ACE ALERT: Billing Epidurals for Medicare

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ACE Alert, December 2, 2021 Volume 48
Billing Epidurals for Medicare Now is More Restrictive and Requires Additional Documentation

As we have previously reported, December is the month when the CMS intermediaries across the country will roll out the revised epidural policy. While highly anticipated by the pain community, these policies tighten the use of epidural injections. No longer will low back pain, M54.5, be a covered diagnosis and specific limitations of no more than 4 epidurals per year will be allowed. 

A bit of advice is to be sure to pull the actual LCD and Billing policy for your specific state/area. While the policy was intended to be national guidance, ACE has found some significant differences in the amount of drug that is to be injected as well as the acceptable limitations and exceptions allowed.

While no one is surprised, sedation nor anesthesia services will be paid. Anesthesia and pain groups that are routinely providing sedation for epidurals need to get an ABN process in place or realize that they will be doing the sedation for free.

Again a new component is identifying the diagnostic selective nerve root injections with the KX modifier.  They do caution that aberrant use of the -KX modifier may trigger focused medical reviews.

Watch your diagnosis coding as the combination codes that include radiculopathy will need to be used with disc disorder codes. Also, while the LCD does state that epidurals are appropriate for osteophyte or osteophyte complexes, none of the approved diagnosis codes reflect that condition so you will need to code the radiculopathy component first followed by the cause of osteophyte as a secondary diagnosis.

ACE knows and is concerned for providers regarding the additional level of documentation now required and has developed a documentation tool to assist in organizing and capturing the required elements listed in the LCDs. It is available for purchase. We are happy to answer any questions and we hope that this tool will assist pain practices with compliance and additional documentation in light of the revised LCD.

 We are offering this form with two options.

  • ACE Client–  Pay once, at $19.99 and download to use the form. 
  • Current ACE Client– If you have used ACE for services in 2021, you can contact Kayla in our office to get the code to purchase the form at  $9.99 
Check out the website to buy the new form, and stay tuned for more training modules coming soon. We are already working on something great for epidurals that we will roll out soon!
If you want additional information on how ACE can help your group, don’t hesitate to get in touch with Kayla Lee at kaylal@aceauditors.com.

Get the Form Today

ACE Christmas Presentation of the 2022 changes is coming!

The elves here at ACE are hard at work preparing the 2022 update for all of our clients. For current clients, ones that have actually had billed services in 2021, the presentation is free. For all others, it is available for a small fee of $59.00 until January 15. After January 15, the price will increase to $159.

We look forward to sharing our perspective of the upcoming coding changes, information regarding the new Surprise Billing regulations and other anesthesia-specific topics.

The presentation should be available as of December 21, barring no delays with the supply chain or changes at the last minute with Congress and the physician fee schedule.

The presentation will be sent out in a special ACE Alert, so make sure you and all your teammates are subscribed. 

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