Interventional Pain Medicine: A Changing...

Session B3 September 18, 2010

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Interventional Pain Medicine:A Changing Battlefield

S. Scott Kramarich, MDAKA “-09”

Riverside Spine and Pain PhysiciansWith many thanks and much respect to

Dr. Lax Manchikanti

Overview- coding for IPM

n IPM: A changing battlefieldn Spine anatomy and ‘pain generators’n Common procedures in IPMn Explode the Code:

n Epidural Injectionsn Facet joint therapiesn OIG studies on payments for 2006/07

n Posers, payors and prognostications


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n Epidural Injectionsn Facet joint therapiesn OIG study on facet payments for 2006


IPM: a Changing Battlefield

n Underlying demand driving increased utilization, supply creating demand

n Evidence-based medicine and outcomes research: difficult to find!

n Proliferation of ‘pain doctors’n OIG studies on “inappropriate MC

payments” in 2006/2007


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Office of Inspector General

n Medicare payments for interventional services in 2007 were $2B

US Healthcare: expensive & wasteful (all payors)

n $200B ?/year on frauds, scams, kickbacks

n $150B /year on inefficient admin & paper

n $100B / year on “mistakes” – wrong pmts

n $???B / year on “defensive medicine”n $30B /year for us to interact with

payors


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CBS News special: 9/3/10

n Medicare fraud is more predominant than drug dealing

n Medical supply companies bill $500K/mo

n Health care fraud ‘industry’ is easier, more profitable and less risky than drug trade!

n Est $430B / year in paid MC claimsn Fed regulators and investigators cite

“lack of personnel”

Utilization of IPM codes

IPM specialists (-09) use of IPM codes increased by about 17% annually 02-06

n GPs + 87% annually! (mostly due to facets)

n Between 1994 and 2001n LESI’s tripled at 271% increasen 231% increase in facet joint injections


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Empire Medical Training!

IPM services

n In 2006, more than 4.6 Million IPM services were provided

n These are growing at an annual rate of over 20%

n General Practice, Family Practice and Internal Medicine represent the fastest growing performers of lumbar epidural and facet joint injections!


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IPM: Tactical maneuvers

n It is increasingly important that legitimate providers of interventional services:n Obtain and maintain subspecialty training

& certifications/ fellowship/ boardsn Document all aspects of evaluation and

therapy accurately and according to LCDsn Designate themselves as “-09”

Resource: www.asipp.orgAmerican society of interventional pain physicians

http://www.asipp.org


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Epidural Injections

n Interlaminar versus transforaminaln “selective nerve root block, nerve root

sheath or sleeve injection”

n Common pain situationsn Radicular leg pain, herpes zoster

(shingles), post-laminectomy syndrome (FBSS), spondylosis, spinal stenosis, “sciatica”, degenerative disk disease

Epidural injection


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FCSO LCD L29165“epidural injections”

n Interlaminar epiduralsn 62310 cervical or thoracic n 62311 lumbar or sacral

n Transforaminal epiduralsn 64479 C/T, at 1st leveln 64480 C/T, at 2nd and subsequent levelsn 64483 L/S, at 1st leveln 64484 L/S at 2nd and subsequent levels

LCD : epidurals

n The use of fluoroscopy must be recorded and reported with epidural procedures.

n 77003 “paraspinal injection procedures” guidance and location, includes the injection of contrast if chosen

n 62310 may be done “once” (for non-chronic pain) without fluoro


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Fluoroscopy

n 77003 is billed ONCE per sitting

n Contrast injection adds greatly to the accuracy and safety of injections

n Fluoro saves healthcare dollars!

