Facet audits are literally coming out of the woodwork in every region of the country.  For whatever reason, these audits mostly deny medical necessity.  To ensure that your records are compliant please be sure that each record clearly documents the following seven items:
 

1.  Dates and pain scores to show 3 months or moderate to severe pain
2.  Demonstration of functional impairment
3.  Not responsive to conservative care (NSAIDs, acetaminophen, physical therapy, etc.)
4. Exam showing pain is axial and not associated with radiculopathy.  If radiculopathy has been involved, dates treated, and date resolved is necessary.
5.  MRI or X-ray showing no other cause of pain (No fracture, tumor, infection, or deformity).
6.  Nerves clearly documented that were injected with sites, drugs, and doses of medication.  Be sure this states that the drug was injected into each facet joint or at each nerve in a particular interspace.  Note the concentration and dosage of each medication if using steroid and anesthetic.  
7.  Pre AND Post pain scores.

 

It is extremely important that all pain physicians fight these audits.  In ACE’s opinion, Noridian is unfairly interpreting some of the guidelines making it extremely difficult to successfully pass an audit. 

If you need legal guidance on these appeals ACE knows of three excellent attorneys who are engaged in defending the services.  Please reach out if you need assistance and we can put you in touch with one of those attorneys.  

As always, we are here to help.  

The ACE Team
aceadmin@aceauditors.com