CMS proposed authorization for facet procedures

IPSIS: Formerly the Spine Intervention Society
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Ronin1 said:
Just got a heads up that CMS is proposing adding all facet interventions 64490-95, 64633-36 to list of procedures requiring authorization as of 3/1/23. Hassle factor going up some more
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maybe its time to become an opioid only clinic - this budget neutral crap is making me mad,
 
It looks like this is for the hospital outpatient only (similar to what they did for Botox in this setting):

CMS proposes to add Facet Joint Interventions as a new service category subject to the Hospital Outpatient Prior Authorization Process on or after March 1, 2023. For CY 2020, CMS finalized a policy whereby hospitals must seek provisional affirmation of coverage before select outpatient services are furnished to beneficiaries and before a claim can be submitted for processing. This prior authorization requirement applied initially to only five categories of services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation
 
I wonder if this will reduce clawbacks from RAC audits if they have to review for medical necessity first.
 
welp, looks like it went into effect. Had to cancel all my medicare mbb's and RFA's this week because we hadn't gotten authorization. From now on will need authorization for all my medicare facet interventions. What a bunch of ****. Not sure how much longer I can do this job
 
clubdeac said:
welp, looks like it went into effect. Had to cancel all my medicare mbb's and RFA's this week because we hadn't gotten authorization. From now on will need authorization for all my medicare facet interventions. What a bunch of ****. Not sure how much longer I can do this job
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Deac, I don’t recall your current practice situation. Are you HOPD or private practice?

Does this Medicare auth rule you are referring to apply to ASC/office or just HOPD?

I’m wondering if this is different from the MBB/RFA rule that started a couple years ago only for HOPD docs?
 
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clubdeac said:
welp, looks like it went into effect. Had to cancel all my medicare mbb's and RFA's this week because we hadn't gotten authorization. From now on will need authorization for all my medicare facet interventions. What a bunch of ****. Not sure how much longer I can do this job
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This has been about a year or two with my practice. is this new to you?
 
I’m HOPD. I know we talked about it on here but nothing at my hospital changed so I guess I thought it hadn’t gone into effect. Then boom, my admin and scheduler tell me they have to start doing things differently, getting prior auths etc and canceled 1/3 of my procedures this week. Ughhh
 
BobBarker said:
Either their policy was expanded to his MAC or they haven’t been getting paid for a year and just figured it out.
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this is probably it. his local medicare carrier may not have adopted the new rules until 2025. but yes, it is a huge PITA
 
Good questions. I’m not sure. I knew it was mentioned on here but my auth girls and admin never mentioned it so if figured they knew what they were doing. Who knows. All I know is that I share my scheduler with another doc and she’s going to be swamped with damn prior auths. It’s complete garbage
 
clubdeac said:
Good questions. I’m not sure. I knew it was mentioned on here but my auth girls and admin never mentioned it so if figured they knew what they were doing. Who knows. All I know is that I share my scheduler with another doc and she’s going to be swamped with damn prior auths. It’s complete garbage
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it takes a while to work out the kinks. basically, you have to copy and paste the verbiage from the LCD to your note. but there are bunch of data points for every visit and it does take up a lot of time. pro tip: bill an e/m for the follow ups in between the 2 mbbs and the RF. you and your staff is doing the work, make sure you get paid for it
 
It’s so fun.. you pp guys and gals need to join us 🥳
 
SSdoc33 said:
it takes a while to work out the kinks. basically, you have to copy and paste the verbiage from the LCD to your note. but there are bunch of data points for every visit and it does take up a lot of time. pro tip: bill an e/m for the follow ups in between the 2 mbbs and the RF. you and your staff is doing the work, make sure you get paid for it
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Exactly. Thats 2 easy 99213s and G2211s between the MBBs.
 
hopefulgasman said:
your HOPD auth departments stink. Been getting auths for MBBs/RFAs for months at my HOPD. The fact that they were behind the eight ball and now all of your MBB/RFAs were cancelled is unacceptable.
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I agree 100%
 
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SSdoc33 said:
it takes a while to work out the kinks. basically, you have to copy and paste the verbiage from the LCD to your note. but there are bunch of data points for every visit and it does take up a lot of time. pro tip: bill an e/m for the follow ups in between the 2 mbbs and the RF. you and your staff is doing the work, make sure you get paid for it
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how do you bill for it if it's just a nurse calling them for 2 minutes?
 
I have not had any issues like this in PP.
 
you cant bill for the nurse call.

but you can bill a video call to tell the patient the injection risks and benefits and discuss subsequent steps.
 