LCD: epidurals

n A “series of three” is common n Minimum interval is 2 weeksn Can repeat series in 6 months prn

n A “positive response” as defined by ASIPP guidelines > 50% improvement x 6-8w

n Multiple procedures on same day NOT allowedn Except for V58.61 patients who have

stopped blood thinners


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LCD: Cervical epidural

n 62310n 77003

n A bilateral procedure would not be possible or billable

n Multilevel interlaminar ESIs are not clinically rational

LCD: lumbar transforaminal epidurals done at multiple levels, on the same side

n 64483 LTn 64484 LTn 64484 LTn 77003


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Safety note on TF ESIs

In 75% of people, the artery of Adamkiewicz originates on the left side of the aorta between the T9 and T11 vertebral segments**

n The literature reports one case of fatal spinal cord infarction attributed to a transforaminal injection of corticosteroids. As well, the current authors are aware of three other cases in Australia, another in Europe, and 11 in the United States, in which patients have experienced severe neurologic sequelae, including spinal cord or brainstem infarction. These cases have not been published in the literature either because they are still sub judiceor because lawyers and patients have declined to have their case records released into the medical literature. n Anesthesiology: June 2004 - Volume 100 - Issue 6 - pp 1595-1600


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Transforaminal lumbar epidurals done bilaterally

n 64483 -50n 77003

n Note this is NOT properly billed as RT and LT injections






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OIG Study August 2010

n “Inappropriate Medicare Payments for Transforaminal Epidural Injection Services” (in 2007)n Part B payments went from

n 2003: $57M to 2007: $141M

n 34% of TF ESIs did not meet requirementsn $45M improper pmts to doctorsn $23M improper pmts to facilities

OIG on Transforaminals

In 2007, nearly all (86%) TF ESIs were done by the extended IPM group of anesthesiologists, physiatrists, and interventional pain medicine physicians.

10% of these were completely undocumented (fraud?), and 9% were insufficiently documented, contributing to an overall error rate of 34%


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OIG on Transforaminals

n OIG report indicates strongly that injections without fluoroscopy are invalid and dangerous

n OIG places burden on MC regional carriers to develop and enforce LCDsn Frequency, interval, fluoroscopy,

indications, documentation, success and repetition

n Look for new codes with fluoro bundled!






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FCSO LCD L29252“paravertebral facet blocks”

n This LCD includes CPT codes recently revised for 2010n 64490, 91 and 92 for Cervical / thoracic n 64493, 94, and 95 for lumbar / sacral

n AKA intraarticular facet joint injections, medial branch blocks, paravertebral blocks

Lumbar/ cervical facet pain

n Also known on LCD as “posterior element pain”

n Exam findings should be supportive and documented


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Facet joint injections

n Steroid and local anesthesia

n Used to treat arthritic facet joints and pain – these are therapeutic

n Medicine is given directly into the joint

Medial branch blocksn These are nerve

blocks with local anesthesia (usu.)

n Note “dual supply”n These are diagnostic

blocksn LCD specifies two

mbb’s = one facet denervation = “one level”


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Common ICD codes

n Spondylosisn 721.0 Cervical, 721.2 Thoracic, 721.3

Lumbar

n Post Laminectomy syndromen 722.81 C, 722.82 T and 722.83 L

Items of importance from LCD

n New codes replace overused codes from 2009 (64470/72 & 64475/76)

n Diagnostic medial branch blocks may be repeated within 2 weeksn Success as defined by ASIPP

n LCDs are variable but may allow 4 facet series per year as Therapeutic


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CPT codes for 2010

n Fluoroscopy is now bundled and mandatory

n Do not bill 77003

Coding points

n Max level of therapies is now three jointsn If mbb’s this means 4 nerve injections

n Use of -50 for bilateral proceduresn T12/L1 is considered as lumbar/sacral

for coding purposes


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Cervical Coding- IA facetsn 64490 RTn 64491 RTn 64492 RT

Clearly state that you have done three levels on ONE side of the spine

Use fluoroscopy – but don’t charge!

Lumbar coding – IA facets

n IF CT or Ultrasound guided, consult LCD, otherwise use fluoro!

n 64493-50n 64494-50n 64495-50

n This would be a total of 6 injections, the max. reimbursed


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Improper use of 2nd level

Do NOT use a 2nd level designator (64494 or 64491) to indicate the opposite side of the first level.

Proper use of the 2nd and 3rd levels documents that you have moved to a different anatomic LEVEL, not SIDE.






