The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 64635 - Destruction by Neurolytic Agent, Paravertebral Facet Joint Nerve. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons:

• Failure to Return Records
• Documentation does not Support the Medical Necessity as Listed in the Coverage Requirement
• Duplicate Billing

Educational Resources

• How to Respond to ADR
• Signature Requirement Questions and Answers
• JE LCD L34993
• Required Documentation

Education

JE LCD Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34993)

Local Coverage Determination L34993 provides an overview of the coverage requirements for these services. Documentation must support the history of pain which has not been responsive to conservative measures. Documentation must also support the conservative measures that have been tried and failed. The LCD also further clarifies that documentation must support a clinical assessment which supports that the pain is a result of the facet joint and that there is no other pathology that may be causing the pain.

Documentation must reflect the patient pre and post procedure pain rating, procedure report, and the injectate used is within the LCD requirements.

Medical Necessity

As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part.

Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. In order to be considered medically necessary, items and services must be proven as safe and effective.

Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary in order for a claim to be properly evaluated. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2.

Failure To Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.

"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."

Duplicate Billing

It is inappropriate to continually submit claims for the same patient, date of service, and Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS®) code. If you have not received a claim determination, your claim has most likely not been adjudicated yet. Some companies ‘cycle' their claims every 30 days and any claim that has not received a payment or denial is automatically submitted again. This is inappropriate. The only time a claim should be resubmitted to Medicare is when the claim is denied unprocessable. Providers/suppliers are expected to follow the appropriate steps when there is a disagreement in payment or payment has not yet been made.