 | New Jersey Society of Interventional Pain PhysiciansAn Affiliate of the American Society of Interventional Pain Physicians |
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Dr. Woska being honored for his service to our society as the Executive Director for the past 5 years. We congratulate him for all the time and effort that he put forth and the excellent job that he did.
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Proposed Medicare National Coverage Determination for Epidural Steroid Injection
Effective 12/05/2021
The link to the policy is available here:
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38994&ver=7&bc=0
Covered Indications
1. Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following three (3) requirements are met:
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History, physical examination, and concordant radiological image-based diagnostic testing and supporting one of the following:
Cervical, Thoracic, or Lumbar radiculopathy, radicular pain and/or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis.
OR
Post-laminectomy syndrome
Acute herpes zoster associated pain
AND
Symptoms severe enough to impact quality of life or function. An objective pain scale or functional assessment must be performed prior and repeated following intervention to assess response.
AND
Pain duration of at least 4 weeks, and in the inability to tolerate noninvasive conservative care or failure to respond to 4 weeks of noninvasive conservative care.
*Acute herpes zoster pain refractory to conservative care, 4 week wait is not required
2. ESI must be performed under CT or fluoroscopy image guidance with contrast,unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered.
3. Transforaminal EPIDURAL steroid injections (TFESIs) involving a maximum of two (2) levels in one spinal region are considered medically reasonable and necessary. It is important to recognize that most conditions would not ordinarily require ESI at two (2) levels in one spinal region.
4. Caudal EPIDURAL steroid injections (CESIs) and interlaminar EPIDURAL steroid injections (ILESIs) involving a maximum of one level are considered medically reasonable and necessary.
5. It is medically reasonable and necessary to perform TFESIs bilaterally only when clinically indicated.
6. Repeat ESI when the first injection:
At least 50% sustained improvement and/or improvement in function.
If patient fails to respond, repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate, with rationale and medical necessity for second ESI documented in EMR.
7. An initial injection of contrast is required to confirm epidural placement unless the patient has a contraindication to contrast. The subsequent epidural steroid injections should include corticosteroids and may be combined with anesthetics or saline.
8. The ESIs should be performed in conjunction with conservative treatments.
9. Patients should be part of an active rehabilitation program, home exercise program or functional restoration program.
*Note: The scales used to measure of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.
Limitations
1. Injections performed without image guidance or by ultrasound are not considered reasonable and necessary except in cases of documented contraindication to contrast media (e.g., allergy, pregnancy)
2. ESIs performed with biologicals or other substances not FDA designated for this use is considered investigational and not medically reasonable and necessary
3. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, trigger point injections etc.) during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same session
4. 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.
5. ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, cervicogenic headaches are considered investigational and therefore are not considered medically reasonable and necessary.
6. ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.
7. It is not considered medically reasonable and necessary for more than one spinal region to be injected in the same session.
8. It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.
9. It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than one (1) level during the same session.
10. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally.
11. It is not medically reasonable and necessary to prescribe a predetermined series of ESIs.
12. Steroid dosing should be the lowest effective amount, it is recommended not to exceed 80mg of triamcinolone, 12 mg of betamethasone, 15 mg of dexamethasone per session.
13. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.Frequent continuation of epidural steroid injections over 12 months may trigger a focused medical review. Use beyond twelve months requires the following:
a. Pain is severe enough to cause a significant degree of functional disability or vocational disability.
b. ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline).
c. Rationale for the continuation of ESIs including but not limited to patient is high-risk surgical candidates, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months
d. The primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use.
14. ESIs should not be performed when contraindicated including but not limited to: suspected or active localized spinal infection, significant systemic infection, compressive lesions of the spinal cord, conus medullaris or cauda equina, suspicion or major risk factors for cancer.
Update on New Medicare Facet Rules
Dr. Steve Aydin created this informative presentation that was shared during the NJSIPP Annual Fall Meeting. We thank him for sharing his slides below.
URGENT - Medicare proposed reduction in sacral and knee RF reimbursement
This topic was discussed the NJSIPP meeting on Wednesday night. It is Urgent you respond - there are only 10 days left!!!
Medicare has proposed to significantly decrease the payment rates for both the physician and the facility setting for the new knee and SIJ radiofrequency ablation CPT codes that are effective January 1, 2020. These new codes will impact all RFA technologies, both cooled and conventional.
We encourage you to:
1. review the proposed rules and provide comments to Medicare. The deadline for comments is September 27, 2019. Links to the proposed rules and information on how to submit comments are noted at the end of this e-mail. It is very important that Medicare receives comments from as many stakeholders as possible before the Final Rules are released later this year.
2. connect with your societies who participated in the new CPT code development process to express your concerns and encourage them to comment on the proposed rules as well.
Here are some important key facts from the proposed rules:
KNEE RFA IMPACTS
- Physician Rule – The proposed physician RVU valuation for the new CPT code for RFA in the knee has significantly decreased from the current peripheral nerve ablation RVUs. Avanos believes the reduction in rate is not appropriate and will likely result in a decrease in usage of this non-opioid alternative to treating pain. Avanos plans to raise this issue in its comment letter.
- Physician & HOPD Rules – The new Knee RFA CPT code was developed to report 3 nerve ablations during a single procedure versus the current peripheral nerve ablation code where reporting is on a per ablated nerve basis.
- HOPD Rule – The hospital outpatient facility payment for the knee RFA procedure has significantly decreased. The new knee RFA CPT code was assigned to the Nerve “Injection” APC (Ambulatory Payment Classification) unlike the new SIJ procedure CPT code which was assigned to the Nerve “Procedure” APC. Avanos believes that the knee RFA procedure should be properly placed in the Nerve Procedure APC and intends to address this in its comment letter.
The following table provides a snapshot of the proposed changes in Medicare National average payment rates:
SIJ RFA IMPACTS
- Physician Rule – The proposed physician RVU valuation for the new code for SIJ RFA procedures has significantly decreased from the current peripheral nerve ablation RVUs. Avanos believes the reduction in rates is not appropriate and will likely result in a decrease in usage of this non-opioid alternative to treating pain. Avanos plans to raise this issue in its comment letter.
- Physician & HOPD Rules – The new SIJ RFA CPT code was developed to report 3 nerve ablations during a single procedure versus the current peripheral nerve ablation code where reporting is on a per ablated nerve basis.
- The following table provides a snapshot of the proposed changes in Medicare National average payment rates.
Submit your online comments related to CMS Proposed HOPD:
Submit electronic comments on this HOPD regulation to:
Click on - Regulations.gov – CMS-1717-P
or
https://www.regulations.gov/searchResults?rpp=25&po=0&s=CMS-1717-P&fp=true&ns=true
Follow the instructions under the “Comment Now” tab. Reference Rule CMS-1717-P.
Submit your online comments related to CMS Proposed Physician:
Submit electronic comments on this Physician regulation to:
Click on - Regulation.gov – CMS-1715-P
or
https://www.regulations.gov/searchResults?rpp=25&po=0&s=CMS-1715-P&fp=true&ns=true
Follow the instructions under the “Comment Now” tab. Reference Rule CMS-1715-P.
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