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OIG Study of Facets

n “Medicare payments for facet injection services” study of CY 2006 proceduresn 63% of allowed facet services did NOT

meet requirementsn $96M in MD overpmts PLUS $33M to

facilitiesn Errors were in documentation of proceduren Errors were in improper use of 2nd level

designator versus the -50

OIG study on facet joints

n Repetitive billing of add-on codes to represent the contralateral joint at the same level often resulted in 50% overpayments

n Imaging was not mandatory and often these were done ‘blindly’.

n Overutilization of codes ie 64475 x 1 plus 64476 x 5


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Facet services

n Payments by MC more than doubled:n 2003: $141M to 2006: $307M

n Claims for facet services increased by 76% from 2003 to 2006

n These payments represented 15% of costs for all interventional procedures

n FPs, GPs and IMs did 19% of these pro’s!

Who is responsible for facet billing errors?

n Highest percentage of errors were in the office setting by PCPsn 97% of GPs, 87% of IMs and 78% of FPs

procedures were found to have errors in documentation

n Anesthesiology, IPM -09s and Physiatry were much better, at between 53 and 63%


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FCSO LCD L29132“destruction of paravertebral facet nerve”

n These are known as radiofrequency neurotomy, denervation, RF lesioning, cryoablation, & thermal ablation

n This is a destructive procedure of the medial branches to the facet joints, which should result in months of pain relief

Radiofrequency lesioning

n A thin wire is advanced through a needle placed onto the mb nerves, and heated to 80 Centigrade for 90 seconds

n Special sensory & motor testing for safety


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Highlights of the RF LCD

n Requires the use of fluoroscopy, although this is not bundled

n Prior to RF, a diagnostic series of mbb’s with local anesthesia, and “success”, as previously described, with pain and functional assessments documented

n RF May not be done more than twice per year

RF lesioning

n 64622 – 1st lumbosacral facet level denervated

n 64623 – 2nd & subsequent L/S levels

n 64626 – 1st Cervicothoracic leveln 64627 – 2nd & subsequent C/T levels

n Cannot bill more than 5 levels totaln Use of -50 is required for contralateral sides


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Denervating L5/1 facet bilaterally

n Requires the destruction of L4 and L5 medial branch nerves, bilaterally

n Coding:n 64622-50n 77003

Denervating L3/4, L4/5 and L5/1 facet joints

n Requires destruction of L2, L3, L4 and L5 mb nerves

n Coding:n 64622 LTn 64623 LTn 64623 LTn 77003


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Posers

n Overall growth and utilization of IPM procedures will be restricted to those with proper training and credentialing

n PCPs, currently the fastest-growing segment of the IPM procedure market, will face credentialing challenges in ASCs and hospitals

n Those who are not -09’s face scrutiny


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Don’t be a poser – be a provider

n Properly documenting the procedure, with a supporting ICD-9 diagnosis

n Include proper sites/levels and sides for pain procedures

n Include proper use of RT or LT or -50 to add clarity to procedure note

n Perform procedures under fluoro guidance and conform to LCD requirements!

Payors

n Will increasingly require advanced training and certifications for physicians doing IPM procedures when credentialing

n Will find ways to perform frequent automated audits against LCD requirements, and prevent overutilization


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Payors

n Increasingly recognize and demand the safety and efficacy advantages of image guidance

n Will continue to develop new CPT codes with the AMA that incorporate mandatory bundled fluoroscopy

n Will try to use the literature to define procedures as ‘experimental’

Prognostication

n Due to demonstrated error rates in the office setting, and the proliferation of fluoroscopy in unregulated pain clinics, reimbursement in the non-ASC and non-hospital settings will continue to decline


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Prognostication

n As scientific advances in the study and measurement of pain are made, the clinical literature will catch up with our empirical experiences that

Pain procedures usually work when done for the right diagnosis, by the right physician, in the proper environment and in the right way

Prognostication

n An aging, arthritic, obese population will live longer and demand more pain related medical services, and continue to drive the OIG crazy


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Take this home:

n Your physicians do not know what LCDs are

n You should print them out and tell them it’s like a ‘cheat sheet’ for getting paid

n You should utilize the resources of www.asipp.org, www.fcso.com in addition to your others

Participate!

n You should have regular sessions with your physicians to go over problems with coding, denials & documentation

n For inexplicable or irrational payment denials, coordinate with local and national colleagues!

n Have your physicians join ASIPP/FLSIPPand support national agendas for pain!

http://www.asipp.org

http://www.fcso.com

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