Watch How You Code for Facet Joint Injections
In 2006, the Centers for Medicare & Medicaid Services (CMS) allowed approximately $96 million in improper payments for facet joint injections services and an additional $33 million in improper payments for associated facility claims, according to an Office of Inspector General (OIG) September report. That’s a whopping 63 percent of facet joint injection services allowed by Medicare in 2006 that did not meet Medicare program requirements. This finding and the realization that Medicare Part B payments for facet joint injections have increased from $141 million in 2003 to $307 million in 2006—a 76 percent increase in the number of Medicare claims for facet joint injections—has prompted the OIG’s recommendation for CMS to take certain measures.
The OIG recommends CMS:
- Assist carriers in developing ways to scrutinize claims for facet joint injections;
- Strengthen program safeguards;
- Clarify billing instructions for bilateral services; and
- Take appropriate action regarding improper payments identified in the OIG’s sample.
How sure are you that your physician or facility’s policy for facet joint injections meets Medicare program requirements? To ensure compliancy, you should determine what policies and safeguards currently exist.
The National Correct Coding Initiative Policy Manual (NCCI manual) for Medicare Services and the Medicare Claims Processing Manual state that you should use modifiers to indicate when a service differs from CPT® definition. Up to two modifiers are allowed for each CPT® code on a claim. Use modifier 50 bilateral procedures to indicate bilateral facet joint injections performed on both the right and left sides of a level. This increases reimbursement to 150 percent of the base rate. If a physician performs multiple bilateral injections, attach modifier 50 to each facet joint injection code.
Primary codes 64470 Injection; Paravertebral facet joint or facet joint nerve; cervical/thoracic, single level and 64475 Injection; Paravertebral facet joint or facet joint nerve; lumbar/sacral, single level include pre-surgical and post surgical expenses related to the procedure. Use add-on codes to represent additional levels, not sides. Do not bill multiple lines of CPT® add-on codes +64472 Injection; Paravertebral facet joint or facet joint nerve; cervical/thoracic, each additional level and +64476 Injection; Paravertebral facet joint or facet joint nerve; lumbar/sacral, each additional level in addition to the primary code.
Aside from that, no national coverage determination exists, so look to your carrier’s local coverage determination (LCD) for further guidance regarding:
- Indications and limitations of coverage and medical necessity;
- Covered diagnosis codes;
- Documentation requirements; and
- Utilization guidelines.
In addition to proper coding, always submit the medical record with documentation of the services, describing the procedure. Procedure notes must include details, such as which levels and sides of the back were injected. Make sure the medical record contains a history or physical exam to show the treatment was medically indicated. Additionally, include imaging studies in the record to support the diagnosis and treatment.
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