New Prior Auth Requirements for Novitas for facet procedures

[jsaul]

I am sure you are all aware that starting July 1st Novitas is requiring all facet procedures (MBBs, injections, RFAs) to get pre authorized if done in an HOPD. So all you employed hospital docs and those of you doing procedures in a surgical hosptial will now be required to get pre auth for all facet procedures in regular medicare patients if you want yo get paid. And then Novitas stated it can take 10 business days to get approval.
This is going to be a ****show

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[Ducttape]

ive been getting prior auth for all injections, for the past 4 years.

dont have Novitas in this area though.

 

[jsaul]

How and why did you get prior auth for traditional Medicare patients. With other insurances you can mainly get prior auth online but for regular Medicare how did you even do that

 

[Ferrismonk]

We don't have Novitas either, but yes, Medicare is requiring auth for branch blocks and RF for us soon as well.

 

[Ronin1]

I’m assuming it is the same way that we have been getting Medicare approval for scs for the last year. I’ve gone to requiring a follow up visit between MBB and before RFA to get appropriate documentation to get authorization. More wrvus lol. Just another bit of nonsense

 

[painfree23]

I’m assuming it is the same way that we have been getting Medicare approval for scs for the last year. I’ve gone to requiring a follow up visit between MBB and before RFA to get appropriate documentation to get authorization. More wrvus lol. Just another bit of nonsense

Is it really more wrvu? Did u not bill an office visit and RFA-modifier 25?

 

[Ronin1]

Is it really more wrvu? Did u not bill an office visit and RFA-modifier 25?

Separate office and procedure visits. We used to skip the in between visits Donnie additional 99213s

 

[Analgesia108]

Does CMS require 2wks in between facet procedures? In which case, the following is a possible timeline:

Office visit --> 1st MBB visit -->1wk later, Office Visit to document >80% relief and improved function--> 1wk later-->2nd MBB visit --> 1wk later, Office Visit to document >80% relief and improved function-->1wk later, RFA visit

 

[SC Tian]

my understanding, it is only applied to HOPD, similar to scs authorization, office and asc based injections are not affected.

 

[geauxg8rs]

my understanding, it is only applied to HOPD, similar to scs authorization, office and asc based injections are not affected.

For now

 

[Ducttape]

does anyone have the link to this new policy? i tried looking online but didnt find it.

 

[DOctorJay]

does anyone have the link to this new policy? i tried looking online but didnt find it.

 

[manowar rules]

Does CMS require 2wks in between facet procedures? In which case, the following is a possible timeline:

Office visit --> 1st MBB visit -->1wk later, Office Visit to document >80% relief and improved function--> 1wk later-->2nd MBB visit --> 1wk later, Office Visit to document >80% relief and improved function-->1wk later, RFA visit

No wonder it’s so hard for pain patients to maintain employment

 

[Asclepius186]

No wonder it’s so hard for pain patients to maintain employment

Fwiw you could do those MBB f/u visits via Telehealth

 

[DrMDAware]

Separate office and procedure visits. We used to skip the in between visits Donnie additional 99213s

I’d argue it is a 99214. One diagnosis. Still
Being managed. Not improved. Recommending procedure.

 

[buddababa]

Does CMS require 2wks in between facet procedures? In which case, the following is a possible timeline:

Office visit --> 1st MBB visit -->1wk later, Office Visit to document >80% relief and improved function--> 1wk later-->2nd MBB visit --> 1wk later, Office Visit to document >80% relief and improved function-->1wk later, RFA visit

I wish I could do that. I’m so busy that doing so would put out my next injection availability (and OV) more than the 2.5 months that it is.

 

[Dr. Ice]

I wish I could do that. I’m so busy that doing so would put out my next injection availability (and OV) more than the 2.5 months that it is.

How can you justify a 2.5 month wait for a cortisone shot? My patients can’t even wait 3 weeks. I’m constantly putting them in places I don’t even have

 

[buddababa]

How can you justify a 2.5 month wait for a cortisone shot? My patients can’t even wait 3 weeks. I’m constantly putting them in places I don’t even have

I can’t. I just apologize. But people wait. For severe ones I add on to end of the day, but it’s been like this for over a year now.

