# cheat sheet for MBB, TESI and RF 2014 guidelines



## 574coding (Apr 22, 2014)

Hello,
Does anyone have a cheat sheet that they can share with me on the new 2014 guidelines on MBB, RF, and TESI?  Our providers need something that they can look at to know how many they can do during a procedure and how many each year.  I just have not had time to make one up yet and was hoping someone has done this already.  
Thank you for your time.


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## dwaldman (Apr 23, 2014)

It can be narrowed down but the main components of the Medicare carrier LCD that you billed can be provided. In the indications there are number and frequency of injections. If it is necessary to provide the conditions they state are indicated that can also be provided. Additionally, the documentation and utilization guidelines in the LCD provide documentation requirements and other pertinent information. Again it can be narrowed down then what I provided below from WPS Medicare J5. This can be also copy and pasted from Commercial carriers where carriers like Cigna and Aetna and UHC policy can be acess thru the internet..


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Facet Joint Blocks: 
The paravertebral facet joint, known as the zygapophysial joint is made up of two superior processes (extensions of bone projecting upward), interconnecting with two inferior processes (which project downward) from the vertebra directly above.

A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebra. For the purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). There are two (2) facet joints at each level, left and right.

For the purpose of this LCD an anatomical region is defined as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495). A facet joint level refers to the facet joint or the nerves (e.g., medial branch nerves) innervating that joint. 

Facet joint block is one of the methods used to document/confirm suspicions of posterior elemental biomechanical pain of the back. The patient with this condition usually has back pain that does not have a strong radicular component, no associated neurologic deficit and the pain is aggravated by hyperextension of the spine.

Facet joint injections are considered medically necessary for the diagnosis or treatment of chronic pain that has failed conservative therapy.

During this procedure a needle is placed in the facet joint under fluoroscopic or CT guidance and a long acting local anesthetic agent is injected in the facet joint or around or into the nerve supplying the joint, to temporarily anesthetize the facet joint. After satisfactory blockade of the pain has been obtained, the patient is asked to indulge in the activities that usually aggravated his/her pain and to record his/her impressions of the effect of the procedure 4-8 hours after the injection. Temporary or prolonged significant pain relief of the back pain suggests that facet joints were the source of the symptoms and appropriate treatment may be prescribed.

A series of two injections may be medically necessary for diagnostic blocks to establish consistency of results, particularly if diagnostic blocks are to be followed by facet joint denervation.

Multiple nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. It is reasonable to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first procedure fails to produce the desired effect or rules out the diagnosis, the provider may proceed to the next logical test or treatment if desired.

Accordingly, providing a combination of epidural block, facet joint blocks, bilateral sacroiliac joint injections, lumbar sympathetic blocks or providing more than three levels of facet joint blocks to a patient on the same day is considered not reasonable or necessary. Such therapy can lead to an improper diagnosis or unnecessary treatment.

Indications: 
Suspicion of facet joint pain. 

Limitations: 
Radiculopathy should be ruled out by physical or electrophysiologic examination.

Monitored Anesthesia Care (MAC) is rarely necessary for these procedures. 

Given that a facet joint receives nerves from three levels, it may be appropriate to block up to three levels when one level of facet joint involvement is suspected. 

Facet Joint Denervation: 

If the patient gets sufficient relief of pain from a facet joint block for a meaningful period of time but the pain recurs, one of the options is to denervate the facet joint. This procedure requires placement of a needle in the facet joint under fluoroscopic or CT guidance, injection of a local anesthetic agent, and if the pain is relieved (confirming that the needle is in the area desired to be denervated), injection of a neurolytic agent to destroy the facet joint nerve. This denervation can also be achieved by passing an electric current through a similarly placed electrode, by applying heat or by using radiofrequency.

When facet joint block has been effective in managing the back pain under consideration, then a permanent denervation may be considered, but should be restricted only to the level or levels that, from the results of the blocks, can be reasonably considered the source of the pain. This may not include all the levels that were blocked.

CPT codes mentioned in this policy may not be used to treat patients with acupuncture techniques or variations of those techniques.

