The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Current Procedural Terminology (CPT®) code 64483 - Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level. The quarterly edit effectiveness results from April 1, 2023 through June 30, 2023 are as follows:

Top Denial Reasons

• Supporting Covered Indications
• Conservative Treatment in Combination with Injections
• Pain History and Rating Requirements
• Epidural Steroid Injection Treatment Greater Than One Year
• Frequency of Repeat Injections
• Limitations

Educational Resources

• Documentation Requirements
• Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L39240)
• Local Coverage Article (LCA): Billing and Coding: Epidural Steroid Joint Injections for Pain Management (A58993)
• IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3

Education

Supporting Covered Indications

Per the LCD L39240, three requirements need to be met to be considered reasonable and necessary:

• Documentation must support at least one of the following:
  • Radiculopathy, radicular pain, and/or neurogenic claudication; or
  • Post laminectomy syndrome; or
  • Acute herpes zoster
• Documentation must support both of the following:
  • Severe pain greatly impacting the beneficiary's quality of life; and
  • At least four weeks of pain; unable to tolerate conservative measures or failure to response after trialing for four weeks

The history, physical examination, and radiological imaging should all be submitted to support the indications for medical necessity. Per the LCA A58993, the medical record should support the main complaint through:

• An assessment
• A medical history
• Results of related tests and/or procedures
• Signed and dated office notes supporting medical necessity and conservative measures trialed
• A procedure note

Conservative Treatment in Combination with Injections

Conservative measures should be performed along with undergoing epidural steroid injections (ESI). These can include, but are not limited to non-steroidal anti-inflammatory medications, analgesics, physical therapy, chiropractic care, etc.

The beneficiary should be participating in an active rehabilitation program, home exercise program, or a functional restoration program during their ESI treatment.

Refer to the LCD L39240 for additional information.

Pain History and Rating Requirements

Per the Local Coverage Determination (LCD) L39240, a pain scale or functional assessment needs to be performed at baseline, prior to conservative measures. The same scale must be used throughout the beneficiary's treatment for proper assessment of response.

The submitted documentation needs to support the beneficiary has had the pain for four weeks and is severe. The chart should also include how the pain affects the beneficiary's quality of life or functional abilities.

Additionally, per the LCA: Billing and Coding: Epidural Steroid Injections for Pain Management (A58993), pre-procedural pain rating and post-procedural pain rating need to be included in the submitted documentation. The pre procedural pain rating should be obtained from the beneficiary the day of the injection and the post procedural pain rating should be obtained immediately post injection.

Epidural Steroid Injection Treatment Greater Than One Year

Per the Analysis of Evidence (Rationale for Determination) of the LCD L39240, there are situations when a beneficiary is not a good candidate for surgery or does not want surgery. Continued ESIs, in combination with other conservative care measures, are an option for decreased pain and increased function.

If epidural steroid injections (ESIs) are continued for greater than one year, the medical record needs to support:

• Severe pain causing the significant functional disability
• ESIs are continuing to provide 50% improvement of pain and/or function for at least three months
• Rationale for continuing the ESIs
• The beneficiary's primary care provider is notified of the continued performance for awareness of the repeated and continued steroid use

Frequency of Repeat Injections

Per the LCD L39240, there is a limit on how many epidural steroid injections (ESIs) can be completed within specific timeframes. A maximum of four ESIs per spinal region in a rolling twelve-month period.

Repeat ESIs are appropriate to perform if the prior ESI provided at least 50% sustained improvement in function and pain relief for at least three months. The documentation should reflect the duration and percentage of the relief using the same pain scale or functional assessment throughout the beneficiary's chart.

There may be situations where an epidural does not provide relief. If a prior epidural did not result in any relief, the practitioner may perform a repeat injection after a 14 day wait period using a different approach, level, and/or medication. The documentation should also support the reason for the repeat injection after the failed response.

Limitations

Per the LCD L39240, there are limitations on performing epidural steroid injections (ESIs). Procedure limitations include, but are not limited to:

• Performing:
  • Multiple blocks during the same session, such as trigger point injections, facet blocks, etc. Facet synovial cyst ruptures and ESI are the exception in this limitation.
  • More than one spinal region per session, such as cervical and lumbar ESIs
  • More than two nerve root levels for transforaminal nerve root injections per session
  • A predetermined series of ESIs
• Injecting more than the lowest effective amount of medication per session

Refer to the LCD L39240 for a full listing of limitations.