 

[Ronin1]

I’d argue it is a 99214. One diagnosis. Still
Being managed. Not improved. Recommending procedure.

It’s a 1 minute visit by my NP usually or me in between procedures. 99213 is enough for me

 

[BobBarker]

agreed. 1-2 min visit typically. Best done by NP via telemed.

 

[DrMDAware]

agreed. 1-2 min visit typically. Best done by NP via telemed.

It can still be a 99214 if done via tele or an NP.

 

[BobBarker]

You got to have a few level 3s somewhere might as well be these visits.

 

[Dr. Ice]

I can’t. I just apologize. But people wait. For severe ones I add on to end of the day, but it’s been like this for over a year now.

Where do you practice? Where I’m at, someone would scoop that patient up in no time. No one in the northeast is dealing with pain for 2.5 months when someone around the block can do the shot in 3 days

 

[buddababa]

Where do you practice? Where I’m at, someone would scoop that patient up in no time. No one in the northeast is dealing with pain for 2.5 months when someone around the block can do the shot in

Agree with you. Negatives of being in HOPD. Staff doesn’t wanna work hard and stay late. I’m in Midwest.

 

[painfree23]

Separate office and procedure visits. We used to skip the in between visits Donnie additional 99213s

But why not 99213-25 + the 2nd injection in the same visit?

 

[Dr. Ice]

Where do you practice? Where I’m at, someone would scoop that patient up in no time. No one in the northeast is dealing with pain for 2.5 months when someone around the block can do the shot in 3 days

I knew I should have relocated..🤦🏽‍♂️

 

[DrMDAware]

You got to have a few level 3s somewhere might as well be these visits.

I hear what you’re saying and largely I agree. I have enough patients sprinkled throughout the day to get a level 3, though. Refilling non opioids, talking about PT, muscle strain and recommending apap etc.

And I know it’s a weak defense but I see straight 4s billed out by ortho quite frequently and they’re still collecting (to my knowledge).

It’s not my fault insurance companies make it so there’s two test injections.

 

[lobelsteve]

But why not 99213-25 + the 2nd injection in the same visit?

Probably have to submit the diary info and weight for 4 days for auth.

 

[sloh]

I hear what you’re saying and largely I agree. I have enough patients sprinkled throughout the day to get a level 3, though. Refilling non opioids, talking about PT, muscle strain and recommending apap etc.

And I know it’s a weak defense but I see straight 4s billed out by ortho quite frequently and they’re still collecting (to my knowledge).

It’s not my fault insurance companies make it so there’s two test injections.

Don’t hate the playa, hate the game baby

 

[Ronin1]

But why not 99213-25 + the 2nd injection in the same visit?

We will see how it plays out but I suspect we will need authorization for each MBB and RFA separately so eval(99204) to get auth for 64493/94 then fu(99213/4) 2-3 days later to get auth again for mBB. Then fu again to get auth for RFA.
Each time can take up to 10 days for authorization so the process with now Take even longer.

As usual well intentioned regulations lead to more costs

 

[Dr. Ice]

We will see how it plays out but I suspect we will need authorization for each MBB and RFA separately so eval(99204) to get auth for 64493/94 then fu(99213/4) 2-3 days later to get auth again for mBB. Then fu again to get auth for RFA.
Each time can take up to 10 days for authorization so the process with now Tai even longer.

As usual well intentioned regulations lead to more costs

This is how it is now with private payors

 

[Dr. Ice]

I tell everyone that the whole rfa process make take 6 weeks or longer based on requirements, authorizations and scheduling. And I tell them right off the bat after they wonder why x doctor just talked about epidurals all day. And then I say that’s cause no one wants to have the long winded conversation I’m having with you right now. Some laugh, some don’t think it’s funny

 

[RoloTomassi]

MAs just do documented phone calls getting % relief. Giving up a couple E&Ms but overall smoother process, faster turnaround.

 

[bedrock]

MAs just do documented phone calls getting % relief. Giving up a couple E&Ms but overall smoother process, faster turnaround.

