Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Facet Joint Injections billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

Facet joint injections are an interventional technique used to diagnose and/or treat back pain. The injections are administered to a very specific set of joints, placed into and around the facet joints. Facet joint injections have been a topic of interest for the Office of the Inspector General (OIG) in the past, and the OIG has found significant billing errors in this area. An OIG report published in October 2020 found that an audit completed on improper payments due to coverage limitations Medicare improperly paid out $748,555.

Reason for Review

The SMRC was tasked with performing a claim review on a sample of facet joint injection claims from January 1, 2019, through December 31, 2019. The SMRC conducted medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Insufficient Documentation
  • Incomplete/Insufficient information. Refer to Internet-Only Manual, Pub 100- 08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, Social Security Act 1833(e), 42 CFR 424.5(a)(6).
  • The documentation submitted was incomplete and/or insufficient. Refer to 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), Social Security Act 1833(e).
• Medical Necessity
  • The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to: Social Security Act 1862(a)(1)(A); Medicare Program Integrity Manual IOM 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2 & Chapter 3, Section 3.4.1.3.
  • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination. Refer to Social Security Act 1862, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2.
• Non-Response to the Documentation Request
  • No medical record documentation was received. Refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6) and Social Security Act Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A).
  • The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A).

References/Resources

Social Security Act (SSA) Title XVIII

• §§ 1812(1) (b) (3). Scope of Benefits.
• § 1814(a). Conditions of and Limitations on Payment for Services.
• § 1815(a). Payment to Providers of Services.
• § 1832. Scope of Benefits.
• § 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).
• § 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
• § 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1893(b). Medicare Integrity Program.

Code of Federal Regulations (CFR) Title 42

• § 405.904. Determinations, Redeterminations, Reconsiderations, and Appeals under Original Medicare (Part A and Part B).
• § 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.
• § 424.5 Basic Conditions
• § 424.5 (a)(6). Basic Conditions of the Medicare Payment; Sufficient Information.

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

• Chapter (Ch.) 6, § 20. Outpatient Hospital Services.
• Ch. 15, § 30.1. Provider-Based Physician Services.
• Ch.15, §§ 50-50.6. Drugs and Biologicals.
• Ch.16, § 20. Services Not Reasonable and Necessary.

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

• Ch. 4., § 20.4. Reporting of Service Units.
• Ch. 4., § 20.6. Use of Modifiers.
• Ch. 12, § 20.3. Bundled Services/Supplies.
• Ch. 12, § 30. Correct Coding Policy.
• Ch. 12, § 70. Payment conditions for Radiology 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. 30, § 40.3.6. Advance Beneficiary Notice of Non-coverage (ABN).
• Ch. 30, § 50.6.1. ABN Standards Proper Notice Documents.

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

• Ch. 3, § 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests.
• 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. Section 3.6.2.2. Reasonable and Necessary Criteria.
• Ch. 3, § 3.6.2.4. Coding Determinations and Denial Types.
• Ch. 3, § 3.6.2.5 Denial Types
• Ch. 3, § 3.6.2.5.A. Distinguishing Between Benefit Category, Statutory Exclusion and Reasonable and Necessary Denials.

Related Local Coverage Determination (LCDs)

• L33930. Facet Joint Interventions for Pain Management. Effective October 1, 2015
• L34832. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective October 1, 2015; Retired May 1, 2021
• L34892. Facet Joint Interventions for Pain Management. Effective October 1, 2015
• L35936. Facet Joint Interventions for Pain Management. Effective October 1, 2015
• L35996. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective October 1, 2015; Retired April 24, 2021
• L36471. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective February 15, 2016; Retired April 24, 2021

Related Local Policy Article (LCAs)

• A55906. Paravertebral Facet Joint Blocks – Revision to the Part B LCD. Effective March 1, 2018; Retired August 13, 2021
• A56463. Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective September 19, 2019; Retired May 1, 2021
• A56670. Billing and Coding: Facet Joint Interventions for Pain Management. Effective July 11, 2019
• A56687. Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective July 11, 2019; Retired April 24, 2021
• A57553. Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. Effective Date November 1, 2019; Retired April 24, 2021
• A57787. Billing and Coding: Facet Joint Interventions for Pain Management. Effective October 3, 2018
• A57826. Billing and Coding: Facet Joint Interventions for Pain Management. Effective December 5, 2019; Revision April 25, 2021
• A58105. Paravertebral Facet Joint Blocks – Revision to the Part B LCD. Effective January 8, 2019

Last Updated Oct 10, 2022