Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections

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1 Policy Number FAC RP Ultrasound and Fluoroscopic Approved By UnitedHealthcare Medicare Committee Current Approval Date 06/25/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates. You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies use Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general resource regarding UnitedHealthcare s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee s benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations. UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT copyright 2010 (or such other date of publication of CPT) American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Table of Contents Application...2 Summary...2 Overview...2 Reimbursement Guidelines...2 Documentation Requirements...3 CPT/HCPCS Codes...3 Modifiers...4 References Included (but not limited to):...4 CMS LCD(s)...4 CMS Article(s)...4 CMS Claims Processing Manual...4 UnitedHealthcare Medicare Advantage Coverage Summaries...4 UnitedHealthcare Reimbursement Policies...4 UnitedHealthcare Medical Policies...5 MLN Matters...5 History...5 Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 1

2 Application Ultrasound and Fluoroscopic This reimbursement policy applies to services reported using the Health Insurance Claim Form CMS-1500 or its electronic equivalent or its successor form, and services reported using facility claim form CMS-1450 or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians, and other health care professionals. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing UnitedHealthcare. It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. Compliance with the provisions in this policy is subject to monitoring by pre-payment review and/or post-payment data analysis and subsequent medical review. The effective date of changes/additions/deletions to this policy is the committee meeting date unless otherwise indicated. CPT codes and descriptions are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS restrictions apply to Government use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Current Dental Terminology (CDT), including procedure codes, nomenclature, descriptors, and other data contained therein, is copyright by the American Dental Association, 2002, All rights reserved. CDT is a registered trademark of the American Dental Association. Applicable FARS/DFARS apply. Summary Overview Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior element biomechanical pain are: The pain does not have a strong radicular component. There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level. A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. For purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g.. C4-5 or L2-3). It is further noted that there are two (2) facet joints at each level, left and right. During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected. After the injection(s) have been performed, the patient is asked to indulge in the activities that usually aggravate his/her pain and to record his/her impressions of the effect of the procedure. Temporary or prolonged abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment may be prescribed in the future. Some patients will have long lasting relief with local anesthetic and steroid, others will require a denervation procedure for more permanent relief. Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first set of procedures fail to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495). Reimbursement Guidelines It is not expected that an epidural block, or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage will Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 2

3 be extended for only one type of procedure during one day/session of treatment unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management. Paravertebral blocks, facet joint injections, and medial branch blocks per Current Procedural Terminology (CPT ) should be performed utilizing direct visualization with fluoroscopy and documented. Blocks performed without the use of fluoroscopy are generally considered not medically necessary. Per CPT Imaging guidance (fluoroscopy CT) and any injection of contrast are inclusive components of A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and radiofrequency ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine. Diagnostic Injections Procedures performed during the diagnostic phase should be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region on any given date of service. A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the incidence of false positive responses due to placebo effect). Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure. Therapeutic Injections It is not expected that a patient would undergo a therapeutic block at more than three (3) levels (unilateral or bilateral) per anatomic region on any given date of service. It is not expected that patients would undergo repeat treatment at same anatomic region at less than 90- day intervals. It is also not expected that all patients will present with pain in both anatomical regions (cervicothoracic and lumbosacral), therefore the routine performance of facet joint/medial branch block (both diagnostic and therapeutic) to both regions may prompt a pre-payment review. Routinely exceeding the above parameters, by utilizing the procedure codes on the same beneficiary in unusual patterns may result in pre payment review. Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare. The medical record must clearly support both procedures. Documentation Requirements Assessment of the outcome of this procedure depends on the patient s responses, therefore documentation should include: Whether the block was a diagnostic or therapeutic injection Pre and postoperative evaluation of patient Patient education Subjective and objective responses from the patient regarding pain, including facet pain provocative maneuvers documented by pre and post operative measurement According to ASIPP guidelines, a positive response to the paravertebral facet joint block is noted when a greater than 50% relief of pain is obtained. CPT/HCPCS Codes Code Description 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 3

4 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or third and any additional level(s) (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) Modifiers Code Description RT Right side (used to identify procedures perform on the right side of the body) LT Left side (used to identify procedures performed on the left side of the body) 50 Bilateral Procedure References Included (but not limited to): CMS LCD(s) Numerous LCDs CMS Article(s) Numerous Articles CMS Claims Processing Manual Chapter 14, 20 List of Covered Ambulatory Surgical Center Procedures UnitedHealthcare Medicare Advantage Coverage Summaries Pain Management and Pain Rehabilitation UnitedHealthcare Reimbursement Policies Category III CPT Codes Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 4

5 UnitedHealthcare Medical Policies Epidural Steroid and Facet Injections for Spinal Pain MLN Matters Article SE1102, Inappropriate Medicare Payments for Transforaminal Epidural Injection Services History Date Revisions 08/06/2014 Administrative updates 06/25/2014 Annual Review for MRP Committee presentation and approval 02/13/2013 presented to MRP Committee and was approved 01/25/2013 Policy re-review 06/22/2011 Policy developed Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 5

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