Check for Transforaminal Epidural Injection Errors

The Centers for Medicare & Medicaid Services (CMS) released an MLN Matters Special Edition article based on an August 2010 U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) report, “Inappropriate Medicare Payments For Transforaminal Epidural Injection Services.” The purpose of the Special Edition article is “to remind physicians of the importance of properly documenting the services for which they bill.”

The study found that in 2007:

  • 34 percent of transforaminal epidural injection services that Medicare allowed did not meet Medicare requirements.
  • 19 percent of transforaminal epidural injection services had a documentation error (10 percent were undocumented and 9 percent were insufficiently documented).
  • 13 percent of injection services had a medical necessity error and 8 percent had a coding error resulting in overpayments for miscoded services—primarily using add-on codes and bilateral modifiers improperly; and in some instances, performing less intensive procedures, but billing for transforaminal epidural injections.

These errors were found more often in offices than facilities.

To be sure you are properly claiming these procedures, CMS wants you to consider any local coverage determinations (LCDs) found in the CMS Medicare Coverage Database.

Of importance, for example, are LCD L30481 and LCD L27512 documentation requirements for transforaminal epidural and paravertebral facet joint injections. In particular, for  LCD L27512, you should code according to this guidance:

“The primary codes 64479, 64483, 64490 and 64493 are used for a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code, 64480, 64491, 64492 (cervical/thoracic) and 64484, 64494 and 64495 (lumbar/sacral) for use when injections are provided at multiple spinal levels. Unilateral injections are performed on one side of the joint level, while bilateral injections are performed on the right and left side of the joint level. The Centers for Medicare and Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing modifier 50.”

Remember: Modifier 50 was revised for 2011 to delete the term “operative” from its descriptor, and now simply reads “Bilateral procedure.”

LCD number 27512 also discusses the general documentation requirements. See MLN Matter SE1102 for the rest of transforaminal epidural and paravertebral facet joint injections requirements.

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