Contractor Information LCD Information

FUTURE Local Coverage Determination (LCD): Facet Joint Injections (L34974)

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Please note: Future Effective Date.

Contractor Information

Contractor Name Novitas Solutions, Inc.

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Contract Number 04412

LCD Information

Document Information

Contract Type A and B MAC

Jurisdiction J - H

L34974

LCD ID

Original ICD-9 LCD ID L32707

LCD Title Facet Joint Injections

AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS 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.

The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright ? American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Jurisdiction Texas

Original Effective Date For services performed on or after 10/01/2015

Revision Effective Date For services performed on or after 10/01/2015

Revision Ending Date N/A

Retirement Date N/A

Notice Period Start Date N/A

Notice Period End Date N/A

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UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ("AHA"), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA." Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for facet joint injection services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for facet joint injection services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding facet joint injection services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

? Medicare Benefit Policy Manual ? Pub. 100-02, Chapters 1 and 15. ? Medicare National Coverage Determinations Manual ? Pub. 100-03. ? Correct Coding Initiative ? Medicare Contractor Beneficiary and Provider Communications Manual ? Pub.

100-09, Chapter 5. ? Social Security Act (Title XVIII) Standard References, Sections:

1862 (a)(1)(A) Medically Reasonable & Necessary. 1862 (a)(1)(D) Investigational or Experimental. 1862 (a)(7) Screening (Routine Physical Checkups). 1833 (e) Incomplete Claim.

Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) 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 as follows:

? 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 Printed on 9/21/2015. Page 2 of 13

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. Before proceeding to a denervation treatment, the patient should experience at least a 50 percent reduction in symptoms for the duration of the local anesthetic effect.

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 fails 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).

Limitations

Medicare does not expect that an epidural block or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on the same day could lead to improper or lack of diagnosis. Coverage will 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.

Fluoroscopic or Computed Tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by CPT codes 64490, 64491, 64492, 64493, 64494, and 64495. For paravertebral spinal nerves and branches ? image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of CPT codes 64490, 64491, 64492, 64493, 64494, and 64495.

The CPT codes included in this policy include CT or fluoroscopic guidance; do not bill these codes unless CT or fluoroscopic guidance is performed. If guidance is performed with Magnetic Resonance Imaging (MRI) or if no guidance is performed, use an appropriate unlisted CPT/HCPCS code such as 64999. If the service is performed with ultrasound guidance, bill with the appropriate HCPCS code(s) from the 0213T, 0214T, 0215T, 0216T, 0217T and 0218T series of codes.

The CMS Internet-Only Manual (IOM) Pub.100-08, Program Integrity Manual, Chapter 13, Section 5.1, outlines that "reasonable and necessary" services are "ordered and /or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. Training and expertise must have been acquired within the framework of an Accreditation Council for Graduate Medical Education (ACGME) accredited residency and/or fellowship program in the applicable specialty/subspecialty. If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit. Documentation of training must be available upon request.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

? Safe and effective. ? Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates

of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). ? Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

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 Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

Furnished in a setting appropriate to the patient's medical needs and condition. Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient's medical needs. At least as beneficial as an existing and available medically

appropriate alternative.

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Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health 073x Clinic - Freestanding 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic - Federally Qualified Health Center (FQHC) 083x Ambulatory Surgery Center 085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Bill Type Note (above): Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Note: The Contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance. 032X Radiology - Diagnostic - General Classification 036X Operating Room Services - General Classification 045X Emergency Room - General Classification 049X Ambulatory Surgical Care - General Classification 051X Clinic - General Classification

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052X Freestanding Clinic - General Classification 076X Specialty Services - General Classification 096X Professional Fees - General Classification 0981 Professional Fees - Emergency Room Services 0982 Professional Fees - Outpatient Services 0983 Professional Fees - Clinic

CPT/HCPCS Codes Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes: 64490 Inj paravert f jnt c/t 1 lev 64491 Inj paravert f jnt c/t 2 lev 64492 Inj paravert f jnt c/t 3 lev 64493 Inj paravert f jnt l/s 1 lev 64494 Inj paravert f jnt l/s 2 lev 64495 Inj paravert f jnt l/s 3 lev

ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Note: Providers should continue to submit ICD-10-CM diagnosis codes without decimals on their claim forms and electronic claims.

The CPT/HCPCS codes included in this LCD will be subjected to "procedure to diagnosis" editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 64490, 64491, 64492, 64493, 64494 and 64495:

Covered for:

Group 1 Codes:

ICD-10 Codes

Description

M43.00

Spondylolysis, site unspecified

M43.01

Spondylolysis, occipito-atlanto-axial region

M43.02

Spondylolysis, cervical region

M43.03

Spondylolysis, cervicothoracic region

M43.04

Spondylolysis, thoracic region

M43.05

Spondylolysis, thoracolumbar region

M43.06

Spondylolysis, lumbar region

M43.07

Spondylolysis, lumbosacral region

M43.08

Spondylolysis, sacral and sacrococcygeal region

M43.09

Spondylolysis, multiple sites in spine

M43.10

Spondylolisthesis, site unspecified

M43.11

Spondylolisthesis, occipito-atlanto-axial region

M43.12

Spondylolisthesis, cervical region

M43.13

Spondylolisthesis, cervicothoracic region

M43.14

Spondylolisthesis, thoracic region

M43.15

Spondylolisthesis, thoracolumbar region

M43.16

Spondylolisthesis, lumbar region

M43.17

Spondylolisthesis, lumbosacral region

M43.18

Spondylolisthesis, sacral and sacrococcygeal region

M43.19

Spondylolisthesis, multiple sites in spine

M47.011

Anterior spinal artery compression syndromes, occipito-atlanto-axial region

M47.012

Anterior spinal artery compression syndromes, cervical region

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