Medicare to stop audit on third and fourth level?

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Prior authorization (PA)for facet joint intervention

www.novitas-solutions.com www.novitas-solutions.com

Note: The following CPT codes were removed on August 16, 2024, and no longer require prior authorization:

64492 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s))
64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s))
Three (3) or four (4) level procedures are not medically necessary and therefore are non-covered.
 
yeah, i heard this, too.

basically it cannot be done, unless patient pays out of pocket, from my understanding
 
I’ve been doing L3/4 and L5/S1 to give patients their 3 levels if they really absolutely need it. Sucks to do unpaid work but I also need the procedures to “succeed” in order to keep patients and referring doctors happy
 
LOL. IPSIS cant figure it out, either.
 
A perfect example of how the insurance system is a broken: medicare can arbitrarily say 3 levels isn’t “necessary” as a blanket statement, yet approve COT for MSK pain despite no good evidence to support it… and plenty of downstream ill effects, which ends up hurting patient and costing the health system and society plenty of $$$
 
This could be a good thing if you have the time to explain an ABN and patients that are willing to pay another $100 per injection for another level bilaterally. I probably won’t go to that effort but some will.
 
BobBarker said:
This could be a good thing if you have the time to explain an ABN and patients that are willing to pay another $100 per injection for another level bilaterally. I probably won’t go to that effort but some will.
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at HOPD, the extra level is $3-4K
 
SpineandWine said:
Hard to justify
I’d have a hard time shelling that out for additional level RFA
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it is not justifiable. i dont even offer it. i tell them to find a PP guy if they want that 3rd level. nobody has yet, though
 
Agast said:
I’ve been doing L3/4 and L5/S1 to give patients their 3 levels if they really absolutely need it. Sucks to do unpaid work but I also need the procedures to “succeed” in order to keep patients and referring doctors happy
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that's what I've been doing as well!
 
I do it occasionally as well.
Not happy about it as we’re just screwing ourselves in long term/getting scammed

I might see if hospital may let me charge less for additional levels.
Do you know what process I need to charge patients for additional levels? Is there a Medicare form they have to fill out?
 
I’m pretty sure that’s why they did away with the 3rd level. To force doctors to practice leaner.
 
Agast said:
I’m pretty sure that’s why they did away with the 3rd level. To force doctors to practice leaner.
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I do but I still do what you describe since it’s not one size fits all
I do b/l L3-4 and L5-S1 if patient needs it


Which I feel we as pain specialty is screwing itself
 
Just do the extra needle for free is what I do. It doesn't add too much time to your procedure, and the outcomes are most likely going to be better.

It's infuriating and wrong, but not the patient's fault.
 
SSdoc33 said:
yeah, i heard this, too.

basically it cannot be done, unless patient pays out of pocket, from my understanding
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I've been having them pay out of pocket the whole time. It's the right thing to do when the government second guesses your medical decision making.
 
au bon pain said:
A perfect example of how the insurance system is a broken: medicare can arbitrarily say 3 levels isn’t “necessary” as a blanket statement, yet approve COT for MSK pain despite no good evidence to support it… and plenty of downstream ill effects, which ends up hurting patient and costing the health system and society plenty of $$$
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Just remember: The status quo is not an accident or unintended consequence. It's the direct result and a failure by design of actions and inactions.
 
Wondering what you guys do if they only get 50% reported from C3-5 mbb. Would you try again at C4-6 or C5-7 depending on pain location. It’s possible to do this per insurance/CMS guidelines right? 4 mbb per year per spinal segment or something like that
 
clubdeac said:
Wondering what you guys do if they only get 50% reported from C3-5 mbb. Would you try again at C4-6 or C5-7 depending on pain location. It’s possible to do this per insurance/CMS guidelines right? 4 mbb per year per spinal segment or something like that
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If they say something to the effect of it not hitting the right spot, yes, or just do a repeat and see if the second one works better.
 
drusso said:
I've been having them pay out of pocket the whole time. It's the right thing to do when the government second guesses your medical decision making.
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I do the same. It’s a slippery slope. Government and insurance companies take advantage of our altruism. I will frequently do 3rd levels or uncovered procedures for cash, because I refuse to let them take advantage of me.

