CMS facet updates 12/1

[Taus]

Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)

Anyone already have the cliff notes?

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[Sig123]

Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)

Anyone already have the cliff notes?

If you scroll all the way to the bottom of the article, it lists what was changed for each revision. In this case, it was minimal.

‘Article revised and published on 11/30/2023 effective for dates of service on and after 04/25/2021 in response to an inquiry. The language addressing use of CPT code 64999 for facet cyst aspiration/rupture has been removed. The following CPT code has been removed from the ICD-10 Group 1 Paragraph: 64999.’

 

[painfree23]

If you scroll all the way to the bottom of the article, it lists what was changed for each revision. In this case, it was minimal.

‘Article revised and published on 11/30/2023 effective for dates of service on and after 04/25/2021 in response to an inquiry. The language addressing use of CPT code 64999 for facet cyst aspiration/rupture has been removed. The following CPT code has been removed from the ICD-10 Group 1 Paragraph: 64999.’

So what do you bill for facet cyst aspiration?

 

[Ducttape]

it really only gives you one choice - just 64493...

 

[Drd105]

Mbb timing question for Medicare pls advise: would any of you who did mbb #1 on 11/30/22 do #2 on 12/14/23? That would be me doing #2 ON the 14th day… I have been waiting until day 15 minimum for all but some lovely person scheduled patient on day 14. Should I reschedule?

 

[bedrock]

Is this a thing with MBB? I know that unilateral RFA must be 10 days apart due to to global period. ESI have to be at least two weeks apart and rightly so.

But I didn’t think there was time restriction with MBB?

 

[BobBarker]

@Drd105 there is an error on your dates 22 vs 23
I think it is ok to proceed as long as it has been 10 days. I think I have some that are 7-10 days recently but can’t be certain.

 

[Ducttape]

2 weeks. at least for Medicare/Medicaid or any following LCDs.

your 14 days is okay.

the 10 days is not, technically.

The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure.

LCD - Facet Joint Interventions for Pain Management (L35936)

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

www.cms.gov

 

[drrosenrosen]

We always do ours at 14 days, no problems

 

[CleanUp]

We always do ours at 14 days, no problems

Between MBB 1 and MBB2
Or is it between MBB 1 , MBB2 and RFA?

Thanks

 

[bedrock]

2 weeks. at least for Medicare/Medicaid or any following LCDs.

your 14 days is okay.

the 10 days is not, technically.

LCD - Facet Joint Interventions for Pain Management (L35936)

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

www.cms.gov

What about 12 days. I have alternate procedure days each week.

Never an issue with ESI, but I wonder if 12 days apart will be ok for MBB?

 

[Ducttape]

given that this is medicare, one would only find out if it gets clawed back.


i had one insurance - one of the Option plans that has 3 initials and starts with M - that did not allow asking for RFA until 2 weeks after last MBB.

 

[drrosenrosen]

Between MBB 1 and MBB2
Or is it between MBB 1 , MBB2 and RFA?

Thanks

MBB#1 - 12/1, MBB#2 - 12/15, RFA - 12/29

 

[cowboydoc]

MBB#1 - 12/1, MBB#2 - 12/15, RFA - 12/29

Better make sure each is scheduled later in the day than the former. Awaiting clarification whether the scheduled time or time stamp of signing the note is used to determine time of day.

 

[painfree23]

MBB#1 - 12/1, MBB#2 - 12/15, RFA - 12/29

Do u do a follow up in between mbbs?

 

[drrosenrosen]

Do u do a follow up in between mbbs?

No we're office based so no need (yet)

 

[Ducttape]

you have to have some documentation that the said procedure had the effective benefit for the appropriate duration of the local anesthetic

an office visit generates the most income, but...

i am booked 6 weeks out, so currently patients are instructed to send in the "pain diary" results the next day documenting 80% reduction of pain, and when their pain has returned to >6 (typically when they contact us), we request the next injection.

 

[Dr. Ice]

Do u do a follow up in between mbbs?

Always do, telehealth at the very least

 

[powermd]

Have our specialty societies done anything to challenge the ridiculous two-week guideline-that's-actually-a-rule on MBBs? This is so inconvenient to patients.

 

[Drd105]

@Drd105 there is an error on your dates 22 vs 23
I think it is ok to proceed as long as it has been 10 days. I think I have some that are 7-10 days recently but can’t be certain.

