5 Ways to Avoid Scrutiny in Pain Management Codes 2023

It’s no secret that the federal government monitors every prescription, procedure, and office visit to ensure that money earmarked for Medicare and Medicaid is spent appropriately. It can be challenging, however, to determine what the reviewers might be scrutinizing and how to keep up with current billing and reimbursement codes, especially in pain management. And now, auditing agencies have announced that they are performing audits of spinal pain management services for Centers for Medicare & Medicaid Services (CMS).

The HHS Office of Inspector General is considered the “watchdog” for CMS.¹ Also known as the OIG, the agency publishes an up-to-date Work Plan online to share the issues it is actively auditing,² and recently added an item related to spinal pain management services.³

The OIG’s current audit regarding Medicare payments for spinal pain management include:

• facet joint injections
• facet joint denervation sessions
• lumbar epidural injections
• trigger point injections

Of note, CMS outsources some of its audits to Recovery Audit Contractors (RACs).⁴ These entities seek improper payments that practices received from Medicare and Medicaid so they can give the money back to the government. The RACs collect a percentage of the money they recoup from providers, leading some practices to refer to them as Medicare’s “bounty hunters.”⁵

In 2021, the RACs added spinal cord stimulation (SCS) to their list of services to be reviewed and it remains on their list in 2023.⁶ During a 2021 audit, the OIG found that Medicare overpaid providers $636 million for surgeries to implant neurostimulator devices.⁷ The frequency of these procedures increased by 175% over an 11-year period, and the coding error rate was a startling 72%. This could be the impetus behind the agency’s new reviews of claims for SCS services (more om this below).⁸

Detail Facet Joint Injection Documentation

CMS has repeatedly audited facet joint injections, and the error rate typically hovers around 50%. Considering that annual Medicare payments for these services come to nearly $100 million,⁹ claims paid in error for facet joint injections cost the government a tremendous amount of money.

Each Medicare Administrative Contractor (MAC) maintains its own policy about what the documentation must include to compliantly report facet joint injections, but some of the MACs have overlapping guidelines. One detail that most Medicare payers will require is that practices cannot collect for intra-articular facet joint injections unless the medical record indicates justification about why the less invasive radiofrequency ablation cannot be performed.¹⁰

Limit Facet Joint Denervation Sessions to Two

Pain providers will find that Medicare limits them to two facet joint denervation sessions for each covered spinal region during any given 12-month period.¹0 During a recent audit to confirm that providers were heeding this guideline, the government found that $7.2 million was paid improperly.¹¹

It is important for every clinician providing denervation services to track the number of sessions performed on each spinal region so the two sessions per 12-month period limitation are not exceeded. Keep in mind that this limitation applies to the beneficiary, not to the practice.

Watch the Calendar for Lumbar Epidural Injections

Pain management providers must also heed very specific limitations when it comes to reporting epidural injections. The OIG is specifically reviewing those addressing the lumbar region, but in general, the limitations apply similarly to all of the areas of the spine.

Most Medicare payers will not reimburse pain providers for epidural steroid injections (ESIs) unless the following time limitations are met:¹²

• Pain duration of at least 4 weeks
• The inability to tolerate noninvasive conservative care OR medical documentation of failure to respond to four weeks of noninvasive conservative care OR acute herpes zoster refractory to conservative management where a four week wait is not required.

Bill Trigger Point Injections by Location

When a pain provider performs trigger point injections, it is very important to bill them based on the site injected and not the number of injections performed. Medicare counts one injection service per site, regardless of how many actual injections are administered.¹³

However, clinicians should still document how many injections were performed, as well as the site(s) addressed, as part of maintaining thorough medical record documentation.

Spinal Cord Stimulation Needs Documented Trial

To collect for SCS, pain providers must perform a two-stage service.¹⁴ During the first stage, the patient receives a temporary external device for about 1 to 2 weeks. If the trial is successful and the patient’s pain is reduced, only then will the patient be a candidate for the implantable device.

Pain practices should remain vigilant by maintaining thorough and complete documentation that justifies medical necessity for all procedures performed. At practices where providers are lax about creating thorough documentation, the recently announced audits could serve as a training opportunity to emphasize the importance of strong medical records with clinicians and staff.