Medicare si joint requirements

[buddababa]

This probably applies to some commercial as well, as i have gotten information from aetna and certain BCBS out of state plans

For medicare part a & b, do we need to do 2 diagnostic blocks (aka without any steroid usage)? before we can do a therapeutic injection? Or can we actually use steroid in the diagnostic block (the LCD isn't clear)

Thoughts?

whats everyone doing so far?

i can't get a clear answer from my hospital

LCD - Sacroiliac Joint Injections and Procedures (L39475)

Use this page to view details for the Local Coverage Determination for Sacroiliac Joint Injections and Procedures.

www.cms.gov

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[cowboydoc]

This probably applies to some commercial as well, as i have gotten information from aetna and certain BCBS out of state plans

For medicare part a & b, do we need to do 2 diagnostic blocks (aka without any steroid usage)? before we can do a therapeutic injection? Or can we actually use steroid in the diagnostic block (the LCD isn't clear)

Thoughts?

whats everyone doing so far?

i can't get a clear answer from my hospital

LCD - Sacroiliac Joint Injections and Procedures (L39475)

Use this page to view details for the Local Coverage Determination for Sacroiliac Joint Injections and Procedures.

www.cms.gov

1. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the day of the SIJ injection, post-intervention on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.

You can put steroid in your "diagnostic" injection.

 

[buddababa]

1. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the day of the SIJ injection, post-intervention on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.

You can put steroid in your "diagnostic" injection.

that's what i assumed so, but then how does it become diagnostic - what makes it different than a "therapeutic" injection?

 

[thiswonthurtabit]

My reading of the LCD is a single positive diagnostic block. One potential challenge of using steroid in your "diagnostic" injection is that it needs to provide 75% relief for the duration of the steroid rather than the "therapeutic" threshold of 50%.

Don't forget the additional documentation requirements if you go beyond a year:

1. It generally would not be considered medically reasonable and necessary for treatment with SIJIs to extend beyond 12 months. Frequent continuation of SIJIs injections over 12 months may trigger a focused medical review. Use beyond twelve month requires the following:
   1. Pain is severe enough to cause a significant degree of functional disability or vocational disability and providers use established and measurable goals and objective scales to assess functionality and ADLs measures.
   2. SIJIs provides at least 50% sustained and consistent improvement of pain and/or 50% sustained and consistent objective improvement in function (using same scale as baseline) for at least three (3) months.
   3. Rationale for the continuation of SIJIs including but not limited to patient who are high-risk surgical candidates, the patient does not desire surgery, and/or the recurrence of pain in the same location was sustained and consistently relieved with the SIJIs for at least three (3) months.
   4. The primary care provider should be notified regarding continuation of procedures and prolonged repeat steroid use to allow for systematic care delivery treatment surveillance and multidisciplinary biopsychosocial rehabilitation (MBR).

 

[bedrock]

Exactly. Just do two SIJ injections. One diagnostic and then one therapeutic. This way you can
1- charge Medicare twice for this stupid rule , 2- help the patient by NOT including steroid in the first injection so that all subsequent SIJ injections only have to provide 50 % relief to be repeated (not 75% relief)

 

[buddababa]

Exactly. Just do two SIJ injections. One diagnostic and then one therapeutic. This way you can
1- charge Medicare twice for this stupid rule , 2- help the patient by NOT including steroid in the first injection so that all subsequent SIJ injections only have to provide 50 % relief to be repeated (not 75% relief)

thanks, much appreciated

 

[clubdeac]

These nuanced and differing rules are getting absolutely ridiculous. 50%, 75% , 80% relief. It’s a damn different cut off for everything. How completely asinine