I do the same.....for government patients. It just isn't worth the time to arrange all those f/u visits when you're getting paid so little for them anyway.

 

[Dr. Ice]

I do the same.....for government patients. It just isn't worth the time to arrange all those f/u visits when you're getting paid so little for them anyway.

But for private payors you are bringing them back in each time right?

 

[Tboned]

But for private payors you are bringing them back in each time right?

No

 

[DrMDAware]

MAs just do documented phone calls getting % relief. Giving up a couple E&Ms but overall smoother process, faster turnaround.

Do you have to sign off on it? Are they asking about any complications? I know a lot of people do this. I’m just wondering if there’s any pushback by the insurance companies.

 

[Tboned]

Do you have to sign off on it? Are they asking about any complications? I know a lot of people do this. I’m just wondering if there’s any pushback by the insurance companies.

Zero pushback. Only MBBs I follow up on are negative.

I think my patients would be pissed coming in after a +MBB to see me for 1 minute to say it’s positive and tell them the next step, which I’ve already explained to them when I ordered the original MBB.

I guess some patients would put up with this mumbo jumbo, vast majority of mine would not.

 

[RoloTomassi]

Zero pushback. Only MBBs I follow up on are negative.

I think my patients would be pissed coming in after a +MBB to see me for 1 minute to say it’s positive and tell them the next step, which I’ve already explained to them when I ordered the original MBB.

I guess some patients would put up with this mumbo jumbo, vast majority of mine would not.

Especially true for commercial patients who often have a copay or high deductible so they are paying some amount of cash for that 1 min. Document amount of relief, duration, functional improvement (many insurances requiring this now) complications.

 

[DrMDAware]

Especially true for commercial patients who often have a copay or high deductible so they are paying some amount of cash for that 1 min. Document amount of relief, duration, functional improvement (many insurances requiring this now) complications.

good point about commercial patients. But again, why should we not bill anything since it’s the insurance company’s stupid games?

And if you do bilateral they’ll “love you back” and pay 50%. Wtf.

Zero pushback. Only MBBs I follow up on are negative.

I think my patients would be pissed coming in after a +MBB to see me for 1 minute to say it’s positive and tell them the next step, which I’ve already explained to them when I ordered the original MBB.

I guess some patients would put up with this mumbo jumbo, vast majority of mine would not.

I hear what you’re saying. My patients need to have it explained multiple times though. “Wait so this first one wasn’t the burn? When’s the epidural?”

I’d caution you to not view it as mumbo jumbo my friend. It technically is a procedure and there are risks involved. If anything goes wrong the plaintiff attorney would have a field day. It is silly sure I’m not arguing with you but if some/most other people are checking in on them (or having their PA/NP) see them then one could argue it’s not standard of care.

 

[Ferrismonk]

I'm curious how you get auth with only phone call documentation? My insurances tend to want office notes between shots to document relief/functional improvement.

 

[Ducttape]

It can still be a 99214 if done via tele or an NP.

you have to justify the 99214 for that MBB follow up - im talking specifically about the first one. it isnt a 25 minute visit, the complexity is just not there for a level 4 visit, and they already know what happens with MBB.

now i can see stretching out the education/counselling and setting up an RFA as a level 4 visit after the second MBB, and the complexity of the procedure itself, but it is a little iffy... but thats not what i do.


i typically will tell patients that insurance wants follow ups after each MBB, and we will have a follow up - usually telemed - after the first MBB. if that one is successful and while the patient is signing consent for the second one, i tell them that we will assess right after this second MBB and forego the in person follow up for this MBB if it does have immediate effects, as long as they call the next day to document that it did last for a couple of hours and that pain has returned to >6.


i ask for RFA if they do their part, and i ask the staff to call for follow up if they dont or if it doesnt work.

Where do you practice? Where I’m at, someone would scoop that patient up in no time. No one in the northeast is dealing with pain for 2.5 months when someone around the block can do the shot in 3 days

i live in the NE.

outside of Manhattan, this is not the case. people do wait - if they trust the doctor. this local area has a 1 1/2 month wait for new patient evaluations from essentially all physicians in the area.

