Part A/B Facet Joint Injection and RFA Review

Presented by Part A and Part B Medical Review and

Provider Outreach and Education

December 2014

Workshop Protocol

• Cannot register with WebEx using mobile device – Must use desktop or laptop

• When entering/throughout workshop – all lines muted

• Presentation emailed 3 days before webinar – Adobe PDF format (with printing instructions)

• Throughout workshop – Questions pertinent to workshop slide addressed

– Address Q & A to “all panelists”; not to host directly

– All other questions, call Part A Provider Contact Center

• Workshop conclusion – Asking questions aloud? Use “raise/lower hand” feature

– MUTE phones – never place on HOLD

2 December 2014

Using WebEx During Workshop

Participants You have the option to ask a question at the end of the workshop. Use the raise/lower hand feature. Once your question is answered, you will need to lower the hand.

Chat If you are not the person that registered for this workshop, enter your name, facility & city/state in this section. This helps track attendance for both you and Noridian.

Q&A If you have a question during the workshop, type your question in the box and send to all panelists, not the host. We will respond to questions in the order they are submitted. Keep questions to topic and previous slides discussed today.

3 December 2014

Continuing Education Unit (CEU)

• When registering, add additional attendees – First and last names

• Attend entire workshop – Optional to stay for Q/A

• Take short polling survey – After closing out of webinar

• CEU emailed 3 days after presentation – Earn between .5 and 1.5 CEUs

– No password or index number needed

– All providers use CEU certificate • Certificate of Attendance no longer available

4 December 2014

Part A Web-Based Workshops

Date Time (CT) Workshop Title

12/10/2014 1 PM Cert A/B MAC Outreach & Education Task Force

12/11/2014 1 PM Recovery Auditor (RA) Program

12/15/2014 1 PM Therapy Cap Exception Process

12/16/2014 1 PM JF Website Tour to Locate Educational Tools

12/18/2014 1 PM Proper Billing & Coding of Outpatient Drugs & Biologicals

12/30/2014 1 PM Utilizing the Benefit Period

01/08/2015 1 PM JE Part A Website Tour to Locate Educational Tools

Register Now!

JE https://med.noridianmedicare.com/web/jea/education/training-events

JF https://www.noridianmedicare.com/parta/train/workshops/index.html

5 December 2014

Part B Web-Based Workshops

Date Time (CT) Workshop Title

12/10/14 1 PM Lab Services and CERT Documentation

12/11/14 1 PM Initial Preventive Physical Examination (IPPE) & Annual Wellness Visit (AWV)

12/16/14 1 PM CERT A/B MAC Outreach & Education Task Force

12/17/14 1 PM Website Tour to Locate Educational Tools

12/18/14 1 PM Modifier 59 Clarification and Changes

12/22/14 1 PM Reopenings

12/30/14 1 PM The Basics of Medicare Ambulance Coverage

01/08/14 1 PM Modifier 59 Clarification and Changes

Register Now!

JE https://med.noridianmedicare.com/web/jeb/education/training-events

JF https://www.noridianmedicare.com/partb/train/workshops/index.html

December 2014 6

Printing this Presentation

JE Part A Website JF Part A Website

https://med.noridianmedicare.com/web/jea/education/event-materials

https://www.noridianmedicare.com/parta/train/workshops/archive.html

Click on ‘Download Documents’ and print

7 December 2014

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8 December 2014

DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

9 December 2014

Objective

• This presentation is designed to give an

overview of Facet Local Coverage

Determination (LCD) Coverage

Guidelines, Facet Review Results,

Common Errors Seen in Medical Review,

Corrective Action providers can take, and

resources/references providers can utilize.

December 2014 10

Agenda

• Facet LCD Coverage Guidelines

• Facet Review Results

– Part A Results

– Part B Results

• Common Errors Seen in Medical Review

• Corrective Action

• References

• Questions

December 2014 11

Facet Local Coverage Determination

(LCD) Coverage Guidelines

Facet Policy Numbers

• JF: – Part A: L34127

– Part B: L33842

• JE – Part A: L34129

– Part B: L34131

• Note below the effective dates of all the above LCDs: – Original effective date: For services performed on or

after 03/05/2014

– Revision effective date: For services performed on or after 10/06/2014

December 2014 13

Definitions

Facet Joint “Level”

• Zygapophyseal

(aka facet) joint

“level”:

