Wiki Identifying the correct number of levels to report for Lumbar Intraarticular Facet Joint Injection

[tatumroe]

We often get a denial for a third level for medical necessity and I would like to know if someone can help me to identify the number of levels to report for. In reading the report below it looks as though the provider injected three levels but Medicare denies it for medical necessity. Is the third level supported and we should appeal each time or is there only two levels supported and why or does it have to do with the diagnosis? Any guidance on this is appreciated.

Assessment:

Assessment: 1. Lumbar spondylosis - M47.816 (Primary)

Plan:

	Procedures: Procedure: Lumbar Intraarticular Facet Joint Injection ***Location: Right L3-4, L4-5, L5-S1 Anesthesia: Local - PRE-OPERATIVE DIAGNOSIS: Lumbar spondylosis POST OPERATIVE DIAGNOSIS: SAME AS ABOVE - Indication: The patient is scheduled for lumbar intraarticular facet joint injection(s). The patient has a history of low back pain which has been decreasing the patient's function and quality of life. The patient has failed, or has contraindication to, a combination of conservative treatment modalities (physical therapy/chiropractic treatments/home exercise program, medication management [NSAIDs, tylenol, topical gels/creams], rest, activity modification, ice/heat, stretching). - PROCEDURE IN DETAIL: Risks and benefits: Prior to the procedure, the risks, benefits, and alternatives of treatment were fully explained to the patient, and signed and verbal consent was obtained prior to the procedure. These risks are rare and include, but not limited to, dural puncture and associated headache, epidural abscess or hematoma, adverse reactions to the local anesthetic (circumoral/tongue numbness, metallic taste in mouth, visual or auditory disturbances, nausea, dizziness, hallucinations, muscle twitching/tremors, drowsiness, unconsciousness, seizures, coma, respiratory arrest, cardiovascular depression, angina, bradycardia, arrhythmias), bleeding, scar formation, infection, nerve damage, lack of improvement or worsening of symptoms, allergic reaction and possibly death. An opportunity for questions and answers was provided for the patient, and all questions were answered to the satisfaction of the patient. The patient fully understands the risks, acknowledged understanding of the above verbally and signed consent form, and is willing to proceed with the procedure with the above in consideration. - Patient preparation: The patient was assisted onto the fluoroscopy table and placed in the prone position using a pillow under the abdomen/iliac crests for positioning and comfort. The skin overlying the lumbar and sacral region was then prepped broadly and thoroughly using ChloraPrep stick and draped in the usual sterile fashion. The injectionist was wearing a mask and hair/head covering prior to entering the procedure room, and sterile gloves were worn at all times during the procedure. All vials of medication were sterilized with alcohol swabs prior to drawing up medications and allowed to dry. Appropriate pre-procedure protocol was performed, including time out, which included verifying correct patient, correct procedure, any applicable lateralization, and allergies. - Procedure: Under intermittent AP fluoroscopic guidance, the C-arm fluoroscope was adjusted caudad/cephalad and obliqued accordingly until the target facet joints were clearly identified. A 27 gauge 1.5 inch needle was used to raise a local skin wheal with 0.5% lidocaine placed coaxial to the fluoroscopic beam. Then, a 25 gauge 3.5 inch spinal needle was inserted and directed toward the SAP of the lower level of the joint (ex. L4 SAP in L3-4 facet joint), for each level listed above. After needles contacted bone (the SAP) and confirmed to be in proper position under fluoroscopy, the needle was turned slightly medially and slipped into the target facet joint while making sure the needle does not go medial to the inferior articular process of the facet joint. Then, 0.25 ml of Omnipaque contrast was injected into each facet joint which showed appropriate flow into the facet joint. After contrast confirmed needle placement within the facet joint, 1ml mixture of the injectate listed below was injected at each facet joint. This process was repeated for each targeted facet joint listed above. The needles were withdrawn, and injection sites were covered with sterile dressings using digital pressure to control and stop any bleeding. Band-aids were placed over the injection sites once bleeding was stopped. The patient was assisted off the examination table and taken to the recovery room. - FLUOROSCOPY: Fluoroscopy was used for guidance of needle insertion to the target points as well as confirming the needle tip position and depth. All views and images were read by me and no radiologist was present at any time during the procedure. - Discharge Criteria: Vital signs stable, bleeding absent, ambulates with pre-procedure gait, level of consciousness consistent with pre-procedure status, no paresthesias, no increase in pain, no new symptoms post procedure, patient verbalizes understanding of treatment plan. - Post-procedure: The patient tolerated the procedure well with no complications or new neurological signs/symptoms after the injection. Physical activity as tolerated, however, the patient was advised to avoid strenuous activity for at least three days after the procedure. The patient was, again, reminded and educated about possible side effects from the procedure as detailed above. The patient was monitored for at least 20 minutes after the procedure prior to discharge. The patient was advised to call the office immediately or go to the Emergency Department immediately if experiencing any new weakness, numbness, or unresolving/increase in pain. The patient will follow up in the office in 2-3 weeks for evaluation and continued treatment or as needed. - Disposition: The patient was discharged home in stable, pre-procedure condition - Injectate: 0.75ml of 2% Lidocaine, 0.25ml of Dexamethasone 10mg/ml.