Eventually they will just expect us to work for the salary of a postal worker, despite our superior intelligence, large student debts, and sacrifice of a dozen years + of our twenties and thirties.
 
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bedrock said:
I do the same. It’s a slippery slope. Government and insurance companies take advantage of our altruism. I will frequently do 3rd levels or uncovered procedures for cash, because I refuse to let them take advantage of me.

Eventually they will just expect us to work for the salary of a postal worker, despite our superior intelligence, large student debts, and sacrifice of a dozen years + of our twenties and thirties.
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its more of the fact that pain physicians had taken advantage of the system that these rules, however punitive they may be to the patient, are put in place. we reaped what we sowed.

it should not be standard of care to do 3-4 level RFAs every 3-4 months or 3 level bilateral TFESI every month x3. but this was the modus operandi of many a pain doc.
 
Ducttape said:
its more of the fact that pain physicians had taken advantage of the system that these rules, however punitive they may be to the patient, are put in place. we reaped what we sowed.

it should not be standard of care to do 3-4 level RFAs every 3-4 months or 3 level bilateral TFESI every month x3. but this was the modus operandi of many a pain doc.
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No. It's because of juicing the Vig on the SOS. Too many employed pain docs were willing to trade their gold (independence) for magic beans (SOS) and turn a blind eye to SOS arbitrage and facility fee fraud.

The pro fee on an additional level is pennies on the dollar compared to a ESI in a HOPD.
 
no, its not. you are trying to divert the discussion back to SOS. stay on target.

juicing the whatever you call it has been going on since 2000. remember, we are talking about limiting the injections by eliminating additional levels. that really has nothing to do with site of service because the same HOPD fees apply for 1 level or 3.



64623, each additional level, was $116 per level. so technically the additional 3rd level bilaterally would be at least $116, if not $230.
 
Ducttape said:
no, its not. you are trying to divert the discussion back to SOS. stay on target.

juicing the whatever you call it has been going on since 2000. remember, we are talking about limiting the injections by eliminating additional levels. that really has nothing to do with site of service because the same HOPD fees apply for 1 level or 3.



64623, each additional level, was $116 per level. so technically the additional 3rd level bilaterally would be at least $116, if not $230.
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his answer to everything is juicing the vig on SOS.
Pain docs doing questionable things? Juicing the vig on SOS
Patient sues doctor? Its because he/she juiced the vig on SOS
Global warming? Humans juiced the vig on SOS.
 
SSdoc33 said:
it is not justifiable. i dont even offer it. i tell them to find a PP guy if they want that 3rd level. nobody has yet, though
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i had one patient sign whatever paperwork to do additional level, turns out her supplemental plan covered it. go figure
 
Ducttape said:
its more of the fact that pain physicians had taken advantage of the system that these rules, however punitive they may be to the patient, are put in place. we reaped what we sowed.

it should not be standard of care to do 3-4 level RFAs every 3-4 months or 3 level bilateral TFESI every month x3. but this was the modus operandi of many a pain doc.
Click to expand...
my attending in fellowship, would make sure everyone got 3-4 esi, rfa, tpi and finally offer stim. SMH
 
Status Sciaticus said:
his answer to everything is juicing the vig on SOS.
Pain docs doing questionable things? Juicing the vig on SOS
Patient sues doctor? Its because he/she juiced the vig on SOS
Global warming? Humans juiced the vig on SOS.
Click to expand...

Don't take my word for it:

 
Saw this on Facebook. Seems relevant.
1723841341887.png
 
Status Sciaticus said:
Are you juicing the vig on that SOS and getting that affiliate link money?
😆

waiting for facet fusions to become a thing.
Do 1 facet at a time. Really gonna juice that SOS vig. /s
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I’m confused, do you not think the SOS differential is a thing or not a significant cost to patients or the system as a whole?

Have you yourself ever had to get an MRI or colonoscopy and looked at the out of pocket difference bw HOPD and an outpatient stand alone facility? I’ve done both. Got royally screwed with the colonoscopy when I thought I was doing the right thing. Found out I could’ve had it done at a fraction of the cost at the facility down the street not associated with the hospital, same practice.

