We specialize in RCM analytics (billing analysis) for pain management billing and neurosurgery billing, and we have an interesting example of a payer policy that contradicts itself. It took a very long time to get this payer policy of medical necessity for a medial branch block. In red we have highlighted the contradiction. Notice that the join injection therapy is considered unproven for the treatment of chronic spinal pain and then at the bottom of the policy they quote ASIPP and the suggested frequency and treatment using this methodology. What is so strange is that some claims were paying and some of them were not. This finally clarified why some of the claims with the exact same diagnoses and CPT codes to the exact same payer were reimbursed and some not. Obtaining a copy of the payer policy was extremely difficult. Ultimately, getting the carrier to pay all the unpaid claims was possible but took a great deal of time and energy.
Payer policy for Medial Branch Blocks or Zygapophyseal Joint Injections
Diagnostic facet joint injection and/or facet nerve block (e.g. medial branch block) is proven to localize source of pain to the facet joint in persons with spinal pain.
Therapeutic facet joint injection is unproven for the treatment of chronic and spinal pain.
Clinical evidence about the very existence of facet joint syndrome is conflicting, and evidence from studies is inadequate regarding the superiority of periodic facet joint injections compared to placebo in relieving chronic spinal pain.
- Facet joint injection, as a diagnostic procedure prior to radiofrequency ablation, is not recommended in patients with:
- Neurologic abnormalities
- More than one pain syndrome
- Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
- Previous spinal surgery at the clinically suspected levels
American Society of the Interventional Pain Physicians (ASIPP): Evidence-Based Practice
Guidelines in the Management of Chronic Spinal Pain state that during the diagnostic phase, a patient may receive 2 injections at intervals of no sooner than one week or preferably 2 weeks. In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency would be the 2-3 months of longer between injections, provided that >50% relief is obtained for 8 weeks. (Manchikanti et al., 2009).
An example of three different types of pain management procedures based on Medicare’s LCD’s. It is just showing you the frequencies of the procedures. It is very important that as a pain management medical billing company that we know and understand these policies and that we share this information with the pain management providers, whether they be pain management physicians, neurosurgeons, anesthesiologists, or ambulatory surgery centers.
- Therapeutic phase: procedures should be repeated as medically necessary: no more than four (4) injections of any type per region per patient per year.
- CPT 62310 – 62311
- Maximum of five (5) facet joint injection sessions inclusive of MBBs, IA injections, facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine.
- Injections may be repeated if the first injection results in significant pain relief (>50%) for at least 3 months.
- CPT 64490 – 64492
- CPT 64493 – 64495
- Only when dual MBBs provide 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered.
- Repeat RFAs at same joint will only be considered medically necessary if the patient experienced 50% improvement of pain and specific ADLs documented for at least 6 months.
- CPT 64633 – 64634
- CPT 64635 – 64636
LCDs can even differ between different Medicare contractors around the U.S. For example, an epidural injection (ESI) in their frequencies:
- In the first year, up to six (6) injection sessions per region may be performed; up to two (2) diagnostic and up to four (4) therapeutic
- In the following years, up to four (4) therapeutic injection sessions per region may be performed
- No more than three (3) epidurals may be performed in a 6-month period of time
- No more than six (6) ESI session (therapeutic and/or diagnostic) may be performed in a 12-month period of time regardless of number of levels
- Therapeutic, series of three (3) ESI may be given minimum interval of two (2) weeks
- No more than two (2) levels on any given DOS (unilateral or bilateral)
- A series of three (3) ESI may be repeated at six (6) month intervals
Most providers only use one intermediary, although providers that have locations in multiple states would certainly be impacted by this. It is also possible that the medical billing company is either located in a different region and does not keep up with the different LCDs in each region for pain management billing, or it is possible the biller may have just gotten the wrong LCD unwittingly because it didn’t occur to them that this might vary by region.
Following is another example of where LCD’s can vary, demonstrating that different Medicare contractors not only vary slightly, but sometimes can very extremely significantly. This example is for Medial Branch Blocks:
- In the first year, up to six (6) injection sessions may b performed din the lumbar region; up to two (2) diagnostic and up to four (4) therapeutic
- Following years up to four (4) sessions may be performed
- Maximum of five (5) sessions per year in the cervical/thoracic and five (5) in the lumbar
- Diagnostic phase should be limited to three (3) levels for each anatomical region
- No more than three (3) levels (unilateral or bilateral) per anatomic region on any given DOS – therapeutic and no less than 90 day intervals
And one last example showing the differences for RFA’s:
- A maximum of two (2) sessions per nerve level per year may be performed in the lumbar region
- No more than two sessions will be reimbursed in any calendar year involving no more than four (4) joints per session (either two (2) bilateral levels or four (4) unilateral levels)
- No more than two (2) treatments, right or left within a 12 month (365 day) period of time
If pain management billing LCD’s for Medicare can vary significantly, imagine how much variance there is in commercial payer policies. Even if a payer states that it follows Medicare guidelines – which Medicare guidelines could be a problem since they can match to one of many LCD’s even if they state they are following Medicare rules, and that doesn’t even take into account if the payer does not follow Medicare rules.
This is just one set of examples that demonstrates why in order to be successful in pain management billing it is so important to stay on top of LCD’s and payer policies. This means researching the policies for all of your top payer and checking them quarterly. It also means that there is a process to analyze denials to identify patterns and determine if a payer policy has potentially changed, even if it is not published. This can be very hard for a practice to do and it often gets a low prioritization, which is why it can be helpful to have a strong pain management billing company that specializes in this field. There are huge economies of scale in billing and compliance, since each time we check a policy, it benefits a lot of practices at the same time.
About Apache Health
Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients. Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact: