ACE ALERT: Palmetto Proposed LCD for Epidural Procedures for Pain Management

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ACE Alert, May 26 2021, Volume 22

Epidural Procedures for Pain Management
By: Devona Slater
Palmetto is the first carrier to give us a glimpse as to what we can expect as to the new national epidural policy. https://tinyurl.com/549c6mwx

Coverage indications include three elements that all must be met:

  1.  History, physical examination, and concordant radiological image-based diagnostic testing and supporting one of the following:
    1. Lumbar, cervical, or thoracic radiculopathy and/or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis;
    2. OR Post-laminectomy syndrome
    3. Acute herpes zoster associated pain
  2. Radicular pain is severe enough to cause a significant degree of functional disability or vocational disability measured at baseline using an objective pain scale. A functional assessment scale must be performed at baseline if the function is considered as part of the assessment.
  3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster refractory to conservative management where four (4) week wait is not required.

Covered Indications section topics that caught my attention: 

  • Now all epidurals must be done under radiology guidance with contrast
  • There is a maximum of two levels in one spinal region or one level bilaterally for transforaminal procedures
  • Must have a minimum 50% sustained improvement over baseline
  • ESI injectants must include corticosteroids, anesthetics, anti-inflammatories, and/or contrast agents

The ESIs should be performed in conjunction with conservative treatments as well as the Patient should be part of an active rehabilitation program, home exercise program, or functional restoration program. 
Limitations Include:

  1. Not performing multiple blocks in conjunction with ESI during the same session
  2. Anesthesia is unusually unnecessary
  3. Non-specific low back pain is not covered
  4. A maximum of 4 sessions per spinal region in a rolling 12 month period
  5. One spinal region per session
  6. No reference of “ESIs in a series” will be allowed
  7. Not medically necessary for treatment with ESI to extend beyond 12 months

On the billing requirements, they are requiring the “KX” modifier for diagnostic injections.  So identifying these injections as either diagnostic or therapeutic is an important documentation requirement.
Pretty much the diagnosis coding is limited to herpes zoster, radiculopathy, and spinal stenosis. 

These are in the draft state so be sure and comment to your local MAC when your draft comes out.

Please give us a call if we can do anything to assist you with your coding or compliance needs!

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