Ducttape said:
you cant bill for the nurse call.

but you can bill a video call to tell the patient the injection risks and benefits and discuss subsequent steps.
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video takes too long
 
NVO said:
How do you reason it as a level 4? I've seen mixed views on 3 vs 4
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Level 4 is met by having a chronic, unstable/not controlled condition. Facet arthropathy is chronic and not controlled until RFA complete. I’ve always coded it as a 3 but may start doing it as a 4, as it does meet the letter of the law.
 
mdo1738 said:
Level 4 is met by having a chronic, unstable/not controlled condition. Facet arthropathy is chronic and not controlled until RFA complete. I’ve always coded it as a 3 but may start doing it as a 4, as it does meet the letter of the law.
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So a chronic unstable condition may qualify a level 4 but you need one more thing that qualifies it as a level 4, need 2/3. Are you saying that discussing and scheduling the RFA meets a level 4 for risk as well, thereby qualifying the entire visit as a level 4?
 
mdo1738 said:
Level 4 is met by having a chronic, unstable/not controlled condition. Facet arthropathy is chronic and not controlled until RFA complete. I’ve always coded it as a 3 but may start doing it as a 4, as it does meet the letter of the law.
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So by that logic lumbar radic for ESI is chronic/unstable?

Knee OA with knee IA injection same thing

Nope
 
mdo1738 said:
Level 4 is met by having a chronic, unstable/not controlled condition. Facet arthropathy is chronic and not controlled until RFA complete. I’ve always coded it as a 3 but may start doing it as a 4, as it does meet the letter of the law.
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unstable? not controlled?

the RFA controls it and stabilizes it?

as an ex-ER doc, any disease that can be treated with 3 injections over a 4 week period of time isnt unstable, its chronic.

i do not ever recall admitting a patient to Obs for facet arthropathy lumbar without radiculopathy or myelopathy.
 
SpineandWine said:
You’re likely wRVU, HOPD (they pay you before they get collections)
Hospital eating cost of denials- or will appeal
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there are plenty of ways to "overbill" and collect extra RVUs without the hospital noticing. this may be one of them, although i suspect that almost all 99214s are paid without an audit or clawback
 
SSdoc33 said:
there are plenty of ways to "overbill" and collect extra RVUs without the hospital noticing. this may be one of them, although i suspect that almost all 99214s are paid without an audit or clawback
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My billing department is very strict - they are horrible and not let me bill for my own visits
Same with all the other docs
 
SpineandWine said:
My billing department is very strict - they are horrible and not let me bill for my own visits
Same with all the other docs
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so you dont even check a code in your EMR? some compliance person reads every note then assigns a 99204 or 99213? that is insane
 
SgtThunderfistMD said:
2 diagnosis (facet arthropathy + chronic pain syndrome) that are chronic/stable
+
1 minor procedure scheduled
=
99214
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my calculator gives 99213.

2 or more stable chronic illnesses (moderate) with minor surgery with no identified risk factors (low) is 99213.

you'd have to say that an MBB or an RFA is minor surgery with identified risk factors to get 99214. i dont know about you, but i cant for the life of me say that an MBB or RFA has identified risk factor. what, that the person will get a rash if they lotion up beforehand?

but to each their own i guess.
 
Ducttape said:
my calculator gives 99213.

2 or more stable chronic illnesses (moderate) with minor surgery with no identified risk factors (low) is 99213.

you'd have to say that an MBB or an RFA is minor surgery with identified risk factors to get 99214. i dont know about you, but i cant for the life of me say that an MBB or RFA has identified risk factor. what, that the person will get a rash if they lotion up beforehand?

but to each their own i guess.
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Identified risk factors are related to the patient, not the procedure.

A decision to do a lesi on a healthy 45 year old is a lvl 3 for risk.

The same decision on a 67 year old diabetic is a lvl 4 when you document that you discussed the risk of hyperglycemia, the possibility of dka/hhs and the need to closely monitor their sugar for a few days after the procedure.
 
BoardingDoc said:
Identified risk factors are related to the patient, not the procedure.

A decision to do a lesi on a healthy 45 year old is a lvl 3 for risk.

The same decision on a 67 year old diabetic is a lvl 4 when you document that you discussed the risk of hyperglycemia, the possibility of dka/hhs and the need to closely monitor their sugar for a few days after the procedure.
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Any epidural is a level 4. I’d argue any SHOT is a level 4
 
SSdoc33 said:
Any epidural is a level 4. I’d argue any SHOT is a level 4
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Nah. Peripheral joint injections are considered to involve less risk, less skill to perform, less intellectual work to plan and consent patients vs neuroaxial injections.

This is why ortho bill all their clinic visits as level 3 unless they do a consent/discussion of a patient for surgery. You are over billing if you are charging level 4 clinic codes for peripheral joint injections.
 
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BoardingDoc said:
Identified risk factors are related to the patient, not the procedure.

A decision to do a lesi on a healthy 45 year old is a lvl 3 for risk.

The same decision on a 67 year old diabetic is a lvl 4 when you document that you discussed the risk of hyperglycemia, the possibility of dka/hhs and the need to closely monitor their sugar for a few days after the procedure.
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This right here is correct
 
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