Neurology & Pain Management Coding Alert

Question: I’m having problems with one of my commercial payers denying facet injections, stating that the policy says the patient can only have 2 injections in 1000 some days. I haven’t found anything about this in the policy. Is this correct?

Missouri Subscriber

Answer: The problem might lie with the diagnosis you’re reporting with the procedure. Many payers consider facet joint injections (intraarticular and medial branch blocks) to be medically necessary for patients who are diagnosed with facet pain with chronic back or neck pain. However, payers consider the injections to be experimental and investigational as therapy for back pain, neck pain, and other indications because their effectiveness for these indications has not been established.

A “set” of facet joint injections refers to up to six injections per sitting. This can usually be repeated once in order to establish the diagnosis. Additional sets of facet injections or medial branch blocks are considered experimental because they have no proven value. Many payers (such as Aetna) also consider ultrasound guidance of facet injections experimental and investigational.

Bottom line: Verify the associated diagnosis. If you’re reporting a diagnosis that the payer approves for facet joint injections, file an appeal. Otherwise, notify the patient prior to the procedure that insurance won’t reimburse for the injections so the patient is expected to cover the cost. Have the patient sign a waiver verifying his responsibility.