# Epidurals without flouro guidance



## lerazmus (Jan 30, 2015)

I would like to get clarification regarding specifically codes 62310 and 62311.  In both acute and chronic patient settings, it is absolutely necessary for the attending physician to use fluoroscopic guidance in order to fulfill the Medicare standards in order to be in compliance with billing these codes?  A question has come to our attention from a new possible physician and I would like to get other coders feedback.  Thanks!


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## NIENAJADLY (Feb 5, 2015)

*Epidurals with Fluoro*

Yes, per Medicare guidelines (at least under FL Medicare guidelines) it is required to use fluoro or the injection will be considered not medically necessary.  I would check your Medicare carrier for guidance and use it to support your information to your physicians.

Sincerely,
Kellie


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## dwaldman (Feb 6, 2015)

I agree you would need to look at the local coverage determination policy for the Medicare carrier you bill. For example, here is what is stated for WPS Medicare J5. You should also pull the medical policy for the private payers to get a well rounded consensus of the what carrier's that you bill are requiring. I also copy and pasted some private payers info. 
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30481&ContrId=148 


Many of these procedures, such as those in the peri-operative period, may not require fluoroscopy. 

For treatment of chronic pain, the standard of care is that these procedures be performed under fluoroscopic or CT guided imaging. Therefore injections for chronic pain performed without imaging guidance will be considered not medically necessary. 

Fluoroscopic guidance must be utilized in the performance of single nerve root/transforaminal injections to ensure the precise placement of the needle and medications injected.
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BCBS KC describes the use of fluoroscopy when they describe what falls under their coverage criteria:

Epidural steroid injections performed with fluoroscopic guidance may be considered medically necessary for the treatment of back pain when the following criteria are met:   Lumbar or cervical radiculopathy (sciatica) that is not responsive to at least 4 weeks of conservative management (see Considerations section); AND   Persistent pain is present of at least moderate-severe intensity; AND   Short-term relief of pain is the anticipated outcome; AND   

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Aetna policy does not specifically  address the use of fluoroscopy as requirement, but they do indicate they do not cover epidurals with ultrasound guidance.

http://www.aetna.com/cpb/medical/data/1_99/0016.html

Epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, are considered medically necessary in the outpatient setting for management of persons with radiculopathy or sciatica when all of the following are met:

A.Intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out as the cause of pain; and


B.Member has failed to improve after 2 or more weeks of conservative measures (e.g., rest, systemic analgesics and/or physical therapy); and

C.Epidural injections beyond the first set of 3 injections are provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate.

Epidural injections of corticosteroid preparations, with or without added anesthetic agents, are considered experimental and investigational for all other indications (e.g., non-specific low back pain [LBP] and failed back syndrome) because their effectiveness for indications other than the ones listed above has not been established.

Repeat epidural injections beyond the first set of 3 injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate.  Repeat epidural injections more frequently than every 7 days are not considered medically necessary.  Up to 3 epidural injections are considered medically necessary to diagnose a member's pain and achieve a therapeutic effect; if the member experiences no pain relief after three epidural injections, additional epidural injections are not considered medically necessary.  Once a therapeutic effect is achieved, it is rarely medically necessary to repeat epidural injections more frequently than once every 2 months.  In selected cases where more definitive therapies (e.g., surgery) can not be tolerated or provided, additional epidural injections may be considered medically necessary.  Repeat injections extending beyond 12 months may be reviewed for continued medical necessity. 

Aetna considers ultrasound guidance of epidural injections experimental and investigational because of insufficient evidence of its effectiveness.


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UnitedHealthCare does not describe a requirement of fluoroscopy but they do indicate they do not cover ultrasound guided epidurals. And they point out their policy only addresses lumbar epidurals at unitedhealthcareonline.com under tools, medical and drug policies and coverage determination guidelines

https://www.unitedhealthcareonline....elId=016228193392b010VgnVCM100000c520720a____

Epidural steroid injections in this policy apply to the lumbar spine only. This section does not address cervical injections.  The facet joint injections section of this policy addresses multiple sites, and is not limited to the lumbar spine.  The use of ultrasound guidance for epidural steroid injection(s) and facet joint injection(s) is unproven and not medically necessary. There is insufficient clinical evidence regarding its safety and/or efficacy in published peer-reviewed medical literature. The available published evidence for ultrasound guidance for epidural and facet injections is limited to a small feasibility study and a cadaver study.  Epidural Steroid Injections Epidural steroid injection is proven and medically necessary for the treatment of acute and sub-acute sciatica or radicular pain of the low back caused by spinal stenosis, disc herniation or degenerative changes in the vertebrae.  
Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met: ? The pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and ? The pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy   Epidural steroid injection is unproven and not medically necessary for all other indications of the lumbar spine.  There is a lack of evidence from randomized controlled trials indicating that epidural steroid injections effectively treat patients with lumbar pain not associated with sciatica or radicular pain.  Note: This policy does not apply to obstetrical epidural anesthesia utilized during labor and delivery.  

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Cigna does not address fluoroscopy as a requirement but does not cover ultrasound guided epidural. I was having trouble pulling up their minimally invasive treatment of back pain medical policy but believe I found a versio of it below:

EPIDURAL STEROID INJECTION / SELECTIVE NERVE ROOT BLOCK  Diagnostic Phase: Diagnostic epidural steroid injection/selective nerve root block (CPT codes 62310, 62311, 6447964484) is considered medically necessary when BOTH of the following criteria are met:   
? acute or recurrent cervical, thoracic or lumbar radicular pain (e.g. sciatica) ? failure to improve following at least six weeks of conservative management, including pharmacological therapy, physical therapy, and/or a home exercise program, OR worsening (e.g., incapacitating pain, advancing neurological symptoms) following at least two weeks of conservative management   A maximum of two diagnostic injection treatment sessions is considered medically necessary at a minimum interval of two weeks  Therapeutic Phase Subsequent epidural steroid injections/selective nerve root blocks is considered medically necessary when prior diagnostic/stabilization injections resulted in a beneficial clinical response (e.g., improvement in pain, functioning, activity tolerance) and BOTH of the following criteria are met:   
? cervical, thoracic or lumbar radicular pain (e.g., sciatica) has persisted or worsened  ? minimum interval of two months  between injection sessions  A maximum of four therapeutic injection treatment sessions is considered medically necessary for the same diagnosis/condition within a twelve month period, if preceding therapeutic injection resulted in more than 50% relief for at least two months.  Long-term repeated or maintenance epidural steroid injection/selective nerve root block for any indication because it is considered experimental, investigational or unproven and not medically necessary. Repeat epidural steroid injection/selective nerve root block provided for 12 months or longer may result in medical necessity review.  The following are considered experimental, investigational or unproven and not medically necessary:  
? Epidural steroid injection/selective nerve root block for acute, subacute, or chronic back pain without radiculopathy (e.g., sciatica) ? Epidural steroid injection with ultrasound guidance (0228T-0231T) for any indication


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