Pain Management - Injection of tendon sheaths, ligaments, bursa, and ganglion cysts

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

50 – 50.6 Drugs and Biologicals

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:

30.3 Acupuncture

150.7 Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents

280.14 Infusion Pumps

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

40 Surgeons and Global Surgery

50 Payment for Anesthesiology Services

140.3.2 Anesthesia Time and Calculation of Anesthesia Time Units

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13:

10 ICD-9-CM Coding for Diagnostic Tests

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23:

20.9 Correct Coding Initiative (CCI)

CMS Publication 100-08, Program Integrity Manual, Chapter 13:

13.5.1 – Reasonable and Necessary Provisions in LCDs

National Correct Coding Initiative Policy Manual for Medicare Services, Chapter II: Anesthesia Services. CPT Codes 00000-09999.

Abstract:

Acute pain is elicited by the injury of body tissues and activation of nociceptive transducers at the site of local tissue damage. This type of pain is often a reason to seek health care, and it occurs after trauma, surgical interventions, and some disease processes.

Chronic pain has been defined as "persistent or episodic pain of duration or intensity that adversely affects the function or well-being of the patient, attributable to any nonmalignant etiology" ("Practice Guidelines for Chronic Pain Management: A Report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section"). In addition, the pain has been refractory to repeated attempts at medical management and usually has been present for at least three to six months.

Pain associated with cancer includes pain associated with disease progression as well as treatments. Pain associated with cancer can have multiple causes—namely, disease progression, treatment (e.g., neuropathic pain resulting from radiation therapy), and co-occurring diseases (e.g., arthritis). Regardless of whether the pain associated with cancer stems from disease progression, treatment, or a co-occurring disease, it may be either acute or chronic.

The decision to treat chronic pain by invasive or destructive procedures must be based on a thorough evaluation of the patient and include a systematic assessment of the location, intensity, and pathophysiology of the pain. A detailed pain history that includes prior treatment and response to treatment is essential. A detailed physical examination and review of all pertinent diagnostic tests is also needed. 

For complete coverage detail, please review each of the following sections: Indications and Limitations for Specific Types of Injections, Limitations for All Diagnostic and Therapeutic Pain Management Services. Documentation Requirements and Utilization Guidelines have been moved to Coding and Billing article A52863. 
 

Indications and Limitations for Specific Types of Injections

INJECTION OF TENDON SHEATHS, LIGAMENTS, BURSA, AND GANGLION CYSTS

Injection into tendon sheaths, ligaments, bursa and ganglion cysts is sometimes indicated to provide relief of pain and to reduce the inflammation in these structures when response to conservative measures has failed or is not indicated.

For the purposes of clarity the following descriptions are offered for each term:

Ligament - A band of tissue that connects bones.

Tendon - A fibrous cord of connective tissue attaching a muscle to a bone or other structure. A tendon sheath is the lining enclosing a tendon. It facilitates movement around the tendon.

Ganglion cyst - These knot like masses are non-cancerous and fluid filled cysts that arise from the ligaments, joint linings, or tendon sheaths.

Bursa - a small, fluid-filled sac that acts as a cushion between bones and other moving parts like muscles, tendons, or skin.

Indications for Tendon Sheath, Ligament, Bursa, and Ganglion Cysts:

Injection into tendon sheaths, their origins or insertions, ligaments, bursa, or ganglion cysts is indicated to relieve substantial pain and/or significant functional disability that results from inflammation or other pathological changes in those structures. Proper use of this modality should be part of an overall management plan including diagnostic evaluation in order to clearly identify and properly treat the primary cause.

Other conservative therapy has not provided acceptable relief, is contraindicated, or not appropriate.

There is a reasonable likelihood that injection will significantly improve the patient's pain and/or functional disability.

Limitations for Tendon Sheath, Ligament, Bursa, and Ganglion Cysts:

When a given specific tendon, ligament, bursa, or cyst is injected, it will be considered one injection service regardless of the number of injections administered at that specific anatomical location on a single date of service.

General anesthesia or monitored anesthesia care (MAC) is rarely, if ever required for injections addressed in this policy. In fact, general anesthesia is contraindicated for diagnostic blocks (Manchikanti et al, 2005). Further, monitored anesthesia care or heavy sedation may provide false-positive results.

Provider Qualifications
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

Patient safety and quality of care mandate that healthcare professionals who perform spinal pain management procedures are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. (At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities). A practitioner who works in a hospital or ASC facility at any time should be credentialed by the facility for any procedure also performed in an office setting.

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This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

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• Provider Education/Guidance