The Centers for Medicare & Medicaid Services (CMS) released an MLN Matters Special Edition article based on an August 2010 U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) report, “Inappropriate Medicare Payments For Transforaminal Epidural Injection Services.” The purpose of the Special Edition article is “to remind physicians of the importance of properly documenting the services for which they bill.”
The study found that in 2007:
- 34 percent of transforaminal epidural injection services that Medicare allowed did not meet Medicare requirements.
- 19 percent of transforaminal epidural injection services had a documentation error (10 percent were undocumented and 9 percent were insufficiently documented).
- 13 percent of injection services had a medical necessity error and 8 percent had a coding error resulting in overpayments for miscoded services—primarily using add-on codes and bilateral modifiers improperly; and in some instances, performing less intensive procedures, but billing for transforaminal epidural injections.
These errors were found more often in offices than facilities.
To be sure you are properly claiming these procedures, CMS wants you to consider any local coverage determinations (LCDs) found in the CMS Medicare Coverage Database.
Of importance, for example, are LCD L30481 and LCD L27512 documentation requirements for transforaminal epidural and paravertebral facet joint injections. In particular, for LCD L27512, you should code according to this guidance:
“The primary codes 64479, 64483, 64490 and 64493 are used for a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code, 64480, 64491, 64492 (cervical/thoracic) and 64484, 64494 and 64495 (lumbar/sacral) for use when injections are provided at multiple spinal levels. Unilateral injections are performed on one side of the joint level, while bilateral injections are performed on the right and left side of the joint level. The Centers for Medicare and Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing modifier 50.”
Remember: Modifier 50 was revised for 2011 to delete the term “operative” from its descriptor, and now simply reads “Bilateral procedure.”
LCD number 27512 also discusses the general documentation requirements. See MLN Matter SE1102 for the rest of transforaminal epidural and paravertebral facet joint injections requirements.
March 11th, 2011
Medicare Part B physician payments for transforaminal epidural injection services increased from $57 million in 2003 to $141 million in 2007, according to a recent review conducted by the Office of Inspector General (OIG). That amounts to a 150 percent increase.
A gain in popularity of this magnitude prompted the OIG to conduct a review of this pain management service. In the review, the OIG states that roughly 34 percent of 433 sampled claims for transforaminal epidural injection services performed in 2007 did not meet Medicare requirements. The OIG estimates approximately $43 million in improper payments.
Physicians should prepare themselves for added contractor scrutiny of these types of pain management claims.
Transforaminal epidural injections are a type of interventional pain management technique used to diagnose or treat pain. There are two primary codes used to bill a single injection in the cervical/thoracic or lumbar/sacral area of the spine, and each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. These codes are:
||Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level
||Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
||Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
||Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
Physician payments vary based on the place of service (office vs. ambulatory surgical center (ASC) or outpatient department) and also the modifiers billed. For example, bilateral transforaminal epidural injections, which are performed on both the right and left side of a vertabrel level should be billed using modifier 50. The use of this modifier would increase payment to 150 percent of the base rate.
According to the OIG, “The reviewer found primarily that physicians improperly used add-on codes and bilateral modifiers.”
Medicare covers transforaminal epidural injections that are reasonable and necessary, which are those used in the diagnosis or treatment of illness or to improve the functioning of a malformed body part. To ensure payment, physicians must:
- Properly document medical care to support the service; and
- use uniform procedure codes to report all services.
Documentation should include a description of the service provided, with details such as location and frequency of injections, as well as outcomes that support subsequent injections. Diagnosis codes also must support medical necessity. Most contractors with local coverage determinations (LCDs) in place for transforaminal epidural injections also require the use of radiographic guidance (such as live X-rays), prohibit multiple pain management services on the same day, and limit frequency.
In response, the Centers for Medicare & Medicaid Services (CMS) says it intends to strengthen program safeguards, which may include medical reviews and system edits.
Read the OIG’s August review for complete details.
August 23rd, 2010