Wiki Anyone ever bill for pain management?

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kellit21

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We are getting denials on our 3rd level MBB or Facet injections stating not medically necessary. Are any of you getting this? Any insight on why they would pay for the 1st 2 levels but not the 3rd?
cpt is 64495 and 64492
 
Hi there, Medicare administrative contractors recently implemented a uniform policy that auto-denies 3rd level blocks, but you can appeal. Private payers may have followed suit or adopted a similar policy. This is from an article about the update, quoted with permission:

Third level blocks not covered

Be prepared to appeal a denial if you report a third-level paravertebral facet joint nerve block. “Codes 64492 and 64495 will only be covered upon appeal if sufficient documentation of medical necessity is present,” the articles state. However, the codes have been added to a new list of non-covered codes, including paravertebral facet joint blocks performed with ultrasound. This indicates all MACs have updated their claims processing systems to block the claims as they come in.
Click to expand...
 
For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.
The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. LCD A57787 . Also, the diagnoses list has changed to determine medical necessity , M54.5 nor M54.2 are acceptable DX codes for these injections . M47.812 -M47.817 or M47.892 - M47.897 as well as some additional codes. M48.12 -M48.17 M71.30 & M71.38 CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months, CPT code 64490 through 64494 with the KX modifier will be limited to no more than four (4) sessions, per region,
per rolling 12 months.
 
kellit21 said:
We are getting denials on our 3rd level MBB or Facet injections stating not medically necessary. Are any of you getting this? Any insight on why they would pay for the 1st 2 levels but not the 3rd?
cpt is 64495 and 64492
Click to expand...
Can you share what MAC you are receiving denials from since LCDs may be different depending on the MAC?
 
In GA we get these same denials. Third level injections will be denied. Palmetto Article A58350 states, "64492 and 64495 will only be covered upon appeal if sufficient documentation of medical necessity is present". So far, we have had a few claims they paid on appeal.
 
rperrie said:
Can you share what MAC you are receiving denials from since LCDs may be different depending on the MAC?
Click to expand...
The MACs issued a uniform LCD earlier this year. Therapeutic and third level blocks will require an appeal.
 
Hi, in GA, we are receiving denials for 3rd level MNBB. The CMS letter we have received states: "Explanation of the Decision: Facet joint interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria:
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measures on pain or disability scale*
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture. tumor, infection, or significant deformity.

If you provide documentation to support the above stipulations, then you should receive payment on 3rd level. I have submitted 3 appeals to Medicare on this issue and I am awaiting to see the results.
 

Attachments

  • CMS 3rd level.pdf
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DGgirll20 said:
For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.
The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. LCD A57787 . Also, the diagnoses list has changed to determine medical necessity , M54.5 nor M54.2 are acceptable DX codes for these injections . M47.812 -M47.817 or M47.892 - M47.897 as well as some additional codes. M48.12 -M48.17 M71.30 & M71.38 CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months, CPT code 64490 through 64494 with the KX modifier will be limited to no more than four (4) sessions, per region,
per rolling 12 months.
Click to expand...
Hi, I am having an issuse with the dx code. DX Code M47.816 is denying for CPT 64495. Do you know which codes are acceptable?
 
Jess23009 said:
Hi, I am having an issuse with the dx code. DX Code M47.816 is denying for CPT 64495. Do you know which codes are acceptable?
Click to expand...
M47.816 does provide medical necessity for 64495. However, CMS is auto-denying 64495 and 64492 until appeal is received with documentation to prove
ALL the following criteria:
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measures on pain or disability scale*
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture. tumor, infection, or significant deformity.
 
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