01-087 OIG Facet Joint Denervation Findings of Medical Review
Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC), for the Centers for Medicare and Medicaid Services (CMS), has conducted a post-payment claim review for Medicare Part B billed on dates of service from September 1, 2020, through April 24, 2021. Below are the review results:
| Project ID | Project Title | Error Rate for Reviewed Claims | No Response to ADR Denials |
|---|---|---|---|
| 01-087 | OIG Facet Joint Denervation | 73% | 30% |
Background
In December 2021, the Office of Inspector General (OIG) published a report (A-09-21-03002), titled Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions. Medicare Part B provides coverage for the cost of facet joint denervation sessions when they are medically reasonable and necessary. The report looked at two coverage limitations developed by the Medicare Administrative Contractors (MACs), namely, annual limitations on the number of sessions and limitations on the number of joints per denervation session. The OIG noted these coverage limitations do not apply to facet joint denervation sessions related to the sacral spine. The OIG findings also noted Medicare improperly paid physicians $9.5 million for facet joint denervation services.
Reason for Review
As a result of the OIG report, the SMRC was tasked with performing claim review on a sample of Medicare Part B spinal facet joint denervation claims, with dates of service (DOS) September 1, 2020, through April 24, 2021, following the audit period that exceeded MAC coverage session limitations. The SMRC performed medical record review on supporting documentation, to determine if services were medically necessary. The SMRC conducted medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, and sub-regulatory guidance.
Common Reasons for Denial
- Requested Records Not Received: Refer to 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), Social Security Act 1833(e). No medical record documentation was received. The documentation was not submitted or not submitted timely, to support the claim as requested by the additional documentation request (ADR).
- Reasonable and Necessary Criteria: Refer to Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A), Title XVIII, Section 1833 (e) of the Act; and the Medicare Administrative Contractor (MAC) Local Coverage Determination (LCD) and/or Local Coverage Article (LCA) if applicable. The documentation contained a limitation or contraindication that is not considered reasonable and necessary. The submitted documentation exceeded the annual limitations on the number of sessions and limitations on the number of joints per denervation session.
- Incomplete and/or Insufficient Information: Refer to 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), Social Security Act 1833(e). The documentation submitted was incomplete or insufficient information. The submitted documentation did not include a required post-procedure pain assessment needed for medical review.
References
Social Security Act (SSA), Title XI
- § 1135 Authority to Waive Requirements During National Emergencies
Social Security Act (SSA), Title XVIII
- §§ 1812(a)(1), (b)(3) Scope of Benefits
- § 1814(a) Conditions of and limitations on payment of services
- § 1815(a) Payment to Providers of Services
- § 1833(e) Payment of Benefits
- § 1833(2)(E)(i) Payment of Benefits (Outpatient Hospital Radiological Services)
- § 1833(t)(B)(i) Payment of Benefits (Prospect Payment Service for Outpatient Part B Department Services)
- § 1834(m)(4)(F) Special Payment Rules for Particular Items and Services
- § 1835(a)(2) Procedure for payment of claims of providers of services
- § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
- § 1862(a)(7) Excludes Routine Physicals
- § 1869(f)(1)(B) Determinations; Appeals
- § 1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
- § 1893(b) Medicare Integrity Program
42 Code of Federal Regulations (CFR)
- § 400.200 General Definitions
- § 405.904 Determinations, Redeterminations, Reconsiderations, and Appeals under Original Medicare (Part A and Part B)
- § 410.134 Provider Qualifications
- § 411.15 Exclusions from Medicare and Limitations on Medicare Payment
- § 411.15(k)(l) Particular Services Excluded from Coverage
- § 414.40 Coding and Ancillary Polices – AMA HCPCS Professional Coding Guidelines
- § 419.22 Hospital Services Excluded from Payment
- § 424.5 (a)(6) Basic Conditions of the Medicare Payment; Sufficient Information
Federal Register
- Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
- Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC
- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). Telehealth Services During Certain Emergency Periods PUBL123.PS (congress.gov)
- Interim Final Rule with Comments (IFC), 5531. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Effective March 1, 2020. Retrieved from CMS-55341-IFC
Internet Only Manual (IOM), Medicare National Coverage Determinations Manual (NCD), Publication (Pub). 100-03
- Chapter (Ch.) 1, Part 4, § 220.1. Computed Tomography (CT)
IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02
- Ch. 15, § 30 Physician Services
- Ch. 15, § 50 Drugs and Biologicals
- Ch. 16, § 20 Services Not Reasonable and Necessary
IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 1, General Billing Requirements
- Ch. 4, § 20.4 Reporting of Service Units
- Ch. 4, § 20.6 Use of Modifiers
- Ch. 7, § 50 Billing Part B Radiology Services and Other Diagnostic Procedures
- Ch. 12, § 20.3 Bundled Services/ Supplies
- Ch. 12, § 30 Correct Coding Policy
- Ch. 12, § 40.7 Claims for Bilateral Surgeries
- Ch. 12, § 70 Payment conditions for Radiology Services
- Ch.12, § 190 Medicare Payment for Telehealth Services
- Ch. 13, § 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures
- Ch. 13, § 20 Payment Conditions for Radiology Services
- Ch. 13, § 30 Computerized Axial Tomography (CT) Procedures
- Ch. 23, Fee Schedule Administration and Coding Requirements
- Ch. 23, § 20 Description of Healthcare Common Procedure Coding System (HCPCS)
- Ch. 30, § 50 Advance Beneficiary Notice of Non-coverage (ABN)
IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3, Verifying Potential Errors and Taking Corrective Actions
- Ch. 3, § 3.2.3.2 Time Frames for Submission
- Ch. 3, §3.2.3.4 Additional Documentation Request Required and Optional Elements
- Ch. 3, § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
- Ch. 3, §3.3.2.1 Documents on which to Base a Determination
- Ch. 3, § 3.3.2.4 Signature Requirements
- Ch. 3, § 3.4.1.3 Diagnosis Code Requirements
- Ch. 3, § 3.6.2.1 Coverage Determination
- Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria
- Ch. 3, § 3.6.2.3 Limitation of Liability Determinations
- Ch. 3, § 3.6.2.4 Coding Determinations
- Ch. 3, § 3.6.2.5 Denial Types
- Ch. 5, § 5.11 Evidence of Medical Necessity
- Ch. 13, § 13.5.1 General Requirements
- Ch. 13, § 13.5.4 Reasonable and Necessary Provision in an LCD
CMS Coding Policies
- National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. §§ Effective January 1, 2020, and January 1, 2021
Local Coverage Determinations (LCDs)
- L33930 Facet Joint Interventions for Pain Management
- L34832 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
- L34892 Facet Joint Interventions for Pain Management
- L35936 Facet Joint Interventions for Pain Management
- L35996 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
- L36471 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Local Coverage Articles (LCAs)
- A55906 Paravertebral Facet Joint Blocks-Revision to the Part B LCD
- A56463 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
- A56670 Billing and Coding: Facet Joint Interventions for Pain Management
- A56687 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
- A57553 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
- A57787 Billing and Coding: Facet Joint Interventions for Pain Management
- A57826 Billing and Coding: Facet Joint Interventions for Pain Management
- A58105 Paravertebral Facet Joint Blocks-Revision to the Part B LCD
Other
- CMS. Non-Emergent, Elective Medical Services, and Treatment Recommendations. April 7, 2020. Non-Emergent, Elective Medical Services, and Treatment Recommendations (cms.gov)
- Office of Inspector General (OIG). Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation. December 3, 2021. Retrieved from Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions A-09-21-03002 12-03-2021 (hhs.gov)
Last Updated Mar 22, 2024