ACE Alert, October 28, 2021 Volume 44

New CMS Epidural Policy to be Released in December

While we know it has been coming, the individual MACs have started to give us dates as to when the new Epidural Policy will become effective. The earliest date we have seen is from Palmetto for December 5, 2021. All others seem to follow that date with everyone on board by Christmas, what a present for pain practices.

Regardless of the implementation date, more documentation is going to be required and the use of the KX modifier for diagnostic selective nerve root blocks.

First, let’s review the list of clinical documentation required:
                History
                Physical exam
                Radiology

All must document evidence and fit into one of three categories:

1.  Lumbar, cervical, or thoracic radiculopathy and/or neurogenic claudication due to:
   1. Central disc herniation
   2. Osteophyte or osteophyte complexes
   3. Severe degenerative disc disease that produces foraminal or central spinal stenosis
2. Post Laminectomy syndrome
3. Acute herpes zoster

In Addition:
Radicular pain is severe enough to cause a significant degree of functional disability or vocational disability measured by one of the following pain scales:
                1.  Verbal Rating Scale
                2.  Numerical Rating Scale (NRS)
                3.  Visual Analog Scale (VAS)
                4.  Pain Disability Assessment Scale (PDAS)
                5.  Oswestry Disability Index (ODI)
                6.  Oswestry Low Back Pain Disability Questionnaire (OLBPDQ)
                7.  Quebec Back Pain Disability Scale (QBPDS)
                8.  Roland Morris Pain Scale
                9.  Back Pain Functional Scale (BPFS)
               10. PROMIS Profile
 
Providers need to do this assessment at baseline and then before each procedure.  Remember, the requirement to repeat a second injection is that there must be at least 50% sustained improvement of pain and/or 50% objective improvement in function.

The last coverage requirement deals with prior treatment.  Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive care OR medical documentation of failure to respond to four (4) weeks of noninvasive conservative care. Acute herpes zoster is exempt to conservative four (4) week management requirements.

While it is not our intent to list all requirements, there are a couple that providers must understand that may be a change in practice for some:

1. The ESIs should be performed in conjunction with conservative treatments and patients should be a part of an active rehabilitation program, home exercise program, or functional restoration program.
2. While most conditions would not normally require two (2) transforaminal ESI at two (2) levels in one spinal region, the policy does allow for a maximum of two (2) levels in one spinal region to be treated.
3. Again, following with other policies, the use of General Anesthesia, Moderate Sedation or Monitored Anesthesia Care (MAC) is usually unnecessary.  Only in exceptional cases where documentation clearly establishes the need for sedation in a specific patient will it be considered.
4. The lowest effective amount of steroid is to be used:
   1. 40 mg methyl prednisone
   2. 10-20 mg triamcinolone
   3. 10 mg (10 mg/ML) dexamethasone phosphate

Finally, is the limitation that treatment with ESI would extend beyond twelve months.  Use beyond twelve months requires documentation of the following:

1. Pain is severe enough to cause a significant degree of functional disability or vocational disability.
2. ESI provides at least 50% sustained improvement of pain or 50% objective improvement using the same scale as used at baseline.
3. Rationale for continuing ESIs includes: 
   1. Patient is high-risk surgical candidate
   2. Patient does not desire surgery
   3. Recurrence of pain in same location relieved by ESI for at least three months
   4. Communication with primary care provider regarding patient’s candidacy for prolonged repeat steroid use

We are working on a documentation summary tool to assists practices with these requirements.  We will let you know when the documentation tool is ready. 

If we can help your practice in any way, please reach out via our website or e-mail.

Devona

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