	Therapeutic Injections: Lidocaine HCl 0.5% : 8 mL (Dose No:1) given by Mohammad Abbas Sodium Bicarbonate 8.4% : 1 mL (Dose No:1) given by Mohammad Abbas OMNIPAQUE 300mg/ml : 3 mL (Dose No:1) given by Mohammad Abbas Betamethasone Sodium Phosphate/Betamethasone Acetate 3mg : 6 mg (Dose No:1) given by Mohammad Abbas

Procedure Codes: 64493 INJ PARAVERT F JNT L/S 1 LEV, Modifiers: RT , 64494 INJ PARAVERT F JNT L/S 2 LEV, Modifiers: RT , 64495 INJ PARAVERT F JNT L/S 3 LEV, Modifiers: RT , J3490 Sodium Bicarbonate 8.4 %, Q9967 LOCM 300-399MG/ML IODINE,1ML, Units: 3.00 , J0702 INJ BETAMETHSN ACTAT&SOD PHOSPH-3MG, Units: 2.00

 

[thomas7331]

Your coding looks correct to me as far as the number of levels. Since the diagnosis is the same for all levels, I don't think that the diagnosis code is the issue. But you may want to review your local MAC's LCD for this service - most of the plans have a limitation on the number of injections that they will cover at a specific session as well as the number that will cover in a given 12-month period. If your provider has exceeded the number for this patient, that could be the reason for the denial.

 

[iowagirl77]

We often get a denial for a third level for medical necessity and I would like to know if someone can help me to identify the number of levels to report for. In reading the report below it looks as though the provider injected three levels but Medicare denies it for medical necessity. Is the third level supported and we should appeal each time or is there only two levels supported and why or does it have to do with the diagnosis? Any guidance on this is appreciated.

Assessment:

Assessment: 1. Lumbar spondylosis - M47.816 (Primary)

Plan:

	Procedures: Procedure: Lumbar Intraarticular Facet Joint Injection ***Location: Right L3-4, L4-5, L5-S1 Anesthesia: Local - PRE-OPERATIVE DIAGNOSIS: Lumbar spondylosis POST OPERATIVE DIAGNOSIS: SAME AS ABOVE - Indication: The patient is scheduled for lumbar intraarticular facet joint injection(s). The patient has a history of low back pain which has been decreasing the patient's function and quality of life. The patient has failed, or has contraindication to, a combination of conservative treatment modalities (physical therapy/chiropractic treatments/home exercise program, medication management [NSAIDs, tylenol, topical gels/creams], rest, activity modification, ice/heat, stretching). - PROCEDURE IN DETAIL: Risks and benefits: Prior to the procedure, the risks, benefits, and alternatives of treatment were fully explained to the patient, and signed and verbal consent was obtained prior to the procedure. These risks are rare and include, but not limited to, dural puncture and associated headache, epidural abscess or hematoma, adverse reactions to the local anesthetic (circumoral/tongue numbness, metallic taste in mouth, visual or auditory disturbances, nausea, dizziness, hallucinations, muscle twitching/tremors, drowsiness, unconsciousness, seizures, coma, respiratory arrest, cardiovascular depression, angina, bradycardia, arrhythmias), bleeding, scar formation, infection, nerve damage, lack of improvement or worsening of symptoms, allergic reaction and possibly death. An opportunity for questions and answers was provided for the patient, and all questions were answered to the satisfaction of the patient. The patient fully understands the risks, acknowledged understanding of the above verbally and signed consent form, and is willing to proceed with the procedure with the above in consideration. - Patient preparation: The patient was assisted onto the fluoroscopy table and placed in the prone position using a pillow under the abdomen/iliac crests for positioning and comfort. The skin overlying the lumbar and sacral region was then prepped broadly and thoroughly using ChloraPrep stick and draped in the usual sterile fashion. The injectionist was wearing a mask and hair/head covering prior to entering the procedure room, and sterile gloves were worn at all times during the procedure. All vials of medication were sterilized with alcohol swabs prior to drawing up medications and allowed to dry. Appropriate pre-procedure protocol was performed, including time out, which included verifying correct patient, correct procedure, any applicable lateralization, and allergies. - Procedure: Under intermittent AP fluoroscopic guidance, the C-arm fluoroscope was adjusted caudad/cephalad and obliqued accordingly until the target facet joints were clearly identified. A 27 gauge 1.5 inch needle was used to raise a local skin wheal with 0.5% lidocaine placed coaxial to the fluoroscopic beam. Then, a 25 gauge 3.5 inch spinal needle was inserted and directed toward the SAP of the lower level of the joint (ex. L4 SAP in L3-4 facet joint), for each level listed above. After needles contacted bone (the SAP) and confirmed to be in proper position under fluoroscopy, the needle was turned slightly medially and slipped into the target facet joint while making sure the needle does not go medial to the inferior articular process of the facet joint. Then, 0.25 ml of Omnipaque contrast was injected into each facet joint which showed appropriate flow into the facet joint. After contrast confirmed needle placement within the facet joint, 1ml mixture of the injectate listed below was injected at each facet joint. This process was repeated for each targeted facet joint listed above. The needles were withdrawn, and injection sites were covered with sterile dressings using digital pressure to control and stop any bleeding. Band-aids were placed over the injection sites once bleeding was stopped. The patient was assisted off the examination table and taken to the recovery room. - FLUOROSCOPY: Fluoroscopy was used for guidance of needle insertion to the target points as well as confirming the needle tip position and depth. All views and images were read by me and no radiologist was present at any time during the procedure. - Discharge Criteria: Vital signs stable, bleeding absent, ambulates with pre-procedure gait, level of consciousness consistent with pre-procedure status, no paresthesias, no increase in pain, no new symptoms post procedure, patient verbalizes understanding of treatment plan. - Post-procedure: The patient tolerated the procedure well with no complications or new neurological signs/symptoms after the injection. Physical activity as tolerated, however, the patient was advised to avoid strenuous activity for at least three days after the procedure. The patient was, again, reminded and educated about possible side effects from the procedure as detailed above. The patient was monitored for at least 20 minutes after the procedure prior to discharge. The patient was advised to call the office immediately or go to the Emergency Department immediately if experiencing any new weakness, numbness, or unresolving/increase in pain. The patient will follow up in the office in 2-3 weeks for evaluation and continued treatment or as needed. - Disposition: The patient was discharged home in stable, pre-procedure condition - Injectate: 0.75ml of 2% Lidocaine, 0.25ml of Dexamethasone 10mg/ml.

