Neurology & Pain Management Coding Alert

Question: Our Medicare payer is rejecting all claims for facet joint injections. Any idea why?

Pennsylvania Subscriber

Answer: Assuming that you are using the correct codes to identify these procedures (64470-64476), your payer could be rejecting your claims for one of three reasons:
 
1. You are billing more than the maximum number of allowable injections per session. Most payers will reimburse a maximum of three facet joint injections per session, each at a different spinal level. And payers typically limit the total number of injections the physician may bill for the same patient within a given time frame. For example, Aetna U.S. Healthcare (a large private payer) instructs physicians, "Facet joint injections should be limited to a maximum of three sets of injections over a 12-month period." Aetna defines one "set of injections" as treatment of up to three anatomic sites during a single session. Either individual spinal levels or the left and right sides of a single level count as a separate anatomic site (that is, a bilateral injection counts as two anatomic sites). Medicare follows similar guidelines.
 
2. You have failed to show evidence of "chronic pain" to justify the injections. The majority of payers will only reimburse if the surgeon has proven that the patient has chronic, rather than acute, pain. But the definition of "chronic" differs from payer to payer. For instance, Empire Medicare Services (a Medicare carrier in New Jersey) specifies, "Chronic pain is defined as pain which has been present for six months or more," while Aetna requires only three months to pass.
 
Regardless of payer, the physician must document a history of pain for the minimum specified time. Empire's local medical review policy makes this point very clear, stating, "The indications for any nerve block appro-priately begin with a sequential diagnostic evaluation of chronic pain." At minimum, the surgeon must provide a history and physical explaining the type, severity, exacerbating factors, and medical and psychological disorders related to the pain.
 
3. You have not chosen an acceptable diagnosis. The majority of payers accept diagnoses only from the 720-724 (Dorsopathies) portion of ICD-9 for facet joint injections - but not all payers accept the same particular codes within this range. For example, although most payers accept 721.3 (Lumbosacral spondylosis without myelopathy), not all will allow 724.2 (Lumbago; low back pain; low back syndrome) or 724.8 (Other symptoms referable to back) without further explanation. To be sure that you are linking an appropriate diagnosis to the injections you report, ask your insurer for a list of appropriate ICD-9 codes. In all cases, you must report the diagnoses to the highest level of specificity (e.g., 724.1, Pain in thoracic spine, versus 724.0x, Spinal stenosis, other than cervical).
 
If you have met all of the carrier's specified criteria and are still being denied, it may be time to contact your CMS regional office.