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Spinal Pain Management

Provider Qualifications

  • Medicare Program Integrity Manual states services will be considered medically reasonable and necessary only if performed by appropriately trained providers
  • Healthcare professionals who perform Spinal Pain Management procedures must be appropriately trained and/or credentialed by formal residency/fellowship program and/or are certified by either accredited and recognized organization or by accredited post-graduate training course professional training program
  • Non-physician providers, such as certified nurse anesthetist, with certain exceptions, may certify, order and establish the plan of care as authorized by State law

Documentation Requirements

Documentation to support Spinal Pain Management should include, but is not limited to:

  • Submitted medical record must support use of selected ICD-10-CM code(s). Submitted CPT/HCPCS code must describe service performed
  • For Epidural Steroid Injections:
    • Procedural report clearly documenting indications and medical necessity for blocks along with pre and post percent pain relief achieved immediately post-injection
    • Films that adequately document (minimum of 2 views) final needle position and contrast flow
  • For Spinal Cord Stimulation:
    • Evidence of successful trial
  • Patient's medical record should include, but is not limited to:
    • Assessment of patient by performing provider as it relates to the complaint for that visit
    • Relevant medical history
    • Results of pertinent tests/procedures
    • Signed and dated office visit record/operative report
    • Documentation to support medical necessity of the procedure

Epidural Steroid Injection (CPT codes 62323)

Require the following:

  • History, physical exam, and concordant radiological image-based diagnostic testing supporting one of the following:
    • Lumbar, cervical, or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis
    • Post-laminectomy Syndrome
    • Acute herpes zoster associated pain
  • Radiculopathy, radicular pain and/or neurogenic claudication severe enough to greatly impact quality of life or function. Objective pain scale or functional assessment must be performed at baseline (prior to interventions). The same scale must be repeated at each follow-up for assessment of response
  • Pain duration of at least 4 weeks, and inability to tolerate noninvasive conservative care or medical documentation of failure to respond to 4 weeks of noninvasive conservative care or acute herpes zoster refractory to conservative management a 4-week wait is not required
  • ESIs must be performed under CT or fluoroscopy image guidance with contrast
    • Unless documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered
  • Caudal epidural steroid injections (CESIs) and interlaminar epidural steroid injections (ILESIs) involving maximum of one level are considered medically reasonable and necessary
  • Repeat ESI when first injection directly and significantly provided improvement of condition being treated may be considered medically reasonable and necessary when medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using SAME scale* for at least 3 months
    • If patient fails to respond well to initial ESI, repeat ESI after 14 days can be performed, using different approach, level and/or medication if appropriate, with rationale and medical necessity for the second ESI documented in medical record
  • Initial injection of contrast required to confirm epidural placement, unless patient has contraindication to contrast
    • Subsequent epidural steroid injections should include corticosteroids and may be combined with anesthetics or saline
  • ESIs should be performed in conjunction with conservative treatments
  • Patients should be part of active rehabilitation program, home exercise program or functional restoration program

Facet Joint Intervention (CPT 64635 and 64636)

Facet Joint Interventions will be considered medically reasonable and necessary when the following requirements are met:

  • Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale
    • Pain assessment must be performed and documented at baseline, after each diagnostic procedure using same pain scale for each assessment. Disability scale must also be obtained at baseline for functional assessment (if patient qualifies for treatment)
  • Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
  • Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
  • There is no non-facet pathology per clinical assessment or radiology studies that could explain source of pain, including but not limited to fracture, tumor, infection, or significant deformity

Thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves will be considered medically reasonable and necessary when the following requirements are met:

  • After at least 2 medically reasonable and necessary diagnostic MBBs, with each one providing consistent minimum of 80% sustained relief of primary (index) pain (with duration of relief being consistent with agent used)
  • Repeat thermal facet joint RFA at same anatomic site is considered medically reasonable and necessary provided patient had minimum of consistent 50% improvement in pain for at least 6 months or at least 50% consistent improvement in ability to perform previously painful movements and ADLs as compared to baseline measurement using same scale
  • Frequency Limitation: For each covered spinal region no more than 2 radiofrequency sessions will be reimbursed per rolling 12 months

Spinal Cord Stimulation for Chronic Pain (CPT 63650 and 63685)

Spinal cord stimulation for chronic pain will be considered medically reasonable and necessary when the following requirements are met

  • Implantation of stimulator is used only as late resort (if not a last resort) for chronic intractable pain
  • Other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or judged to be unsuitable or contraindicated
  • Patients have undergone screening, evaluation, and diagnosis by multidisciplinary team prior to implantation
    • Screening must include psychological and physical evaluation
    • Including discussion of risks and benefits of this therapy
  • All facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow up of the patient
  • Demonstration of pain relief with temporarily implanted electrode must precede permanent implantation
    • Trial period of 1 month

Appropriate Signatures

  • Signature and credentials of person performing the service must meet CMS requirements
  • Amendments/corrections/delayed entries are properly identified

For more information regarding signature requirements, please view the following resources:

References

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