alert describing new hurdles Medicare put in place for anesthesia providers in connection with facet intervention cases. Now, Medicare is making it more difficult to get paid in epidural steroid injection (ESI) cases. Beginning this month, a new policy will go into effect across the country that will dramatically reduce the circumstances in which anesthesia services can be reimbursed in connection with patients receiving chronic pain epidurals. This includes not only interlaminar ESIs but transforaminal ESIs, as well.
An example of the policy set to go into effect for all Medicare administrative contractors (MACs) is CGS Medicare's L39015, which the MAC has entitled "LCD - Epidural Steroid Injections for Pain Management." The LCD consists primarily of a list of hurdles that chronic pain physicians will need to navigate in order to get paid for ESI (interlaminar, transforaminal or caudal). However, in a move that directly affects anesthesia providers, the LCD goes on to address certain limitations in payment, including the following critical caveat:
Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.
While the wording of the above LCD excerpt appears to open up the door to possible payment for an anesthesia provider in an ESI case, the overall takeaway is that these services will rarely be reimbursed to anesthesiologists and anesthetists. While Medicare has thus far refused to clarify which "exceptional and unique cases" would establish a need for the services of an anesthesia provider, one MAC (Novitas) published the following rationale for the anesthesia language in the new ESI policy, which readers may find instructive as to the narrowing parameters for payment:
To reduce the risk of direct nerve trauma or spinal cord injury, current guidelines (referenced in LCD) recommend avoidance of deeper levels of sedation so the patient can alert the provider to any paresthesia during the procedure. The evidence of safety of ESIs without anesthesia is robust including the obstetrical population. To reconsider this position, evidence to document the safety and medical necessity of deep levels of analgesia for ESIs will need to be submitted through the LCD Reconsideration Process to request a revision to the LCD once the LCD becomes effective. There is not a set criterion established in the literature or through societal guidelines to determine patients that may require General Anesthesia, Moderate or Deep Sedation, or Monitored Anesthesia Care (MAC). A provider cannot predict certain adverse reactions such as a vagal reaction which can be related to almost any procedure including routine blood draw or shots which would not necessitate anesthesia. It would be unlikely for a patient without an underlying seizure disorder to have a seizure induced by anxiety/pain. There is no supporting data that movement increases risk for ESIs and even sedated patients are at risk for movement. The policy does not limit access to care in patients who meet the evidence-based criteria for ESIs and the level of anesthesia discussed are not a requirement to perform the procedures safely. Based on the published societal guidance, the use of anesthetic may increase the risk associated with the procedures in addition to subjecting the patient to the inherent risk of anesthesia.
Until we are able to determine precisely which conditions Medicare will consider sufficient for the reimbursement of anesthesia services in connection with ESI, we recommend that you document in the record any patient conditions that might help to establish the medical necessity of your service (e.g., mental challenge, psychological disability, advanced Parkinson's). In addition, we recommend that you have the patient complete and sign an Advance Beneficiary Notice (ABN) form. The Medicare ABN can be accessed by clicking here.
This form—which can be used when the provider believes the service to a Medicare beneficiary is likely to be denied for payment—should be presented to the patient at some point prior to the day of the procedure.
The schedule of MAC implementation of this new policy is as follows:
- Novitas – 12/12/21
- First Coast – 12/12/21
- NGS – 12/05/21
- WPS – 12/05/21
- Palmetto – 12/05/21
- CGS – 12/05/21
- Noridian – Unknown as of this writing