New Medicare local coverage determinations (LCD) may hinder the ability to be paid for anesthesia services during Epidural Steroid Injections (ESI) for pain management. The LCDs for several Medicare Administrative Contractors (MACs), like WPS GHA’s L39054 for Indiana, went into effect in late 2021, and others are being rolled out in 2022. They replace and expand upon the retired LCDs for Lumbar Epidural Injections (like L36521 for WPS GHA).
The retired LCDs indicated among their requirements that “local anesthesia or minimal conscious sedation may be appropriate” and the “use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary.” However, the new LCDs do not include that language, and instead, say among the limitations that
The use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.
The Centers for Medicare and Medicaid Services (CMS) received several comments about these changes, particularly related to concerns over the increased risk of movement during the procedure, the low prevalence of nerve damage during the procedures, and from a patient, the limited access to anesthesia that is essential for her care. Still others felt that the limitation may increase narcotic use.
CMS responded with the following:
To reduce the risk of direct nerve trauma or spinal cord injury, current guidelines (referenced in LCD) recommend avoidance of deeper levels of sedation so the patient can alert the provider to any paresthesia during the procedure. The evidence of safety of ESIs without anesthesia is robust including the obstetrical population.
There is not a set criterion established in the literature or through societal guidelines to determine patient’s that may require General Anesthesia, Moderate or Deep Sedation and Monitored Anesthesia Care (MAC). A provider cannot predict certain adverse reactions such as a vagal reaction which can be related to almost any procedure including routine blood draw or shots which would not necessitate anesthesia. It would be unlikely for a patient without an underlying seizure disorder to have a seizure induced by anxiety/pain. There is no supporting data that movement increases risk for ESIs and even sedated patients are at risk for movement.
The policy does not limit access to care in patients who meet the evidence-based criteria for ESIs and the level of anesthesia discussed are not a requirement to perform the procedures safely. Based on the published societal guidance, the use of anesthetic may increase the risk associated with the procedures in addition to subjecting the patient to the inherent risk of anesthesia.
While CMS has not yet elaborated on what exceptional and unique circumstances might apply here, physicians who believe Moderate or Deep Sedation, General Anesthesia, or Monitored Anesthesia Care (MAC) is warranted for a specific patient should thoroughly document the medical necessity. Anesthesiologists should also discuss with the patient and have them sign an Advance Beneficiary Notice (ABN). ABNs are issued to Medicare beneficiaries in situations where Medicare payment is expected to be denied. Current ABN forms are available for download at the Medicare website.
According to a billing and coding article about the new LCDs, the following codes should be used for ESIs:
- An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).
- A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.
Also, when determining when/if to perform and/or code bilateral procedures, the following parameters apply:
- When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.
- For services performed in the ASC, modifier -50 should not be utilized. Report the applicable procedure code on two separate lines, with one unit of service each and append the -RT and -LT modifiers to each line.
- It is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.
The LCD also limits the number of times the procedures can be billed using these guidelines:
- Only one spinal region may be treated per session (date of service).
- Only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (Two unilateral or two bilateral levels). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 64483.
- CPT codes 62321 and 62323 may only be reported for one level per session.
- No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per spinal region in a rolling 12-month period regardless of the number of levels involved.
Finally, the LCD acknowledges that the diagnostic selective nerve root block (DSNRB) is coded identically to an Epidural Injection. For that reason, a -KX modifier should be appended to the appropriate line when coding DSNRB to distinguish it from an epidural injection.
Providers also must follow certain documentation guidelines based on the new LCD. In addition to standard best practices, like writing legibly and maintaining all documentation within the patient’s medical record, CMS also requires that
- The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.
- Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.
Also, as mentioned above, if the physician believes the patient’s condition warrants the use of Moderate or Deep Sedation, General Anesthesia, or Monitored Anesthesia Care (MAC), the documentation should clearly establish the need for such sedation in the specific patient.
Back in December 2021, WPS GHA was tasked by CMS to conduct a TPE review of potential aberrancies related to CPT 62323 in accordance with LCD L39054. They specifically noted the following documentation guidance necessary for a successful review of spinal injections:
- History and Physical
- Physician progress notes
- Physician orders
- Documentation to support four weeks of non-surgical, non-injection care counting from onset of pain
- Documentation to support an exception to the four weeks of non-surgical, non-injection care
- Procedure report and records including the amount of medication injected
- Prior procedure reports supporting the appropriate frequency of injections, if applicable
- Radiology imaging reports
- Signature attestation record, if applicable
- Advanced Beneficiary Notice of Noncoverage (ABN), if applicable
- Any additional records to support the medical necessity of the service billed
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