– Refers to the

zygapophyseal

joint or the two

medial branch

(MB) nerves that

innervate that joint

Medial branch of L3, 4 dorsal ramus

December 2014 15

Clarification of Facet “Levels”

• One Level: – The superior articular

process of a vertebral segment; and

– The inferior articular process of another vertebral segment

• Example: – MB nerves innervating

(or the facet joint connecting) the L4 and L5 vertebral segments form one joint “level”

December 2014 16

Medial Branch Blocks

• Medial branch blocks (MBBs):

– Injection of an anesthetic and, in some cases, a steroid into the location of the two nerves within the facet joint

December 2014 17

Intraarticular Facet Blocks

• Intraarticular (IA)

facet blocks:

– Injection of an

anesthetic and/or

steroid directly into

the facet joint

resulting in “flooding”

the joint

December 2014 18

Other Definitions

Session:

• All facet

injections/blocks/RF

procedures performed on

one day in the same

patient

– Includes medial branch

blocks (MBB), intraarticular

(IA) injections, facet cyst

ruptures, and RF ablations

Region:

• All injections performed in

cervical/thoracic; or

• All injections performed in

lumbar spinal areas

– Note: does not include

sacral spinal areas

December 2014 19

“Diagnosis” of Facet Pain

• Establishment of pain relief following two medial branch blocks (MBBs) performed at different sessions

– Required prior to radiofrequency neurotomy (RF) ablation

• The following alone cannot distinguish facet joint as pain source:

– Physical examination

– Imaging

December 2014 20

Introduction

• Facet joint injection techniques are used in

the diagnosis and/or treatment of chronic

neck and back pain.

• “Ongoing coverage [of facet joint

injections] requires outcomes reporting

as described in the LCD to allow further

analysis of clinical efficacy.”

December 2014 21

Indications

Pain Requirements

• Must have a history of at least 3 months of

moderate to severe pain with functional

impairment

• Failed conservative measures such as:

– NSAIDs

– Acetaminophen

– Physical therapy (as tolerated)

December 2014 23

Pain Requirements Cont.

• Predominantly axial

– Not associated with:

• Neurogenic claudication

• Radiculopathy

– Exception:

• Facet joint cysts

December 2014 24

Pain Requirements Cont.

• There is no non-facet pathology

– Examples:

• Fracture

• Infection

• Significant deformity

• Tumor

December 2014 25

General Procedure

Requirements

Required Pre-procedural

Documentation

• A complete initial evaluation including

history

• A detailed musculoskeletal and

neurological physical examination

• Pertinent diagnostic tests or procedures

December 2014 27

Required Procedural Documentation

• A legible procedure note which includes:

– Detail to allow reconstruction of the procedure

– Description of the techniques employed

– Nerves injected and site(s) of injections

– Drugs and doses with volumes and

concentrations

– Pre and post-procedural pain assessments

December 2014 28

Procedural Imaging Requirements

• Fluoroscopic or computed tomographic

(CT) guidance

– Ultrasound guidance will not be reimbursed

• Total contrast medium volume must be

documented

– Exceptions:

• RF ablations

• Cases in which contrast is contraindicated

December 2014 29

Medial Branch Block (MBB) Volume

Requirements

• Maximum MBB Volume

– Diagnostic:

• 0.5 ml per MB nerve

– Therapeutic:

• 2 ml per MB nerve

– Exception for third occipital nerve block:

• 1 ml for diagnostic

• 2 ml for therapeutic

December 2014 30

Intraarticular (IA) Facet Block Volume

Requirements

• Maximum intraarticular (IA) facet block

volume [including contrast]:

– 1 ml per cervical joint; or

– 2 ml per lumbar joint

• Exception:

– Purposeful facet cyst rupture in the lumbar spine

December 2014 31

Steroid Volume Requirements

• Per any single session, in total, no more than:

– 100 mg of triamcinolone; or

– 100 mg of methylprednisolone; or

– 15 mg of betamethasone or dexamethasone or the equivalents

• Both diagnostic and therapeutic facet joint injections may be acceptably performed without steroids

December 2014 32

Diagnostic Injection

Requirements

Diagnostic MBBs

• Dual MBBs are necessary to diagnose

facet pain prior to a RF ablation

– Single injections have high rate of false

positives

– Exception:

