Ensure Proper Payment for Epidural Injections

Medicare Part B physician payments for transforaminal epidural injection services increased from $57 million in 2003 to $141 million in 2007, according to a recent review conducted by the Office of Inspector General (OIG). That amounts to a 150 percent increase.

A gain in popularity of this magnitude prompted the OIG to conduct a review of this pain management service. In the review, the OIG states that roughly 34 percent of 433 sampled claims for transforaminal epidural injection services performed in 2007 did not meet Medicare requirements. The OIG estimates approximately $43 million in improper payments.

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Physicians should prepare themselves for added contractor scrutiny of these types of pain management claims.

Transforaminal epidural injections are a type of interventional pain management technique used to diagnose or treat pain. There are two primary codes used to bill a single injection in the cervical/thoracic or lumbar/sacral area of the spine, and each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. These codes are:

  64479 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level
+64480 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
  64483 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
+64484 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Physician payments vary based on the place of service (office vs. ambulatory surgical center (ASC) or outpatient department) and also the modifiers billed. For example, bilateral transforaminal epidural injections, which are performed on both the right and left side of a vertabrel level should be billed using modifier 50. The use of this modifier would increase payment to 150 percent of the base rate.

According to the OIG, “The reviewer found primarily that physicians improperly used add-on codes and bilateral modifiers.”

Medicare covers transforaminal epidural injections that are reasonable and necessary, which are those used in the diagnosis or treatment of illness or to improve the functioning of a malformed body part. To ensure payment, physicians must:

  • Properly document medical care to support the service; and
  • use uniform procedure codes to report all services.

Documentation should include a description of the service provided, with details such as location and frequency of injections, as well as outcomes that support subsequent injections. Diagnosis codes also must support medical necessity. Most contractors with local coverage determinations (LCDs) in place for transforaminal epidural injections also require the use of radiographic guidance (such as live X-rays), prohibit multiple pain management services on the same day, and limit frequency.

In response, the Centers for Medicare & Medicaid Services (CMS) says it intends to strengthen program safeguards, which may include medical reviews and system edits.

Read the OIG’s August review for complete details.

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