OOP difference for MRI was $150 instead of $1250. I fortunately chose correctly on that one despite two different people from the insurance company telling me otherwise on the phone. It’s truly a corrupt system and that corruption, I would argue, dwarfs the few bad apple physicians duct sanctimoniously bemoans

Most patients have no idea the 10x difference in cost for the same service/procedure. It’s a complete racket
 
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clubdeac said:
I’m confused, do you not think the SOS differential is a thing or not a significant cost to patients or the system as a whole?

Have you yourself ever had to get an MRI or colonoscopy and looked at the out of pocket difference bw HOPD and an outpatient stand alone facility? I’ve done both. Got royally screwed with the colonoscopy when I thought I was doing the right thing. Found out I could’ve had it done at a fraction of the cost at the facility down the street not associated with the hospital, same practice.

OOP difference for MRI was $150 instead of $1250. I fortunately chose correctly on that one despite two different people from the insurance company telling me otherwise on the phone. It’s truly a corrupt system and that corruption, I would argue, dwarfs the few bad apple physicians duct sanctimoniously bemoans

Most patients have no idea the 10x difference in cost for the same service/procedure. It’s a complete racket
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…and exactly why private practice groups and solo docs are slowly becoming a thing of the past.

Systems buying practices en masse. You cannot compete.

Seems like everything is contracting into a few small entities in every industry.
 
clubdeac said:
I’m confused, do you not think the SOS differential is a thing or not a significant cost to patients or the system as a whole?

Have you yourself ever had to get an MRI or colonoscopy and looked at the out of pocket difference bw HOPD and an outpatient stand alone facility? I’ve done both. Got royally screwed with the colonoscopy when I thought I was doing the right thing. Found out I could’ve had it done at a fraction of the cost at the facility down the street not associated with the hospital, same practice.

OOP difference for MRI was $150 instead of $1250. I fortunately chose correctly on that one despite two different people from the insurance company telling me otherwise on the phone. It’s truly a corrupt system and that corruption, I would argue, dwarfs the few bad apple physicians duct sanctimoniously bemoans

Most patients have no idea the 10x difference in cost for the same service/procedure. It’s a complete racket
Click to expand...
The largest healthcare expenditures are administrative costs, primarily administrative salaries and payroll, not this SOS vig juicing BS.
Yep, I've had MRIs done. I specifically go to freestanding centers that charge minimal to my deductible. If I am maxed on my OOP, then IDGAF where I go as long as its most convenient and quickest.

If you have such an issue, juice the vig, send out that SOS, whatever you call it, and then drop the patient portion. Patients dont pay much, insurers pay like they are supposed to, and you get paid appropriately.
 
Whoever doesn’t believe, want to believe, is in denial about believing or is actually part of the SOS machine…is actually the problem

Hospitals need to stop hiding behind emtala as reason to “squeeze everyone’s juice dry”

Im fairly certain Harris and her boy toy are just going to continue to drive docs into more “controllable” massive systems which are themselves out of control from a cost perspective.

It’s funny how she wants to talk about grocery stores price gauging but can’t comprehend how much hospitals price gauge bandaids…
 
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SpineandWine said:
What’s wrong with bloat?
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That’s exactly why nothing will ever change and just continue to worsen. The facility will never take a pay cut..but we will continuously
 
Dr. Ice said:
That’s exactly why nothing will ever change and just continue to worsen. The facility will never take a pay cut..but we will continuously
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But you’re back handed paid if wRVU (depending on negotiated price, you make out more than collections) or own shares in ASC

So its good for physicians as well

So it appears bloat is not bad
But what you’re getting at is feeling of unfairness in pro fee cut, which I agree is bad
 
SpineandWine said:
But you’re back handed paid if wRVU (depending on negotiated price, you make out more than collections) or own shares in ASC

So its good for physicians as well
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You don’t find something wrong with your payment being mostly (and if it continues, solely) based on under what roof you place the needle and not that fact that YOU acquired the skill to place it?
 
Dr. Ice said:
You don’t find something wrong with your payment being mostly (and if it continues, solely) based on under what roof you place the needle and not that fact that YOU acquired the skill to place it?
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Ofcourse - only reason I care is that my pro fees are not high

I don’t mind facility being high (is what I’m getting at- other people are arguing facility should be lowered). I’m arguing facility remains as is or higher

Pro fees go much higher
 
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