Limitations:
The effects of denervation should last from six months to one year or longer. In some instances the effects may be permanent. Repeat denervation procedures at the same joint/nerve level will only be considered medically necessary when the patient has had significant improvement of pain after the initial facet joint nerve destruction that lasted an appropriate period of time (greater than or equal to six months.) 
Associated Information 
Documentation Requirements
The medical record must include documentation of the duration of the chronic pain and any conservative treatments that have been tried. 

The pre-operative evaluation leading to suspicion of the presence of the facet joint pathology must be clearly documented in the patient's medical records along with the post-operative conclusions.

Documentation in the patient's medical record should indicate how the provider arrived at the suspected diagnosis. As an example, the patient had back pain without a strong radicular component, no associated neurological deficit and the pain was aggravated by hyperextension of the spine.

The medically necessary reason for the use of CT guided imaging rather than fluoroscopy must be documented in the medical record.

The medical record must be made available to Medicare upon request.

When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as "not reasonable and necessary" under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

Utilization Guidelines
The number of injections in the diagnostic phase should be limited to no more than two times, and should be limited to three levels whether unilateral or bilateral for each region on any given date of service. The second diagnostic injection should be done no sooner than one week following the first diagnostic injection. 

In the treatment or therapeutic phase the intervention procedures should be repeated only as medically necessary. No more than four therapeutic injections per region per patient would be expected for the majority of patients during a one year period.

Significant pain relief is defined as greater than or equal to 80% initially with the ability to perform previously painful maneuvers.

Injection of phenol or alcohol or pulsed radiofrequency ablation of the facet joint is considered experimental or investigative.

Prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents are not covered services per National Coverage Determinations 150.7.

Physicians typically perform facet joint injections using radiological guidance to ensure correct needle placement and avoid nerve or other injury. Facet joint injections performed without the use of fluoroscopy or CT guidance are considered not medically necessary.

Epidural injections are used for acute and chronic pain, in addition to cancer pain management. Epidural injections are utilized both for diagnostic and therapeutic purposes. 

A multi-disciplinary or collaborative comprehensive evaluation (e.g. orthopedics, neurologist, neurosurgeon, physiatrist, anesthesiologist, pain medicine specialist, and/or attending physician), is recommended prior to initiating a trial of these injections for relief of chronic recurrent pain. 



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Epidural steroid injections, both interlaminar/translaminar and transforaminal should be used only in the presence of radiculopathy.

Indications for Diagnostic and Therapeutic Epidural Injections

Diagnostic interlaminar/translaminar or caudal epidural steroid injections are seldom used. Although the medication injected can sometimes be confined to a limited area, bilateral effects and spread to adjacent levels often occur.

Therapeutic interlaminar/translaminar or caudal epidural injections and infusions of opioid, local anesthetic, or other medications may be used for the treatment of acute and chronic pain or cancer pain. 

Epidural injections (interlaminar/translaminar or caudal) may be used for the following. 

Acute obstetric, post traumatic and postoperative pain
Advanced cancer pain, primary or metastatic 
Acute/sub acute and chronic pain syndrome including cervical, thoracic and lumbar pain with radiculopathy and intervertebral disc disease (with neuritis or radiculitis) with or without myelopathy that has failed to respond to adequate conservative management.
Nerve root injuries and neuropathic pain and post traumatic including post laminectomy syndrome (failed back syndrome).
Spinal cord myelopathy
Complex regional pain syndrome
Epidural scarring from prior infection, hemorrhage and/or surgery
Multiple rib fractures
Vertebral compression fractures
Post herpetic neuralgia and herpes zoster
Phantom limb pain 

Indications for Diagnostic and Therapeutic Transforaminal Epidural Injections

Transforaminal epidural injection is a selective injection of the cervical, thoracic, lumbar or sacral nerve roots with proximal spread of contrast or local anesthetic through the neural foramen to the epidural space. With the aid of fluoroscopic or computed tomography (CT) imaging, the needle tip is placed within or adjacent to the lateral margin of the neural foramen and contrast material is injected to obtain a neurogram and visualize spread of the injected solution. 

