01-304 Facet Joint 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 claims for Medicare Facet Joint Injections billed on dates of service from January 1, 2019 through December 31, 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

Facet joint injections are an interventional technique used to diagnose and/or treat back pain. The injections are administered to a very specific set of joints, placed into and around the facet joints. Facet joint injections have been a topic of interest for the Office of the Inspector General (OIG) in the past, and the OIG has found significant billing errors in this area. An OIG report published in October 2020 found that an audit completed on improper payments due to coverage limitations Medicare paid out $748,555 improperly.

Reason for Review

The SMRC is tasked with performing a claim review on a sample of facet joint injection claims from January 1, 2019 through December 31, 2019. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

POS / Revenue Code / TOB CPT / HCPCS / ICD-10
TOB 13X and TOB 85X 64490, 64491, 64492, 64493, 64494, 64495

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. Physician or Non-Physician Practitioner (NPP) order for date of service or intent to order
  2. Initial pre-procedural evaluation including, but not limited to history and physical including musculoskeletal and neurological assessment, complete pain history including pain scales, qualifying diagnosis, prior imaging studies and findings, treatment plan, documentation of other treatment methods that have been trialed and failed, and functional impairment.
  3. Procedure Report to support services billed, including, but not limited to procedure details, medication administration record (MAR), evidence of radiographic guidance (fluoroscopy or computed tomography), and pre- and post-procedure evaluation.
  4. Periodic re-evaluation including, but not limited to summarization of the patient’s history and interventions, responses to the procedure including functional status and pain scales, rationale for ongoing intervention, and other pain management techniques.
  5. Documentation to support indications and criteria as specified in the local coverage determination (LCD) or coverage article.
  6. Any other documentation that supports medical necessity of the injection services.
  7. Advanced Beneficiary Notice of Noncoverage (ABN), if applicable.
  8. Valid electronic and handwritten physician and/or clinician signatures including signature logs and signature attestation statements to be submitted when physician and/or clinician signatures are illegible.
  9. If medical record documentation is submitted vis esMD; Beneficiary identification, date of service, and provider of service should be clearly identified on each page of the submitted documentation.

References/Resources

  • Social Security Act (SSA), Title XVIII, 1812(a)(1),(b)(3)). Scope of Benefits.
  • Social Security Act (SSA), Title XVIII, Section 1814(4). Conditions of and limitations on payment of
  • Social Security Act (SSA) Title XVIII, Section 1815(a). Payment to Providers of Services.
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits.
  • Social Security Act (SSA), Title XVIII, Section 1833(2)(E)(i). Payment of Benefits (Outpatient Hospital Radiological Services).
  • Social Security Act (SSA), Title XVIII, Section 1833(t)(B)(i). Payment of Benefits (Prospect Payment Service for Outpatient Part B Department Services).
  • Social Security Act (SSA), Title XVIII, Section 1835(a)(2). Procedure for payment of claims of providers of services.
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(7). Excludes Routine Physicals.
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
  • Social Security Act (SSA) Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • Social Security Act (SSA) Title XVIII, Section 1893(b). Medicare Integrity Program.
  • Code of Federal Regulations (CFR) Title 42, Section 405.904. Determinations, Redeterminations, Reconsiderations, and Appeals under Original Medicare (Part A and Part B).
  • Code of Federal Regulations, Title 42, Section 411.15. Exclusions from Medicare and Limitations on Medicare Payment.
  • Code of Federation Regulations (CFR) Title 42, Section 411.15(k)(l). Particular Services Excluded from Coverage.
  • Code of Federal Regulations, Title 42, Section 414.40. Coding and Ancillary Polices – AMA HCPCS Professional Coding Guidelines.
  • Code of Federal Regulations (CFR) Title 42, Section 424.5 (a)(6). Basic Conditions of the Medicare Payment; Sufficient Information.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 6, Section 20. Hospital Services Covered Under Part B.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 30.1. Covered Medical and Other Health Services.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 50- 50.6. Drugs and Biologicals.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 3.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 4, Section 20.4. Reporting of HCPCS Service Units.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 4, Section 20.6. Use of Modifiers.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 7, Section 50. Part B Billing, Inpatient Part B and Outpatient.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 12, Section 20.3. Bundled Services/ Supplies.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 12, Section 30. Correct Coding Policy.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 12, Section 70. Payment conditions for Radiology Services.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 13, Section 10.1. Billing Part B Radiology Services and Other Diagnostic Procedures.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 13, Section 20. Payment Conditions for Radiology Services.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 13, Section 30. Computerized Axial Tomography Procedures.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 23. Description of HCPCS.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, Section 40.3.6. Advanced Beneficiary Notice of Non-Coverage.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, Section 50.6.1. ABN Standards Proper Notice Documents.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requirements.
  • Medicare Program Integrity Manual (MCPM), Publication 100-08, Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.1. Coverage Determination.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3. Section 3.6.2.2. Reasonable and Necessary Criteria.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.4. Coding Determinations.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.5, A. Distinguishing Between Benefit Category, Statutory Exclusion and Reasonable and Necessary Denials.
  • Local Coverage Determination (LCD) L33930. Facet Joint Interventions for Pain Management. Effective October 1, 2015.
  • Local Coverage Determination (LCD) L34832. Facet Joint Injections, Medial Branch Blocks, and FACET Joint Radiofrequency Neurotomy. Effective October 1, 2015; Retired May 1, 2021.
  • Local Coverage Determination (LCD) L34892. Facet Joint Interventions for Pain Management. Effective October 1, 2015.
  • Local Coverage Determination (LCD) L35936. Facet Joint Interventions for Pain Management. Effective October 1, 2015.
  • Local Coverage Determination (LCD) L35996. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective October 1, 2015; Retired April 24, 2021.
  • Local Coverage Determination (LCD) L36471. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective February 15, 2016; Retired April 24, 2021.
  • Local Coverage Article (LCA) A56463. Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective September 19, 2019; Retired May 1, 2021.
  • Local Coverage Article (LCA) A56687. Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective July 11, 2019; Retired April 24, 2021.
  • Local Coverage Article (LCA) A57553. Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective Date November 1, 2019; Retired April 24, 2021.
  • Local Coverage Article (LCA) A57787. Billing and Coding: Facet Joint Interventions for Pain Management. Effective October 3, 2018.
  • Local Coverage Article (LCA) A57826. Billing and Coding: Facet Joint Interventions for Pain Management. Effective December 5. 2019; Revision April 25, 2021.
  • Local Coverage Article (LCA) A56670. Billing and Coding: Facet Joint Interventions for Pain Management. Effective July 11, 2019.
  • Local Coverage Article (LCA) A58105. Paravertebral Facet Joint Blocks – Revision to the Part B LCD. Effective January 8, 2019.
  • Local Coverage Article (LCA) A55906. Paravertebral Facet Joint Blocks – Revision to the Part B LCD. Effective March 1, 2018; Retired August 13, 2021.
  • Local Coverage Article (LCA) A54561. Response to Comments: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy L35996. Effective October 1, 2015.
  • Local Coverage Article (LCA) A56010. Response to Comments: Facet Joint Interventions for Pain Management. Effective June 28, 2018.

 

Last Updated Dec 2, 2021