Observations Related to Newly Implemented CMS MAC Facet Policy
By: Judith L. Blaszczyk RN, CPC, ACS-PM, ICDCT-CM
Devona made you aware in her ACE Alert on April 14, 2021, that CMS was working on a nationwide policy for facet joint interventions. After a multijurisdictional committee hearing with input from many pain management experts, the Medicare MACS each released a comprehensive policy detailing the medical necessity requirements for these commonly performed procedures. The local coverage determinations/articles detail the conditions that must be met to support the medical necessity for providing these treatments. Criteria include the duration and nature of the patient’s pain; diagnostic requirements; approved techniques; frequency and number of services that may be performed, qualifying diagnoses, and documentation requirements. The policy also provides regulations related to image guidance, sedation/anesthesia with facet procedures, performance of other services at the same session, medications that may be injected, as well as noting related treatments that are not covered. ACE will continue to provide additional guidance on the nuances of this policy as we gain more insight based on client questions and issues that may arise now that the policy has become effective. (All MACS with the exception of CGS, April 25, 2021. Effective date for CGS, May 2, 2021).
One important issue that became apparent as we studied the new rules was the very limited list of qualifying diagnoses. Unlike many previous facet policies, there are no signs or symptoms that may be reported, such as neck or back pain, when the provider is still in the process of establishing the patient’s diagnosis. So, although the policy clearly requires two diagnostic facet injections to support a definitive diagnosis of spondylosis, there are no approved diagnoses to report during this stage of the process. Paradoxically, the following statement is included in the section detailing the ICD-10-CM codes that prove medical necessity. “The diagnosis code(s) must best describe the patient’s condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.” With the current list, following this advice would result in a denial. We will be paying close attention to how this conundrum may be rectified by the contractors.
ACE has also observed differences between some of the LCDs. Although it is our understanding that the policy was to be the same across all jurisdictions, we noticed, when detailing qualifiers for therapeutic facet injections, NGS includes only the IA (intraarticular) technique, whereas WPS notes both IA and MBB (medial branch blocks). To date, we have not been able to find out if this is an error or if these two MACs truly have chosen different responses to this issue. We bring this to your attention to encourage you to comb carefully through the LCD and article published by YOUR Medicare MAC to ensure you are complying with their specific regulations.
Stay tuned for further updates as we continue to monitor the implementation of this collaborative CMS policy.