Medicare has found that insufficient documentation is a common cause for improper payments for facet joint injection procedures.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter, a newsletter from CMS developed to help providers to avoid common billing errors and other erroneous activities when dealing with the Medicare Program.

The figure was determined through a Comprehensive Error Rate Testing (CERT) program’s special study of claims with lines for facet joint injection procedures billed with Healthcare Common Procedure Coding System (HCPCS) code 64635, submitted from July through September 2015. The long description of this HCPCS code is “destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint.” The consumer-friendly version of this HCPCS code descriptor is “destruction of lower or sacral spinal facet joint nerves using imaging guidance.”

Facet joints are a common source of chronic low-back pain. Facet joint injection is a procedure using an imaging-assisted local injection and denervation technique. This procedure may be indicated when there is chronic low back pain. Destruction of a paravertebral facet joint nerve(s) requires the use of fluoroscopic guidance to confirm the proper positioning of the needle or electrode at the level of the involved paravertebral facet joint(s).

Documentation Causes Most Improper Payments

Insufficient documentation means that something was missing from the medical records submitted. For example, there was:

  • No documentation to support the medical need for the procedure
  • No procedure note
  • No physician’s signature on a procedure note, diagnostic report or progress note
  • No valid physician order (includes physician signature or date)
  • No preoperative surgeon’s office notes
  • No signature log or attestation submitted
  • No documentation submitted to adequately describe the service defined by the HCPCS code or HCPCS modifier billed
  • Though a valid ICD-9 code(s) was submitted, the ICD-9 code(s) alone was insufficient information

Examples of Improper Medicare Payments

Here are two examples of improper payments due to insufficient documentation, specifically missing clinical documentation.

Example 1: A physician billed for HCPCS 64636 and, in response to the CERT contractor’s request for documentation, submitted the following:

  1. A record of informed consent for the procedure and anesthesia, signed by the patient and physician
  2. A history and physical signed by the physician showing left L(lumbar) 3/4, L4/5, L5/SI (sacroiliac) radiofrequency ablation
  3. Pre- and intra-anesthesia records
  4. An order for procedural sedation and medication
  5. An operative report for the billed procedure signed by the billing provider
  6. Pre- and post-procedure pain management orders signed by the physician
  7. A pain clinic nursing assessment showing starting pain level 1/10
  8. A bilateral hip and SI joint x-ray
  9. A dated progress note showing follow up from a SI joint injection under ultrasound, pain with palpation of facets and plan for billed ablation procedure
  10. A dated operative report
  11. A progress note dated more than one month after the claim date of service

The medical reviewer made phone calls and sent letters requesting additional documentation to support the HCPCS code that was billed. The provider did not submit clinical documentation to support that the patient had failed conservative treatment. The documentation submitted did not meet the requirements of the applicable Local Coverage Determination (LCD). The LCD applicable to this claim requires documentation that supports the patient has failed conservative treatment. Conservative treatments may include local heat, traction, non-steroidal anti-inflammatory medications, and an anesthetic. The submitted documentation was insufficient to support the medical necessity for the facet joint injection since there was no evidence in the documentation submitted that the patient had tried conservative treatment(s).

This claim was scored as an insufficient documentation error and the payment was recouped from the provider.

Example 2: A physician billed for HCPCS 64636 and in response to the CERT contractor’s request for documentation submitted the following:

  1. A progress note from the date of service that did not indicate that conservative treatment was tried and failed
  2. A procedure note from the date of service
  3. A consent form

The medical reviewer made phone calls and sent letters requesting additional documentation to support the HCPCS code that was billed. Duplicate documentation was received. The provider failed to submit documentation to support that the patient failed conservative treatment. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications and anesthetic. There was no initial evaluation from the physician with a summary of diagnostic tests or procedures to justify the possible presence of facet joint pain, nor was there clinical documentation to rule out another etiology for the symptoms. CERT scored this claim as an insufficient documentation error and payment was recouped from the provider.

Medical Billing Guidance

To avoid these improper payments, Medicare advises providers to understand the requirements for Medicare coverage of facet joint injection services and make sure the medical record documentation meets Medicare requirements.

Source: CMS

If your organization is experiencing an increase in denied claims and days in A/R which is leading to a decrease in revenue, consider outsourcing your billing to PGM Billing. PGM is a leading medical billing service provider that has served physicians and healthcare facilities since 1981. PGM’s range of customizable products and services provide clients with a complete platform encompassing the entire medical practice workflow, and have made PGM one of the fastest growing medical billing companies in the United States.