	Therapeutic Injections: Lidocaine HCl 0.5% : 8 mL (Dose No:1) given by Mohammad Abbas Sodium Bicarbonate 8.4% : 1 mL (Dose No:1) given by Mohammad Abbas OMNIPAQUE 300mg/ml : 3 mL (Dose No:1) given by Mohammad Abbas Betamethasone Sodium Phosphate/Betamethasone Acetate 3mg : 6 mg (Dose No:1) given by Mohammad Abbas

Procedure Codes: 64493 INJ PARAVERT F JNT L/S 1 LEV, Modifiers: RT , 64494 INJ PARAVERT F JNT L/S 2 LEV, Modifiers: RT , 64495 INJ PARAVERT F JNT L/S 3 LEV, Modifiers: RT , J3490 Sodium Bicarbonate 8.4 %, Q9967 LOCM 300-399MG/ML IODINE,1ML, Units: 3.00 , J0702 INJ BETAMETHSN ACTAT&SOD PHOSPH-3MG, Units: 2.00

I agree with Thomas- it does appear to be coded correctly. My MAC states '64492 and 64495 are only allowed on appeals basis.' So basically anytime the 3rd level is billed, it will need to be appealed with documentation. I suppose that will help catch providers that are not documenting/billing the number of levels correctly, but yours appears to be correct.

 

[cgipson]

Try M47.817 when injecting to Lumbar and Sacral like the example. They will always deny third level no matter what your dx is. You just have to present the documentation upon appeal. I am in Iowa, we do outpatient hospital POS. Our MAC reads that third levels on UNILATERAL procedures are never medically necessary, only BILATERAL with supporting evidence. Make sure your provider clearly documents the 4 required points and the reason as to why the third level is needed. "One to 2 levels, either unilateral or bilateral, are allowed per session per spine region. The need for a 3 or 4-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. "

I would have them add the pre and post procedure pain scale. This should be noted every time along with when the provider orders a new injection.

"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 measured 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.

*Pain assessment must be performed and documented at baseline, after each diagnostic procedure and at each follow-up using the same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment)."

They also need to state if it is diagnostic or therapeutic. If therapeutic, they need to mention all of the following:

1. "Therapeutic Facet Joint Procedures (IA or MBB):
   Therapeutic facet joint procedures is considered medically reasonable and necessary for patients who meet ALLthe following criteria:
   1. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used); AND
   2. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale; AND
   3. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device)
   4. Frequency Limitations: For each covered spinal region no more than four (4) therapeutic facet joint (IA) sessions will be reimbursed per rolling 12 months."

The note mentions it is intraarticular. They would need to state why MBB was not performed instead:

1. "Intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly documented in the medical record and made available upon request."

If diagnostic they need to mention the following:

1. "Diagnostic Facet Joint Procedures (IA or MBB):
   The primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly documented in the medical record and made available upon request.
   Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) procedure would be considered the primary treatment goal at the diagnosed level(s).
   A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate an exception to the 2-week duration may be considered on an individual basis and must be clearly documented in the medical record.
   For the first diagnostic facet joint procedure:
   1. For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the patient must meet the criteria outlined under indications for facet joint interventions.
   2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet ALLthe following criteria:
      1. The patient meets the criteria for the first diagnostic procedure; AND
      2. After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used).
   3. Frequency limitation: For each covered spinal region, no more than four (4) diagnostic joint sessions will be reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure."

Of course, there are more to it like if the pt has had other injections in the spine in the last 12 months, etc. Look into KX modifier for those. We have had a ton of issues as well so we are working through it. LOTS of research!