• Documented anatomic restriction

• Second confirmatory MBB allowed:

– If first MBB: ≥ 80% relief of primary pain

December 2014 34

Diagnostic IA Facet Blocks

• Only reimbursed as a diagnostic test when

technical performance of MBBs is

precluded:

– Must have a specific documented anatomic

restriction

– Examples:

• Cardiac pacemaker

• Implantable spinal cord stimulator

• Posterior spinal fusion (above or below joint)

December 2014 35

Therapeutic Injection

Requirements

Therapeutic Injections

• IA facet blocks or MBBs may be repeated

when:

– Recurrent pain at the site of previously

diagnosed and/or treated facet joint; and

– Greater than 50% pain relief from the

previous injection for at least 3 months

December 2014 37

Thermal Medial Branch

Radiofrequency (RF) Neurotomy

Initial Thermal Medial Branch RF

Neurotomy

• Allowed when:

– Dual MBBs provided ≥ 80% relief of primary or index pain; and

– Duration of relief consistent with agent used

• Note: A positive response to dual IA facet blocks will not substitute for dual MBBs unless MBBs cannot be performed due to anatomic restrictions or contraindications to MBBs is indicated.

December 2014 39

Repeat Thermal Medial Branch RF

Neurotomy

• Repeat denervation procedures involving

the same joint:

– Only medically necessary if:

• At least 6 months of:

– At least 50% improvement of pain; and

– Improvement in patient specific ADLs

December 2014 40

Limitations of Coverage

Session Limits

• Per patient a maximum of:

– Five (5) facet joint injection sessions per year

– Inclusive of:

• Medial branch blocks (MBBs)

• Intraarticular (IA) injections

• Facet cyst rupture

• RF ablations

December 2014 42

RF Region Limits

• Per patient a maximum of:

– No more than two (2) thermal RF sessions

per each covered spinal region per year

– Cannot involve more than four (4) joints per

session

• Two (2) bilateral levels; or

• Four (4) unilateral levels

December 2014 43

Other Limitations of Coverage

• Conscious sedation and monitored

anesthesia care (MAC):

– Not routinely necessary; and

– Not routinely reimbursable

December 2014 44

Non-Covered Procedures

• Non-thermal RF modalities

• Pulsed RF modalities

• Intraarticular and/or extraaarticular facet

joint prolotherapy

December 2014 45

Non-Covered Procedures Cont.

• Performance of more than one type of

injection for pain treatment on same day

– Examples:

• Epidural steroid injections

• Sacroiliac joint injections

• Lumbar sympathetic injections

December 2014 46

Coding Information

CPT Coding Requirements

• Refer to the CPT® Manual

• Bill the CPT code that most accurately

identifies the procedure(s) and/or services

completed

– Documentation must support the code(s)

billed

December 2014 48

CPT Coding Modifier Requirements

• Use appropriate modifiers

• For unilateral, use either:

– Modifier LT (left side); or

– Modifier RT (right side)

• For bilateral, always use:

– Modifier 50

December 2014 49

ICD-9 Diagnosis Requirements

• Refer to LCD for covered diagnoses

– Documentation must support billed diagnoses

– Note: The claim may be subject to correct

coding with potential underpayment or a

denial in full if a supported diagnosis in the

LCD is not used

December 2014 50

Facet Review Results

JF Part A Facet Review Results

Region

Number of

Claims Reviewed

Dollars

Reviewed

Dollars in

Error

Error Rate

AK, ID, OR, WA 100 $228,246.60 $122,290.10 54%

AZ 99 $293,259.02 $177,528.62 61%

UT 91 $225,270.92 $195,587.20 87%

MT 90 $145,869.33 $95,216.14 65%

Date Range: 05/07/2014 - 10/10/14

December 2014 52

JF Part B Facet Review Results

State

Dollars Reviewed

Dollars in Error

Error Rate

AK $574.74 $574.74 100%

AZ $16,160.13 $7,515.20 47%

UT $5,598.44 $2,402.70 43%

ND $4,513.84 $2,491.88 55%

SD $3,564.94 $1,289.08 36%

WY $2,145.06 $1,251.96 58%

WA $3,169.04 $1,904.66 60%

OR $11,580.32 $8,529.36 74%

ID $17,360.91 $15,607.83 90%

Overall $65,730.56 $41,567.41 63%

Date Range: 9/1/2014 – 11/30/2014

December 2014 53

JE Part B Facet Review Results

State Dollars Reviewed Dollars in Error Error Rate

Northern CA $1,873.96 $1,114.40 59%

Southern CA $10,815.50 $7,598.82 70%

Overall $12,689.46 $8,713.22 69%

Date Range: 7/1/2014 – 9/30/2014

December 2014 54

Common Errors and Tips

Part A and Part B

Pain Not Clearly Documented

• Less than 3 months in duration

• Not moderate to severe in nature

• Not primarily axial

– Associated with radiculopathy and/or

neurogenic claudication

• No effect on ADLs

December 2014 56

Inadequate Conservative Measures

• Conservative measures trialed were

either:

– Not documented

– Not sufficient

• Patient had good response to conservative

measures

December 2014 57

Excess Volume Used

• Anesthetic; and/or

• Steroid; and/or

• Total Volume

– Including Contrast

December 2014 58

Billing Errors

• Levels billed greater than completed

– Example:

• Three facet joint injections billed, however

documentation supported two were completed

– Results in partial denial of excess levels

December 2014 59

Billing Errors Cont.

• Levels billed less than completed

– Example:

• Two facet joint injections were billed, however

documentation supported three were completed

– Results in correct coding of claim

December 2014 60

Evaluation Not Supported

• No initial evaluation

– For long-standing condition- may use interim updates which include:

• Details of which conservative measures were ineffective

• Pain is still present

• No History and Physical (H&P)

– Must be focused on musculoskeletal and neurological examination

• No set time frame needed to be completed prior to injection

December 2014 61

Pre-Procedural Pain Not Supported

• Immediate pre-procedural pain

assessment:

– Required to determine effectiveness of the

injection

– Pain not present = procedure not indicated

December 2014 62

Post-Procedural Pain Not Supported

• Immediate post-procedural pain

assessment:

– Required to determine the effectiveness of the

injection

– Example:

• If a second confirmatory MBB was completed

without providing the percentage of pain relief from

the first MBB then the 2nd injection would not be

indicated

December 2014 63

Other Documentation Errors

• Missing diagnostic tests

– Reports support diagnosis & etiology of pain

• Missing procedures

– Procedure reports support effectiveness of

prior injections

• Missing anatomic restrictions

– Without documentation of the anatomic

restriction, IA facet blocks were not indicated

December 2014 64

Inadequate Pain Relief Provided

• Percentage of pain relief required:

– Diagnostic facet injection: > to 80%

– Therapeutic facet injection: > 50% with pain

relief for at least 3 months

• Inadequate pain relief = Subsequent

injections not indicated

December 2014 65

Required ICD-9 Diagnosis Code

Missing

• Documentation supported a required

diagnosis code:

– Claim correct coded and counted as an error

• Documentation did not support a required

diagnosis code:

– Claim denied in full

December 2014 66

Corrective Action

• Verify documentation supports:

– Medical necessity

– Requirements of the LCD

• Submit all requested documentation

December 2014 67

References

Part A References

• JF LCD L34127 (Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy) – https://www.noridianmedicare.com/parta/coverage/active.html

• JE LCD L34129 (Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy) – https://med.noridianmedicare.com/web/jea/policies/lcd/active

• Additional References: – JF:

• https://www.noridianmedicare.com/parta/coverage/

• https://www.noridianmedicare.com/parta/coverage/outpatient_services/references_outpatient_services.html

– JE: • https://med.noridianmedicare.com/web/jea/cert-reviews/mr

December 2014 69

Part B References

• JF LCD L33842 (Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy) – https://www.noridianmedicare.com/partb/coverage/active.h

tml

• JE LCD L34131 (Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy) – https://med.noridianmedicare.com/web/jeb/policies/lcd/acti

ve

• Additional References: – JF:

https://www.noridianmedicare.com/partb/coverage/index.html#mr

– JE: https://med.noridianmedicare.com/web/jeb/cert-reviews/mr

December 2014 70

Continuing Education Unit (CEU)

• When registering, add additional attendees – First and last names

• Attend entire workshop – Optional to stay for Q/A

• Take short polling survey – After closing out of webinar

• CEU emailed 3 days after presentation – Earn between .5 and 1.5 CEUs

– No password or index number needed

– All providers use CEU certificate • Certificate of Attendance no longer available

71 December 2014

Questions?

Thank You