Medicare facet denials

[myrandom2003]

I am 0 for 15 this week with Medicare. Each one cited not documenting a functional disability scale.
The LCD said a pain scale counted. I document a VAS/Numeric pain scale. But it looks like it doesn’t count. I am in the WPS region of Medicare.
What disability scale are all of you documenting?

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[gaschicago]

ODI

 

[Agast]

What happens if you appeal the denial? I think they hire 3rd party reviewers who are over zealous on denials but if you appeal it goes to CMS

 

[DrMDAware]

ODI

For each MBB one has to complete ODI?

Oh god…

 

[callmeanesthesia]

I use the PEG score. 3 items 0-10 each.

 

[GlowInTheDark]

ODI filled out prior to performing and on followup, scanned in chart. I have never ever ever looked at a single one.

 

[Ferrismonk]

We do a fresh ODI on every straight medicare patient every office visit and every procedure. I'm in WPS as well. VAS is a pain score, you need a functional score as well.

 

[Agast]

We do a fresh ODI on every straight medicare patient every office visit and every procedure. I'm in WPS as well. VAS is a pain score, you need a functional score as well.

How long does that take you? Do you just have them the sheet with their intake paperwork

 

[Drd105]

How long does that take you? Do you just have them the sheet with their intake paperwork

Agast I thought you were private practice? Are you having to get PAs for CMS facets in your region? (I’m palmetto)

 

[bedrock]

I am 0 for 15 this week with Medicare. Each one cited not documenting a functional disability scale.
The LCD said a pain scale counted. I document a VAS/Numeric pain scale. But it looks like it doesn’t count. I am in the WPS region of Medicare.
What disability scale are all of you documenting?

Are you HOPD or private practice?

 

[Agast]

Agast I thought you were private practice? Are you having to get PAs for CMS facets in your region? (I’m palmetto)

Nope, not for primary medicare

Texas is probably the least regulated area. I do all my procedures in an ASC. The surgery center got audited and Novitas said we failed showing medical necessity on a bunch of injections going after things like, MA was the one who called and got % improvement a week after, we didn’t document % improvement right after the procedure when they were still sitting in PACU….it was appealed and we kept our money.

The denials we got quoted specific sections of the CMS handbook but when I looked it up none of it seemed to really support what they were going after.

I was told that the 3rd party reviewers are paid by Insurance for each claim that gets fully denied, so they have an incentive to really nail you on borderline things.

 

[GlowInTheDark]

Nope, not for primary medicare

Texas is probably the least regulated area. I do all my procedures in an ASC. The surgery center got audited and Novitas said we failed showing medical necessity on a bunch of injections going after things like, MA was the one who called and got % improvement a week after, we didn’t document % improvement right after the procedure when they were still sitting in PACU….it was appealed and we kept our money.

The denials we got quoted specific sections of the CMS handbook but when I looked it up none of it seemed to really support what they were going after.

I was told that the 3rd party reviewers are paid by Insurance for each claim that gets fully denied, so they have an incentive to really nail you on borderline things.

All of their guidelines are geared to nail you.

None of it has any medical benefit, it is all built to deny care.

 

[Ferrismonk]

How long does that take you? Do you just have them the sheet with their intake paperwork

There is a one page sheet we have the patient fill out as part of the intake paperwork. It is tallied and put in the note by either the MA in the office or the RN at a procedure.

A functional assessment scale has been required on medicare epidurals for a while now. There isn't an auth required (yet), but clawback can be done if you're not doing this.

 

[Agast]

A functional assessment scale has been required on medicare epidurals for a while now. There isn't an auth required (yet), but clawback can be done if you're not doing this.

Are they required to demonstrate a target level of improvement or does it just need to be documented that it was done

 

[Ferrismonk]

LCD states they need to make improvement, but there isn't a number. In fact, you can use any functional disability scale you want, even one you make up yourself. I *think* you do need to show moderate functional impairment on your scale though. Our group says ODI must be at least 40%.

If they score lower than 40%, we "clarify" what they mean on the questionnaire. We also don't deny further care based on non-improvement on this score, but that's a calculated risk we're willing to take. We document functional limitations in our note too.

This whole stupid game is bull$h!t.

 

[bedrock]

I haven’t been doing this but want to avoid clawbacks.
Can someone post or DM the ODI form you use for Medicare patients?

 

[cowboydoc]

Free Online ODI Score Calculator - OrthoToolKit

orthotoolkit.com

 

[Tboned]

We use OBERD and patients fill out NRS and ODI on iPad when they check in for appointments

 

[callmeanesthesia]

https://www.med.umich.edu/1info/FHP/practiceguides/pain/PEG.Scale.12.2016.pdf

My MAs ask these 3 questions when rooming the patient and enter the score into the note. Saves time compared to ODI, and I’ve occasionally found it helpful on the old farmer types who tell you their pain score is a 0-1 because “it’s not really pain, I just get so much pressure in my back that I can’t walk more than 100 yards.”

