CMS Noridian Audit for transforaminal injections

[hcrypt]

I am getting denial of payments and was told that I am over utilizing the epidural injections from Noridian CMS reviewer.

A patient received unilateral 2 level TFESI and was billed 64483 and 64484 for one session. Pt subsequently followed up and TFESI gave good relief so subsequently was scheduled to have the same unilateral 2 level TFESI at another date.

Per the reviewer, this accounted as 4 total epidural injection that the patient has received within this time frame of 6months. I was under the assumption that the unilateral 2 level TFESI counted as 1 epidural injection as it was done in one session.

What are your thoughts? I am getting denial stating that these 2 sessions counts as total of 4 epidural injections

PS. I looked up the CMS guidelines again for epidurals and it states the following:

Levels per session:

1. No more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally).
2. One caudal or lumbar interlaminar injection per session and not in conjunction with a lumbar transforaminal injection.

Utilization Guidelines:

• No more than 3 epidurals may be performed in a 6-month period of time.
• No more than 6 epidural injection sessions (therapeutic epidurals and/or diagnostic transforaminal injections) may be performed in a 12-month period of time regardless of the number of levels involved.

Thanks you in advance and what is my recourse. Do I need to hire a health care attorney to fight these?

Hcrypt

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[Ducttape]

I don't think the reviewer knows what he is talking about.

the 2 trasnforaminals count as 1 session.

maybe he is confusing transforaminal epidural injection with interlaminar epidural injection, and thought you did 2 (interlaminart) epidural injections in 1 session....


you should make sure your office did bill for 64483 & 64484, and didn't accidentally bill for 64483 x2.

 

[hcrypt]

Our office did bill 64483 x1 and 64484 x1 at each of the 2 sessions.

How can the reviewer count this as total of 4 epidurals that the patient has received?

Should I consult a health care attorney?

Thanks

 

[hcrypt]

Our office did bill 64483 x1 and 64484 x1 at each of the 2 sessions.

How can the reviewer count this as total of 4 epidurals that the patient has received?

Should I consult a health care attorney?

Thanks

 

[SommeRiver]

You'll win an appeal easily. Just do a P2P if you actually care enough to do it.

Nothing wrong with occasionally giving away a shot.

 

[lobelsteve]

Would also recommend not doing 2 level TFESI if adjacent segments.

 

[painfree23]

Would also recommend not doing 2 level TFESI if adjacent segments.

Multilevel severe stenosis, esp if stenosis in the recess, doesn’t want surgery, can try a 2 level IMO . May better than interlaminar if the stenosis is super severe

 

[SommeRiver]

Multilevel severe stenosis, esp if stenosis in the recess, doesn’t want surgery, can try a 2 level IMO . May better than interlaminar if the stenosis is super severe

Skip levels. Don't do adjacent level.

 

[painfree23]

Skip levels. Don't do adjacent level.

Im not sure I understand what this means? If the stenosis is bad at L4/L5, L5/S1 ur saying do L3 and L5?

 

[lobelsteve]

Multilevel severe stenosis, esp if stenosis in the recess, doesn’t want surgery, can try a 2 level IMO . May better than interlaminar if the stenosis is super severe

reference?

 

[SommeRiver]

Im not sure I understand what this means? If the stenosis is bad at L4/L5, L5/S1 ur saying do L3 and L5?

Severe spinal stenosis L4-S1 I would do S1 and either L4-5 or L3-4 TFESI.

 

[painfree23]

Severe spinal stenosis L4-S1 I would do S1 and either L4-5 or L3-4 TFESI.

Hm ok , What’s the reason?

 

[paindoc007]

Hm ok , What’s the reason?

Furman showed with about 3 cc in a tfesi you can 2-3 level spread.

But he does unilateral adjacent levels ALL the time. I’ve literally seen him at SIS meetings showing L4 and L5 TFESI pics. Whoops.

 

[bedrock]

You don’t necessarily always get medication spread to the nerve compression site by just injecting from below. Covering a level is not the same as treating the actual site of nerve compression, if compressed at lateral recess instead of centrally.
I’ve had patients where I do an S1 and I see dye spread all the way to L3 and it helps but doesn’t completely relieve their pain. Then I follow up with a unilateral L4-L5, L5–S1 and then finally all the leg pain resolves.

 

[SommeRiver]

You don’t necessarily always get medication spread to the nerve compression site by just injecting from below. Covering a level is not the same as treating the actual site of nerve compression, if compressed at lateral recess instead of centrally.
I’ve had patients where I do an S1 and I see dye spread all the way to L3 and it helps but doesn’t completely relieve their pain. Then I follow up with a unilateral L4-L5, L5–S1 and then finally all the leg pain resolves. S1 and L4-5.

S1 + L4-5 TFESI.

 

[Nodolor]

Not sure why skipping levels makes any more sense than doing adjacent levels

 

[10KHertz]

People: you NEED to take these types of denials to a Medicare Federal Judge. I Just won an appeal for MILD denial by an advantage Medicare program . That female Texas judge was great . She basically told the insurance paralegal to blow it out her ass...

 

[bedrock]

People: you NEED to take these types of denials to a Medicare Federal Judge. I Just won an appeal for MILD denial by an advantage Medicare program . That female Texas judge was great . She basically told the insurance paralegal to blow it out her ass...

Agree on the principle. These bustards need to pay. But how much time and money did you spend to fight it?

 

[10KHertz]

Agree on the principle. These bustards need to pay. But how much time and money did you spend to fight it?

It takes 30min of your day, which isn’t great. Appeal the denials until it goes to the Medicare fed judge level . Costs you nothing but the headache every now and then. But it does send a message to these carriers, and it ends up in their permanent record with the state insurance commission...

 

[SSdoc33]

there is no right answer as to which levels to inject. we all have our own way of doing it.

if there is a single nerve that is getting hit -- like an L4-5 paracentral HNP hitting L5 or focal NF stenosis at L4, I'll do a single level. if there is central stenosis, like in a LOL with severe stenosis at L4-5, i will do an L4 and L5 TFESI double level.

as far as P2P, just stop doing them. dont play their game.

 

[painfree23]

there is no right answer as to which levels to inject. we all have our own way of doing it.

if there is a single nerve that is getting hit -- like an L4-5 paracentral HNP hitting L5 or focal NF stenosis at L4, I'll do a single level. if there is central stenosis, like in a LOL with severe stenosis at L4-5, i will do an L4 and L5 TFESI double level.

as far as P2P, just stop doing them. dont play their game.

no P2P? How do you get it approved then?

 

[SSdoc33]

no P2P? How do you get it approved then?

wait for the official, written denial and then resubmit with addended paperwork to meet their "requirements". if it still doesnt get authorized, then tell the patient their insurance is BS and they are playing games. your time is not worth -- or shouldnt be worth -- a peer to peer

 

[Doctodd]

no L3's.......id pound the medicare guidelines into him and have your attorney buddy send a nice letter

 

[deleted875186]

People: you NEED to take these types of denials to a Medicare Federal Judge. I Just won an appeal for MILD denial by an advantage Medicare program . That female Texas judge was great . She basically told the insurance paralegal to blow it out her ass...

What is the process for doing this. I have had a few cases I would be willing to do this for patients I really like.

 

[10KHertz]

What is the process for doing this. I have had a few cases I would be willing to do this for patients I really like.

With denial of benefits, Noridian should give you a chance to appeal . 2nd or 3rd appeal goes to federal judge typically ...at least with my CMS carrier and advantage carriers