 

[Dr. Ice]

I'm curious how you get auth with only phone call documentation? My insurances tend to want office notes between shots to document relief/functional improvement.

I’m not dealing with denials. It clogs up my schedule but these people are coming in after every shot to document improvement prior to rfa.

 

[Ferrismonk]

I get what people are saying, but to bill a 99214, all you need is to address two chronic illnesses and to order a procedure that has moderate risk. MBB counts as moderate risk. Boom, done.

99213 is eval after RF and you high-five them while they schedule f/u prn. (1x chronic illness, reviewing results/complications of RF)

 

[RoloTomassi]

I'm curious how you get auth with only phone call documentation? My insurances tend to want office notes between shots to document relief/functional improvement.

We submit our phone call templates which have all the required info

 

[SSdoc33]

more than 1 way to skin a cat.

seems like the requirements differ based on location and insurance.

i do the mbb f/u myself b/c i dont trust anyone else to do it right and im sure i would lose some RFs if i didnt.

for me, it is MBB, then telehealth f/u 2 weeks later, then second MBB and RF 1 week later. i book the RF at the same time i book the MBB b/c i rarely, if ever, have a negative second MBB.

im not 100% sure i get paid on all the follow-ups -- and i dont really care all that much -- but the procedures always get reimbursed.

 

[Tboned]

good point about commercial patients. But again, why should we not bill anything since it’s the insurance company’s stupid games?

And if you do bilateral they’ll “love you back” and pay 50%. Wtf.


I hear what you’re saying. My patients need to have it explained multiple times though. “Wait so this first one wasn’t the burn? When’s the epidural?”

I’d caution you to not view it as mumbo jumbo my friend. It technically is a procedure and there are risks involved. If anything goes wrong the plaintiff attorney would have a field day. It is silly sure I’m not arguing with you but if some/most other people are checking in on them (or having their PA/NP) see them then one could argue it’s not standard of care.

Here’s my process. I practice in the Midwest FWIW.
I order MBB, discuss MBB/RFA process/risks with the patient during that visit. Give them printed patient education for them to take home and reference. I get written consent on day of procedure and if they have questions regarding the MBB/RFA, they are answered in person by me. I don’t have a midlevel.
After first MBB, patient gets a pain log to fill out. They send it back in and I review. If negative, f/up appt scheduled. If positive my assistant documents %relief and duration, scan pain log into emr and second MBB ordered.
Repeat MBB, consent, answer questions in person. If pain log positive, documented into chart, pain log scanned, RFA ordered.
Patient consented in person, by me, and final, if any, questions answered on RFA procedure day. (Obviously always happy to answer questions if need prior to procedure day)
In essence I am checking on them at each visit procedure visit, I’m just not doing it in a formal office visit. If something goes wrong during a MBB/RFA procedure, do you think because you had a midlevel do an MBB followup that it will afford you some sort of extra protection?

 

[DrMDAware]

If something goes wrong during a MBB/RFA procedure, do you think because you had a midlevel do an MBB followup that it will afford you some sort of extra protection?

With all due respect yes. The midleveler can document answers to key questions as well as get me involved, if needed. I can send to get additional testing and medical opinions. I can loop in any family members to answer any questions. I do not trust a patient to evaluate themselves and nor does the medical board because they aren’t licensed to evaluate a patient.

If it ever goes to court you can show you satisfied duty and did not deviate from standard of care:
1. Physician cared enough to document a follow up
2. Physician has concern enough to monitor them and bring them back

You’ll also not look an a hole if you documented you spoke to the family, talked to their PCP, and got more testing or labs.

Having a midleveler will not change the other d which is damage with that you are correct.

If your process works for you then great! We all have different levels of risk tolerance. I err more on the cautious side. To each her own.

This is more of a critique and concern on the litigious nature of our field and not of your process.

 

[Yo GabbaPentin]

Our insurance carriers make us document “facet loading positive” on exam. How do you all manage this via tele-visits?

 

[DrMDAware]

Our insurance carriers make us document “facet loading positive” on exam. How do you all manage this via tele-visits?

Lean back and twist.

Does it hurt?