A small volume of local anesthetic is injected (less than or equal to 1.0 ml) in order to perform a diagnostic reproducible blockade of a specific nerve root. The diagnostic usefulness is lost if more than 1.0 ml of local anesthetic is injected (the block becomes unreliable since the spread of anesthetic to adjacent levels and structures likely occurs). 

Diagnostic transforaminal epidural injections are appropriate for the following purposes.

To differentiate the level of radicular nerve root pain.
To differentiate radicular from non radicular pain
To evaluate a discrepancy between imaging studies and clinical findings
To identify the source of pain in the presence of multi-level nerve root compression
To identify the level of pathology at a previous operative site

It might be necessary to perform injections at two different nerve root levels on the same date of service. When multiple levels of nerve root compression or stenosis is suspected to be responsible for the patient?s symptoms, presence of the compression or stenosis on imaging studies should be documented in the medical record.

Therapeutic transforaminal epidural injections are appropriate for the following purposes:

Corticosteroid can be added as a therapeutic measure. Injections for therapeutic reasons can be of greater volume. The transforaminal injection can be performed for diagnostic, therapeutic or both purposes.

Radicular pain resistant to more conservative measures or when surgery is contraindicated.
Post-decompressive radiculitis or post surgical scarring
Monoradicular pain, confirmed by diagnostic block in which a surgically correctible lesion cannot be identified 
Treatment of acute herpes zoster or post herpetic neuralgia

General Indications and Limitations 
Epidural (interlaminar/translaminar or caudal) and transforaminal epidural corticosteroid injections should not exceed a series of three, per spinal region, within a six-month period when used as treatment for a pain disorder other than treatment for cancer pain. These may be performed at intervals of one week or greater. With each subsequent injection the medical record should clearly document the interval effects from the prior injection(s). Appropriate reasons for a repeat injection are: (a) significant improvement in the patient's symptoms from the prior injection, even if relapsed, or (b) carefully documented technical reasons that it is appropriate to repeat the procedure even if no prior improvement and (c) patients with persistent pain in whom the imaging findings suggest that the pathology should respond to corticosteroid injection. In the absence of a compelling technical reason, it is not appropriate to repeat a procedure a third time if there has been no improvement from the two preceding.

If corticosteroids are used, consideration should be given to the potential complications of repetitive corticosteroid administration. 

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.

Anti-spasmodic drugs administered intrathecally (e.g., baclofen) to treat chronic intractable spasticity are addressed in the Infusion Pump NCD Pub. 100-3 Sec. 280.14. The CPT description of procedure codes 62310, 62311, 62318 and 62319 include anesthetic, antispasmodic, opioid, steroid, other solution; therefore the spasticity conditions are included in this LCD.

Documentation Requirements

Documentation in the medical record must contain the initial evaluation including history and physical examination, diagnosis, pain and disability of moderate to severe degree, site of injection with name and dosage of drug instilled, and the patient?s response to the prior injections.

Documentation of conservative therapies that were tried and failed except in acute situations such as acute disc herniation with disabling and debilitating pain, herpes zoster and post herpetic neuralgia, reflex sympathetic dystrophy, post operative and obstetric pain and intractable pain secondary to carcinoma.

Pre and post procedure evaluation documenting patient?s response to the injection, including pain level and ability to perform previously painful maneuvers must be included in the medical record.

The medically necessary reason for the use of CT guided imaging rather than fluoroscopy must be documented in the medical record.

Daily hospital management of continuous epidural or subarachnoid drug administration must be documented in the medical record.

The medical record must be made available to Medicare upon request.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must send all relevant documentation with the request.

Utilization Guidelines

See Indications and Limitations section of this policy.

Significant improvement in the patient's symptoms is defined as 50% or more improvement in level of pain.

Providing a combination of epidural injections, facet joint injections, bilateral sacroiliac joint injections or lumbar sympathetic blocks to a patient on the same day is considered not reasonable or necessary. Such therapy can lead to an improper diagnosis or unnecessary treatment.


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