Article Detail - JF Part B

Following Noridian's July 2022, webinar, the below questions and answers have been compiled with the Noridian Education and Medical Review team members to offer clarity.

Q1: Is a patient allowed four diagnostic and four therapeutic injections in a rolling 12 months?
A1: Correct. Four diagnostic and four therapeutic injections are allowed in a rolling 12-month period for CPT 64490, 64491, 64493, 64494. CPT 64633-64636 only allow two sessions in 12 months, 64492 and 64495 are only allowed on appeals basis.

Q2: Can we have clarification of pain scales?
A2: Pain assessment must be performed and documented at baseline and after each diagnostic procedure using the same pain scale for each assessment. The scales used for measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS) for pain assessment, Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the Patient-Reported Outcomes Measurement Information System (PROMIS) profile domains to assess function. LCD - Facet Joint Interventions for Pain Management (L38803)

Q3: Do you have references to support the KX modifier for pain injections for all three levels?
A3: The KX modifier should be appended to the line for all diagnostic injections. In most cases, the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and are not indicative of identification of the pain generator, it is necessary to perform additional diagnostic injections at different levels and append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review. The KX modifier demonstrates medical necessity. The need for a there or four- level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and radiofrequency ablation (RFA) that are performed during the same day. Also, remember that the diagnostic blocks and all requirements must be met for each level injected.

Q4: Is the diagnostic procedure required before the therapeutic procedure?
A4: Yes. Two diagnostic procedures, two weeks apart, with the defined criteria in the policy are required before any additional procedure. For the beneficiary to receive any therapeutic intraarticular injections, there must be documentation of why the beneficiary is not able to go on to the definitive treatment of radiofrequency ablation (RFA).

Q5: With respect to therapeutic intraarticular (IA) injections, Noridian requires providers to state why Radiofrequency ablation (RFA) is unable to be performed. If the patient refuses or has failed an (RFA), is this sufficient?
A5: If a patient refuses an RFA or has failed RFA at the same site as the current pain generator, then those are acceptable to perform a therapeutic injection, meeting the same criteria of response to diagnostic injections, etc. is required by the LCD. However, if a large percentage of patients in a practice all refuse or fail RFA routinely, it could trigger a review.

Q6: Can conscious sedation be used for an RFA? Is monitored anesthesia care (MAC) for RFAs allowable?
A6: General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious sedation nor (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be provided on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.

Q7: If the patient has symptoms at two separate regions (T12-L1 and L1-L2). Do they have to have procedures on separate days?
A7: Correct. One region per session is allowed. Reminder that Lumbar (L1-L5) and Thoracic (T1-T12) are different regions.

Q8: If a provider performs 2 medial branch blocks (MBBs), then are we required to do a Radiofrequency ablation (RFA)?
A8: Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) procedure would be considered the primary treatment goal at the diagnosed level(s).

Q9: If the diagnosis supports medical necessity, and the claim is denied for medical necessity, does that typically mean the denial was based on frequency?
A9: Yes, a medical necessity denial may be based on inappropriate frequency, documentation not supporting the diagnosis reported, failure to document pre and post procedure pain levels, number of levels or regions addressed or any other documented failure to adhere to the provisions of the LCD, some of which may be determined on review or appeal.

Q10: We have patients who have greatly benefited from three level facet injections previously and are wanting to continue, even if they must pay for it. The physician would not do a third level if he did not feel it was necessary. Why are providers supposed to perform the procedure, then hope to get paid on appeal? Providers should be allowed to obtain an Advance Beneficiary Notice (ABN) from the patient and have them pay for it if they are requesting it, if Medicare does not feel it meets their criteria. Otherwise, we will be providing them for free.
A10: Yes, providers would be correct in obtaining an ABN from the patient in this circumstance and append the GA modifier on the claim. If the third level procedure were appealed, and found to be reasonable and necessary on appeal, the beneficiary would be reimbursed.

Q11: What would be considered medically necessity for an additional third or more level at the first level of appeal?
A11: Establishing medically reasonable and necessary criteria for a third or more levels would start with responses to the two required diagnostic blocks. Frequency limitations per session are one to two levels, either unilateral or bilateral, per spinal region. This means the maximum levels identified in any diagnostic work up would be two levels identified with the two sessions. For each covered spinal region, four diagnostic joint sessions will be reimbursed per rolling 12 months. Should the provider and beneficiary still believe that additional facet joints could be contributing to pain outside of the area where the diagnostic facet injections have been completed, supporting documentation would be required to allow the provider to perform the additional two diagnostic blocks in the same spinal region, with the same criteria of 80 percent pain reduction after each.

Q12: Can transforaminal epidural injection (TFESI) and facet injections to one area of the spine be performed at the same time?
A12: It is not routinely necessary for multiple blocks (e.g., epidural injections, sympathetic blocks, trigger point injections, etc.) to be provided to a patient on the same day as facet joint procedures. Multiple blocks on the same day could lead to improper or lack of diagnosis. If performed, the medical necessity of each injection (at the same or a different level[s]) must be clearly documented in the medical record. For example, the performance of both paravertebral facet joint procedures(s) and a TFESI at the same or close spinal level at the same encounter would not be expected unless a synovial cyst is compressing the nerve root. In this situation, TFESI may provide relief for the radicular pain, while the facet cyst rupture allows nerve root decompression. Frequent reporting of multiple blocks on the same day may trigger a focused medical review.

Q13: If a patient cannot have the RFA due to a spinal cord stimulator, for example, and injections are performed for pain as therapeutic, is the third level appealable because its therapeutic?
A13: Yes, however, the documentation must support why an RFA is unable to be performed. Independent consideration may be considered with sufficient documentation on appeal.

Q14: How can we bill T12-L1 and L1-L2?
A14: Only one region is allowed per session per day as lumbar and thoracic are different regions. The limitations section of the LCD states," It is not expected that patients will routinely present with pain in both cervical/thoracic and lumbar spinal regions. Therefore, facet joint interventions (both diagnostic and therapeutic) are limited to one spinal region per session. Since T12/L1 is coded using CPT 64490 and L1/L2 is coded using CPT 64493 and these are different spinal regions, these two levels would not be appropriate to perform in the same session.

Q15: If an RFA was performed six years ago and patient reports the same symptoms, do we go right to repeat RFA?
A15: Yes, if the symptoms are the same and there is no question the same level is the source of pain.

Q16: Can practitioners perform four injections on the same side in one session?
A16: No, the policy allows a maximum of two unilateral or two bilateral per session (one spinal region allowed per session with one-two levels unilateral or bilateral per session.

Q17: Are there any extenuating circumstances (i.e., patients taking anticoagulants, etc.) that would allow a second diagnostic test sooner than two weeks?
A17: Yes, if documentation supports it, it will be considered for payment upon review.

Q18: Can a person who has an anterior lumbar interbody fusion have an RFA above or below the anterior lumbar interbody fusion site?
A18: Yes, an RFA can be performed above or below the fusion site.