Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B billed on dates of service from January 1, 2022, through December 31, 2023. Below are the review results:

Background

Nerve blocks are one-time injections delivered to temporarily interrupt the conduction of impulses in the peripheral nerves or nerve trunks and are used to alleviate pain. A local anesthetic solution is injected into the nerve structures acting on the sodium channels at the cellular level which prevents impulse propagation and excitation of the nerve, resulting in pain relief. According to Chapter 2 of the Medicare National Correct Coding Initiative (NCCI) policy, the nerve block may be administered during the preoperative phase, intraoperative phase, or post operatively.

Reason for Review

The SMRC was issued a Task Order 1 and Task Order 6 on May 20, 2024, to perform data analysis and medical review activities on nerve block injections, specific to diagnosis code G89.18. The SMRC performed medical record review on supporting documentation to determine if the nerve block injection was medically necessary and met coverage criteria by Medicare.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the Additional Documentation Request (ADR)
  • The requested records were not received. Code of Federal Regulations (CFR) Title 42, §§405.929 and 405.930, Social Security Act (SSA)1815(a), Social Security Act (SSA) 1833(e) and Social Security Act §1862(a)(1)(A). This requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request. The requested documentation was not submitted or not submitted timely to support reasonable and necessary criteria for the nerve block injection.
• Signed Physician Order or Intent to Order
  • Documentation submitted did not include a signed physician order or documentation to support intent to order. Code of Federal Regulations (CFR) Title 42, 410.32, Social Security Act (SSA) §1842(p)(4), Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3, §3.3.2.4, IOM, Pub 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, §80.6. A valid signed physician order or documentation to support intent to order was not submitted to support the nerve block injection. This was appended to claims when other denials were also applied.
• Services Not Rendered as Billed
  • The documentation submitted did not support the services were rendered as billed. Refer to Internet Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3, §3.6.2.5. In these instances, providers billed the incorrect procedure code for the nerve block injection performed.

References

Social Security Act (SSA) Title XI

• §1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA) Title XVIII

• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1861(s)(2)(A) or (B) Medical and Other Health Services
• §1861(t) Drugs and Biologicals
• §1862 (a)(1) (A) and (a)(7) Exclusions from Coverage and Medicare as Secondary Payer
• §1877(g) Limitation on Certain Physician Referrals
• §1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed

Code of Federal Regulations (CFR) Title 42

• §411.15 Exclusions from Medicare and Limitations on Medicare Payment
• §413.1 Subpart A, Introduction and General Rules
• §424.5 Basic Conditions

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

Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 15, §30 Physician Services
• Ch. 15, §50 Drugs and Biologicals
• Ch. 15, §60 Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service
• Ch. 16 General Exclusion from Coverage

Internet Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 1 General Billing Requirements
• Ch. 12, §40 Surgeons and Global Surgery
• Ch. 12, §50 Payment for Anesthesiology Services
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions
• Ch 13, §13.5.1 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. 2021, 2022, and 2023

Local Coverage Determination (LCDs)

• L36850 Peripheral Nerve Blocks
• L33933 Peripheral Nerve Blocks

Local Coverage Articles (LCAs)

• A57452 Billing and Coding: Peripheral Nerve Blocks
• A57788 Billing and Coding: Peripheral Nerve Blocks

Other

• American Medical Association (AMA), Current Procedural Terminology (CPT), CPT® (Current Procedural Terminology) | AMA
• American Academy of Professional Coders (AAPC), Medical Coding – Medical Billing – Medical Auditing – AAPC
• ASRA Pain Medicine, Regional Anesthesia Billing: Survival Anesthesia Versus Postoperative Analgesia. February 7, 2020. Regional Anesthesia Billing: Surgical Anesthesia Versus Postoperative Analgesia (asra.com)
• MLN907166 Global Surgery cms.gov
• MLN17837722 – Proper Use of Modifier 59, XE,XP,XS,XU (cms.gov)

Last Updated Sep 11, 2025