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