 

[Dr. Ice]

Blocks in the office, rfa in asc,
No issues so far. No “extender” crap for me. All me all the time. Everyone is coming back in. No patience to keep up with when or when not “tele stupid” is gonna get paid or not. No one practicing msk medicine should be for tele anything in my opinion

 

[gaschicago]

are you all seeing patients in the office in between MBB 1 and 2? I see them in the office after MBB 2 to discuss RFA. Didn't want to clog up the schedule with just MBB1 follow up

 

[gaschicago]

also prior auth for this is required for in office procedures or only if you do them in an ASC or hospital setting?

 

[Dr. Ice]

are you all seeing patients in the office in between MBB 1 and 2? I see them in the office after MBB 2 to discuss RFA. Didn't want to clog up the schedule with just MBB1 follow up

I can only speak for myself. Everyone is coming back in all the time for mbb/rfa. I didn’t ask them to have back pain without radicular symptoms lol..I also didn’t ask to be stuck in insurance hell…truly facet peeps are retired anyway. They like the outing so they can have brunch at the diner afterwords

 

[myrandom2003]

Are you HOPD or private practice?

I’m private practice but do certain hmo and Medicare patients at an hopd.

 

[myrandom2003]

also prior auth for this is required for in office procedures or only if you do them in an ASC or hospital setting?

For now, just hopd needs prior auth. But they will all need it eventually. We already see the writing on the wall.

 

[cowboydoc]

Latest denial was because “axial” pain wasn’t spelled out in the description of back pain BETWEEN the first and second MBB.

Nurse phone note said something like “90% relief, 1/10 pain post block for 6 hours, return of pain to baseline.”

Here’s to hoping I get the office based procedure suite I’ve been angling for my entire tenure here.

 

[callmeanesthesia]

Tbh I’m kind of glad. They keep putting more and more onerous and confusing requirements in, and at least if it were pre-authorized I wouldn’t have to worry about them coming back in 2 years and demanding repayment of every MBB and RFA I’ve done in that time.

 

[Ronin1]

We have already adapted our templates to match the wording in their denial letters. Just play their game.

 

[gaschicago]

We have already adapted our templates to match the wording in their denial letters. Just play their game.

mind sharing the wording?

 

[DrMDAware]

FYI the PEG unfortunately does not count as a functional scale

 

[callmeanesthesia]

FYI the PEG unfortunately does not count as a functional scale

Why? It assesses whether the pain interferes with their functionality, and the LCD language on functionality scales says “including but not limited to”

 

[buddababa]

bunch of RF denials from MEDICARE prior auth, because system is broken. Despite clear documentation of 80% relief for a year - denial letter stated COOLEDRF - i've only ever done traditional RF.. smh

 

[cowboydoc]

"If a non-affirmation decision has been issued, provider(s) may resubmit an updated prior
authorization request. This decision was based on the submitted documentation. The submitted
documentation did not confirm the beneficiary had at least 80% pain relief of primary pain of
targeted area. The pre and post pain scores are equivalent to 75% reduction in pain post procedure."

Nurse documented 70-80% improvement after MBB.

 

[MD87]

"If a non-affirmation decision has been issued, provider(s) may resubmit an updated prior
authorization request. This decision was based on the submitted documentation. The submitted
documentation did not confirm the beneficiary had at least 80% pain relief of primary pain of
targeted area. The pre and post pain scores are equivalent to 75% reduction in pain post procedure."

Nurse documented 70-80% improvement after MBB.

I had a patient who had a Medicare advantage plan - MBB dropped pain from 9 to 2. RF got denied. I was able to convince the peer to peer that 77.8% is close enough to 80% and got it approved. Infuriating that I had to waste my time doing it, but at least I got it overturned.

 

[Taus]

I had a patient who had a Medicare advantage plan - MBB dropped pain from 9 to 2. RF got denied. I was able to convince the peer to peer that 77.8% is close enough to 80% and got it approved. Infuriating that I had to waste my time doing it, but at least I got it overturned.

I don’t offer percentages as an option. Outcome is verbally discussed with me or my MA along the lines of…. No relief, slight relief, a lot of relief, complete relief of the pain. The latter 2 are above 80%.

 

[GlowInTheDark]

I had a patient who had a Medicare advantage plan - MBB dropped pain from 9 to 2. RF got denied. I was able to convince the peer to peer that 77.8% is close enough to 80% and got it approved. Infuriating that I had to waste my time doing it, but at least I got it overturned.

I comment on improvement in regards to subjective improvement in pain scores and functional movements. Example, If flex/etc/twisting was no longer painful…”100% improvement of index pain performing previously painful movements.”

 

[DrMDAware]

Why? It assesses whether the pain interferes with their functionality, and the LCD language on functionality scales says “including but not limited to”

I dunno. I would love to use the PEG don’t get me wrong. Just relaying what I was told by our biller. I’m hoping I’m wrong, though. Don’t shoot the messenger.