WOW….yes i meant 2023 for both- sorry- thank you!

 

[Doctodd]

Facet cyst aspiration is still an mbb it seems

 

[Dr. Ice]

I used to try to get approval for 64483 and 64493, facet “injection” and tfesi, as of end of last year some insurances “approved” it

You’re gonna eat something for these, often times if I can’t aspirate, I will “fenestrate” hopefully the capsule. People do reasonably well.

Is there a code for fenestration?

 

[Dr. Ice]

Have our specialty societies done anything to challenge the ridiculous two-week guideline-that's-actually-a-rule on MBBs? This is so inconvenient to patients.

is it more inconvenient than having them come back one side at a time for rfa? That there is physician greed..I’ve never done it even out of training

Yeah yeah let’s tout the head drop for bilateral cervical, that will make us feel better. How bout lumbar?

 

[Ducttape]

when i have done cervical RFA separately, i seem to remember that insurances would only pay for a 50 modifier on the second side.

 

[thiswonthurtabit]

Had a fun one a month or so ago. Guy follows up a few days after MBB#1, did great and was super pleased so I requested auth for MBB#2 (some managed medicare plan) but because I requested auth less than 2 weeks after MBB1 they denied and because it was a "medicare determination" or some other bull**** I couldn't just hop on the phone and explain to a doc in a p2p that we'd be doing the MBB more than 2 weeks after the first one (particularly since the denial came in after that 2 week mark) and they forced me to write a letter to medicare. I wrote a pretty scathing letter stopping just short of calling the denial *****ic. Auth came through a week later. MBB#2 was also positive, RFA pending.

 

[MitchLevi]

Had a fun one a month or so ago. Guy follows up a few days after MBB#1, did great and was super pleased so I requested auth for MBB#2 (some managed medicare plan) but because I requested auth less than 2 weeks after MBB1 they denied and because it was a "medicare determination" or some other bull**** I couldn't just hop on the phone and explain to a doc in a p2p that we'd be doing the MBB more than 2 weeks after the first one (particularly since the denial came in after that 2 week mark) and they forced me to write a letter to medicare. I wrote a pretty scathing letter stopping just short of calling the denial *****ic. Auth came through a week later. MBB#2 was also positive, RFA pending.

This is why I'm relatively sure I won't see this through for an entire career.

 

[SSdoc33]

never do a peer to peer.

never

they are for early-career suckers who rely on your guilt and empathy to do unpaid work. dont do them

 

[MitchLevi]

never do a peer to peer.

never

they are for early-career suckers who rely on your guilt and empathy to do unpaid work. dont do them

I was not of this mindset until recently.

I'm there.

I'll do it under special circumstances.

 

[painfree23]

I was not of this mindset until recently.

I'm there.

I'll do it under special circumstances.

What do you do instead?

 

[bedrock]

never do a peer to peer.

never

they are for early-career suckers who rely on your guilt and empathy to do unpaid work. dont do them

what do you tell patients?

What about if the patient makes another appointment with you, just to ask you to a do a peer to peer?

 

[Ducttape]

you have your secretary call the patient and say "your insurance denied the injection. the doctor is aware and would like to see you to review the reasons for denial so that when he resubmits, there will be no just cause for further denial."

if they ask to do a peer to peer, i tell them that success rate for this is very low.

 

[SSdoc33]

what do you tell patients?

What about if the patient makes another appointment with you, just to ask you to a do a peer to peer?

i tell the patients that their insurance company is playing games with their health, is wrong, or is lying to them.

often times, a peer to peer is requested prior to a formal denial. no way. show me the paperwork. you dont get to waste my time with a peer to peer when i can just read it in 2 seconds. there is always an official denial. then, you can eaily addened your note -- change the pain scale from a 5 to a 6, say they had 80% pain relief, say they have done some form of PT, say they cant vacuum/rake leaves. whatever nonsense happens to to be on the LCD this week. then just resubmit for auth. it almost always gets authorized. if not, im not gonna argue with an insurance shill doc.

if a patient makes a f/u to ask me for a p2p, 1. that would be very unusual, and 2. id tell them im working on the auth.

it is very easy to blame things on insurance b/c the problem is almost almost their fault and people hate insurance companies anyway.

and for the 1% that doesnt think im working hard enough for them? they can certainly find another doc.