Refer to the Local Coverage Determination (LCD) DL40300 Peripheral Nerve Blocks and Procedures for Chronic Pain for reasonable and necessary requirements and frequency limitations.
This policy is for peripheral nerve blocks consisting of local anesthesia with or without corticosteroids and denervation procedures. This policy does not apply to the use of botulinum toxins, cancer-related pain, spasticity treatment, peri-operative and/or operative procedures.
The use of peripheral nerve blocks and radiofrequency neurolysis is non-covered for systemic peripheral neuropathy, generalized chronic pain, and neuropathic pain except refractory trigeminal neuralgia and carpal tunnel syndrome.
This notification does not affect those regional/local blocks done as part of a perioperative or operative procedure when performed as an adjunct to or the sole means of regional/local anesthesia for the procedure or acute surgical pain.
This notification does not apply to blocks utilized for management of pain related to malignancy refractory to medical management.
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 facility claims (specialty 49) report bilateral procedures on two separate lines, with one 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.
No more than 2 steroid injections with or without local anesthetic (LA) for Moton’s neuroma may be administered per lifetime per side.
No more than 3 steroid injections with or without local anesthetic (LA) for carpal tunnel syndrome (CTS) may be administered per lifetime per side.
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.
Multiple blocks, injections, denervation (such as epidural steroid injections, facet procedures, trigger point injections) provided to a patient on the same day as peripheral nerve procedures will be subject to medical review.
“Dry needling" of neuromas, or peripheral nerves may not be billed.
Pre- and Post-operative Anesthetic Blocks:
Peripheral nerve blocks used for anesthesia purposes must align with the criteria outlined in the National Correct Coding Initiative policy manual for Medicare services.
Peripheral nerve block that provides 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 peripheral nerve block 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.
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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.
- The patient’s medical record should include, but is not limited to:
- The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit
- Relevant medical history
- Results of pertinent tests/procedures
- Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.
- Documentation to support the medical necessity of the procedure(s).
Use of Biologicals
The inclusion of biologicals 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, and platelet rich plasma and vitamins fall in this category.
The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.
Coding Guidance 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.
Modifier GX (“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, will automatically be denied services.
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.