 

[Ducttape]

"If a non-affirmation decision has been issued, provider(s) may resubmit an updated prior
authorization request. This decision was based on the submitted documentation. The submitted
documentation did not confirm the beneficiary had at least 80% pain relief of primary pain of
targeted area. The pre and post pain scores are equivalent to 75% reduction in pain post procedure."

Nurse documented 70-80% improvement after MBB.

kiss of death - if it is 70-80%, must round up to 80%.

I dunno. I would love to use the PEG don’t get me wrong. Just relaying what I was told by our biller. I’m hoping I’m wrong, though. Don’t shoot the messenger.

im not sure i would trust a biller to know what is a functional test or not.

it is billed as a tool that measures functionality.

The Pain, Enjoyment of Life and General Activity (PEG) Scale

The Pain, Enjoyment of Life and General Activity scale, or PEG scale, is a pain scale based on th...

www.painscale.com

 

[geauxg8rs]

kiss of death - if it is 70-80%, must round up to 80%.


im not sure i would trust a biller to know what is a functional test or not.

it is billed as a tool that measures functionality.

The Pain, Enjoyment of Life and General Activity (PEG) Scale

The Pain, Enjoyment of Life and General Activity scale, or PEG scale, is a pain scale based on th...

www.painscale.com

Patients need only be given option to answer 80 percent or more or if less than 80 percent you don’t get the RFA. They can make the choice, they should be fully aware of the implications of what number they want to say.

 

[DrMDAware]

kiss of death - if it is 70-80%, must round up to 80%.


im not sure i would trust a biller to know what is a functional test or not.

it is billed as a tool that measures functionality.

The Pain, Enjoyment of Life and General Activity (PEG) Scale

The Pain, Enjoyment of Life and General Activity scale, or PEG scale, is a pain scale based on th...

www.painscale.com

I’d love to use the PEG. Do you happen to have any verbiage from the LCD or health plans that have this included? The quotes I have list other functional scales specifically but not PEG.

 

[Ducttape]

Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria:

1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale*
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient’s pain, including but not limited to fracture, tumor, infection, or significant deformity.

*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment).

Note: The scales used for measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.

so specifically it does not include PEG., but im still using PEG because of the highlighted statement.

the problem with the scales listed above is that all of them take too long. the smallest i believe is 20 questions long.

 

[NJPAIN]

I don’t offer percentages as an option. Outcome is verbally discussed with me or my MA along the lines of…. No relief, slight relief, a lot of relief, complete relief of the pain. The latter 2 are above 80%.

I really like this approach. Our prior authorization department is sending cases back to us with reported 80% relief because we don’t have a before and after VAS score that supports that amount of relief. Is anyone seeing that as a requirement of the LCD or other coverage guidelines?

 

[Dr. Ice]

I really like this approach. Our prior authorization department is sending cases back to us with reported 80% relief because we don’t have a before and after VAS score that supports that amount of relief. Is anyone seeing that as a requirement of the LCD or other coverage guidelines?

Are you doing everything in asc or hopd? I have found as long as mbb done in office, hasn’t been an issue, and my contracts are total garbage. If anyone is gonna get denied it’s gonna be me

 

[DrMDAware]

so specifically it does not include PEG., but im still using PEG because of the highlighted statement.

the problem with the scales listed above is that all of them take too long. the smallest i believe is 20 questions long.

You are correct. I overlooked the “but not limited to” part. Glad we can use the PEG!

 

[SpineandWine]

I used to document post-pain scores right after procedure and call patient.
But I guess no way around it. Patient's have to come by each time for clinic visit after each mbb's for ODI/VAS scores.
Do most people have patients follow up after each medial branch block? What's the subsequent follow up days for each visit and how long does this overall process take now?

 

[NJPAIN]

Are you doing everything in asc or hopd? I have found as long as mbb done in office, hasn’t been an issue, and my contracts are total garbage. If anyone is gonna get denied it’s gonna be me

HOPD

 

[agolden1]

Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria:

1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale*
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient’s pain, including but not limited to fracture, tumor, infection, or significant deformity.

*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment).

Note: The scales used for measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.

@Ducttape - What is your source for this? My practice has been having alot of issues with denials and I'd like to provide them with a source for this.

 

[Dr. Ice]

Here’s a simple solution. Don’t do anything in a hospital..like ever

 

[Ducttape]

@Ducttape - What is your source for this? My practice has been having alot of issues with denials and I'd like to provide them with a source for this.

um....
Centers for Medicare and Medicaid Services.

LCD - Facet Joint Interventions for Pain Management (L38803)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

 

[agolden1]

um....
Centers for Medicare and Medicaid Services.

LCD - Facet Joint Interventions for Pain Management (L38803)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

Know it seems like a dumb question, but I appreciate this. Thanks.