The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Peripheral Nerve Injections and Procedures for Chronic Pain L40263.
Refer to the LCD for reasonable and necessary requirements and frequency limitations.
The related LCD is for peripheral nerve injections (PNIs) consisting of local anesthesia (LA) with or without corticosteroids and denervation procedures for chronic pain. It does not apply to the use of botulinum toxins, blocks utilized for management of pain related to active malignancy refractory to medical management, spasticity treatment, surgical pain including peri-operative and/or operative procedures, regional anesthetic blocks, single diagnostic blocks, joint impingement syndromes, acute pain (including trauma), and pain due to sympathetic neuropathies or neurotomies.
For somatic nerve blocks, it is inappropriate to bill for fluoroscopy (CPT® codes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of service for the same patient by the same provider are included in the CPT® description of the procedure(s) performed.
Bilateral Procedures
For bilateral procedures, report CPT® code with modifier 50 plus add-on code.
For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center (ASC):
ASC facility claims (specialty 49) report bilateral procedures on 2 separate lines, with 1 unit each. Modifiers -LT and -RT are appended to each line. ASC facilities should not report modifier 50. Professional services performed in the ASC should continue to report bilateral procedures with modifier 50.
Utilization Parameters
No more than 1 diagnostic block session, unilateral or bilateral per peripheral nerve, will be considered reasonable and necessary, regardless of the billed code.
It is not routinely necessary for multiple injections such as epidural steroid injections, facet procedures, trigger point injections (TPI) or denervation to be provided to a patient on the same day as peripheral nerve procedures. If performed, the medical necessity of each procedure must be clearly documented in the medical record.
For sympathetic nerve blocks more than 5 blocks per beneficiary per lifetime will require documentation of continued sustained benefit of the block(s) as measured by a 5-point decrease in the CRPS Severity Score (CSS) from baseline for 3 months or longer.
For genicular nerve RFA for each knee, no more than 2 radiofrequency sessions will be reimbursed per rolling 12 months.
A maximum of 4 occipital nerve blocks for occipital neuralgia will be reimbursed per rolling 12 months.
A single suprascapular nerve block (SSNB) may be used as a diagnostic modality for chronic shoulder pain conditions. More than 2 therapeutic SSNB in 12 months is considered rare and may trigger targeted medical review.
The application of more than 3 steroid injections with or without local anesthetic involving the same median nerve is not supported by current evidence and may trigger targeted medical review.
Therapeutic radiofrequency neurolysis may not be billed for clinical conditions other than trigeminal neuralgia.
No more than 2 therapeutic radiofrequency neurolysis (CPT® codes), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.
Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) during nerve procedures should not be billed except for during operative and perioperative nerve blocks.
KX-Modifier
Diagnostic Blocks: The KX modifier shall be appended to the line for initial diagnostic injections. Repeat diagnostic block(s) of the same nerve shall not be billed except for genicular nerve blocks, where 2 will be allowed.
Modifier 52
CPT®64454 requires injecting superolaterial, superomedial and inferomedial branches of the genicular nerve, if all 3 of these genicular nerve branches are not injected report 64454 with modifier 52.
Pre- and Post-operative Anesthetic Blocks:
Peripheral nerve blocks (PNBs) used for anesthesia purposes must align with the criteria outlined in the National Correct Coding Initiative (NCCI) policy manual for Medicare services.
PNBs that provide intraoperative pain management is included in the 0XXXX anesthesia code and is not separately reportable, even if it also provides postoperative pain management.
For CPT® codes 64400-64530: If the operating physician requests that the anesthesia practitioner performs PNB for pain management after the postoperative anesthesia care period terminates, the anesthesia practitioner may report it separately using modifier 59 or XU.
Documentation Requirements
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All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
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Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
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The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT®/HCPCS code must describe the service performed. When applicable, any specific device used to perform the procedure must be listed in the comments section of the claim.
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The procedural report should clearly document the indications and medical necessity for the injection or procedure. For diagnostic blocks, the pre and post-procedure pain intensity using a standardized scale shall be recorded for the duration expected with the anesthetic agent used.
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The patient’s medical record should include, but is not limited to:
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The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit;
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Relevant medical history;
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Results of pertinent tests/procedures;
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Signed and dated office visit record(s)/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.);
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Documentation to support the medical necessity of the procedure(s).
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Imaging Guidance documentation requirements
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Images of all relevant areas should be recorded and stored in a retrievable format;
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For ultrasound guided needle placement there should be at least 1 ultrasonographic image of the needle once it has reached its target;
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For fluoroscopic guided nerve ablations, the documentation shall include the targeted genicular nerves and specific anatomic location, confirmation of fluoroscopic views (Anteroposterior [AP], oblique, lateral), target location verified with contrast dye and patient response to sensory motor testing;
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Imaging data shall include total fluoroscopy time and dose;
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Parameters of the ablation: temperature and duration;
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Outcome: patient tolerance and status post procedure.
Use of Biologicals
The inclusion of biological and/or other non-FDA approved substances as injectants may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, ozone, platelet rich plasma and vitamins fall in this category.
Coding Guidance
The Current Procedural Terminology (CPT®) codes included in this article may be subject NCCI edits or Outpatient Prospective Payment System (OPPS) packaging edits. Please refer to NCCI and OPPS requirements prior to billing Medicare.
Providers should refer to the applicable AMA CPT® Manual to assist with proper reporting of these services.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
The GX modifier (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, services will automatically deny.
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.
If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
