01-034 Transforaminal Epidural Injections Notification of Medical Review

 Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of Transforaminal Epidural Injection claims for Medicare Part B of A outpatient claims and Part B outpatient claims billed on dates of service from July 1, 2018 through June 30, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

In 2018, the Comprehensive Error Rate Testing (CERT) Medicare Fee-for-Service (FFS) Improper Payment Report noted a 29.1% error rate for this service category. The error rate noted an 86.7% insufficient documentation error rate, with a 13.3% error rate directly related to medical necessity.

A previous SMRC contractor reviewed TEI services and found a claims error rate of 40%. Further review was recommended.

In this project, the claim sample will consist of Part B professional services in addition to Part B of A facility claims. The Part B claims will be identified by place of service in the physician location setting. The Part B of A claims were identified by the 13X type of bill (TOB), with dates of service (DOS) of July 1, 2018 through June 30, 2019.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on Transforaminal Epidural Injections (TEI) claims. Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

TOB CPT
13X: Outpatient Hospital
  • 64483: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
  • 64484: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Centers for Medicare and Medicaid Services (CMS) Claim Form
  2. Physician or Non-Physician Practitioner (NPP) order for date of service
  3. Initial pre-procedural evaluation including a history and physical, complete pain history, diagnosis, prior imaging studies and findings, treatment plan, and documentation of other treatment methods that were tried and failed
  4. Procedure report/clinical documentation to support services billed including procedure details, medication administration record, evidence of radiographic guidance (fluoroscopy or computed tomography) and pre and post procedure evaluation
  5. Periodic re-evaluation including a summarization of the patient’s history and interventions, responses to the procedure, and rationale for ongoing intervention or other pain management techniques
  6. Documentation to support indications and criteria as specified in the Local Coverage Determination (LCD) or Coverage Article
  7. Any other documentation that supports medical necessity of the injection services
  8. Advanced Beneficiary Notice of Noncoverage (ABN), if applicable
  9. Documentation submitted must include valid electronic and/or handwritten physician or clinician signatures. Signature logs or attestations may be submitted if applicable

References/Resources

  • Social Security Act (SSA), Title XVIII, §§1833(e). Payment of Benefits
  • SSA, Title XVIII, §§1833(2)(E)(i). Payment of Benefits (Outpatient Hospital Radiological Services)
  • SSA, Title XVIII, §§1833(t)(B)(i). Payment of Benefits (Prospect Payment Service for Outpatient Part B Department Services)
  • SSA, Title XVIII, §§1862(a)(1)(A). Exclusions of coverage
  • SSA, Title XVIII, §§1862(a)(7). Exclusion of Routine Physical examinations.
  • SSA, Title XVIII, §§1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • 42 Code of Federal Regulations (C.F.R.), §482.24. Signature Requirements
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20. Hospital Services Covered under Part B
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50-50.6. Drugs and Biologicals
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 20.3, Bundled Services/Supplies
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 70, Payment conditions for Radiology Services
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 20. Payment Conditions for Radiology Services
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 30. Computerized Axial Tomography Procedures
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 40.3.6. Advanced Beneficiary Notice of Non-Coverage
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 and 3.2.3.8 B/C. No Response or Insufficient Response to Additional Documentation Requests
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.1 and 3.6.2.2. Coverage Determination and Reasonable and Necessary Criteria
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4. and 3.6.2.5A. Coding Determinations and Denial Types
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5.A. Denial Types
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.2.1. Examples of Medicare Fraud
  • Local Coverage Determination (LCD) L33906. (Effective Date October 1, 2015; Revision Effective Date October 1, 2017; Revision Ending Date September 30, 2018)
  • LCD L34807. Lumbar Epidural Steroid Injections. (Effective Date October 1, 2015; Revision Effective Date October 1, 2017; Revision Ending Date September 30, 2018)
  • LCD L34980. Lumbar Epidural Injections. (Effective Date October 1, 2015; Revision Effective Date for services performed on or after October 1, 2017; Revision Ending Date September 30, 2019)
  • LCD L34982. Lumbar Epidural Injections. Effective Date October 1, 2015; Revision Effective Date for services performed on or after October 1, 2017; Revision Ending Date September 30, 2019
  • LCD L35148. Lumbar Epidural Steroid Injections. Effective Date October 1, 2015; Revision Effective Date for services performed on or after February 26, 2018; Revision Ending Date July 3, 2019
  • LCD L35937. Lumbar Epidural Injections. Effective Date October 1, 2015; Revision Effective Date for services performed on or after October 1, 2017; Revision Ending Date October 16, 2019
  • LCD L36521. Lumbar Epidural Injections. Effective Date June 16, 2016; Revision Effective Date for services performed on or after June 1, 2018; Revision Ending Date October 31, 2019
  • LCD L36920. Epidural Injections for Pain Management Effective Date May 4, 2017; Revision Effective Date for services performed on or after January 3, 2019; Revision Ending Date July 10, 2019
  • Local Coverage Article (LCA) A56469. Billing and Coding for Lumbar Epidural Steroid Injections (ESI). Effective Date October 1, 2018
  • Local Coverage Article (LCA) A56651. Billing and Coding: Epidural. Effective Date October 3, 2018
  • Change Request 8271, Transmittal 1262. Informational Unsolicited Response (IUR) or Reject for Add-On Codes billed without respective Primary Codes. Effective Date: January 1, 2014
  • National Correct Coding Initiative Coding Policy – Manual for Medicare Services (Coding Policy Manual) revised January 12, 2018.

Last Updated Sep 17, 2020