Epidural and Transforaminal Epidural Injections – WPS Medicare
As we suspected last year, refining coverage guidelines for Epidural and Transforaminal Epidural Injections now require the use of fluoroscopic or CT guided imaging.
Some highlights from WPS Medicare (Iowa, Kansas, Missouri, and Nebraska), effective October 1, 2015 include:
Coverage Indications, Limitations, and/or Medical Necessity
Epidural injections are used for acute and chronic pain, in addition to cancer pain management. Epidural injections are utilized both for diagnostic and therapeutic purposes.
A multi-disciplinary or collaborative comprehensive evaluation (e.g. orthopedics, neurologist, neurosurgeon, physiatrist, anesthesiologist, pain medicine specialist, and/or attending physician), is recommended prior to initiating a trial of these injections for relief of chronic recurrent pain.
Epidural steroid injections, both interlaminar/translaminar and transforaminal should be used only in the presence of radiculopathy.
Indications for Diagnostic and Therapeutic Epidural Injections
Diagnostic interlaminar/translaminar or caudal epidural steroid injections are seldom used. Although the medication injected can sometimes be confined to a limited area, bilateral effects and spread to adjacent levels often occur.
Therapeutic interlaminar/translaminar or caudal epidural injections and infusions of opioid, local anesthetic, or other medications may be used for the treatment of acute and chronic pain or cancer pain.
Epidural injections (interlaminar/translaminar or caudal) may be used for the following.
Acute obstetric, post traumatic and postoperative pain
Advanced cancer pain, primary or metastatic
Acute/sub acute and chronic pain syndrome including cervical, thoracic and lumbar pain with radiculopathy and intervertebral disc disease (with neuritis or radiculitis) with or without myelopathy that has failed to respond to adequate conservative management.
Nerve root injuries and neuropathic pain and post traumatic including post laminectomy syndrome (failed back syndrome).
Spinal cord myelopathy
Complex regional pain syndrome
Epidural scarring from prior infection, hemorrhage and/or surgery
Multiple rib fractures
Vertebral compression fractures
Post herpetic neuralgia and herpes zoster
Phantom limb pain
Indications for Diagnostic and Therapeutic Transforaminal Epidural Injections
Transforaminal epidural injection is a selective injection of the cervical, thoracic, lumbar or sacral nerve roots with proximal spread of contrast or local anesthetic through the neural foramen to the epidural space. With the aid of fluoroscopic or computed tomography (CT) imaging, the needle tip is placed within or adjacent to the lateral margin of the neural foramen and contrast material is injected to obtain a neurogram and visualize spread of the injected solution.
A small volume of local anesthetic is injected (less than or equal to 1.0 ml) in order to perform a diagnostic reproducible blockade of a specific nerve root. The diagnostic usefulness is lost if more than 1.0 ml of local anesthetic is injected (the block becomes unreliable since the spread of anesthetic to adjacent levels and structures likely occurs).
Diagnostic transforaminal epidural injections are appropriate for the following purposes.
To differentiate the level of radicular nerve root pain.
To differentiate radicular from non radicular pain
To evaluate a discrepancy between imaging studies and clinical findings
To identify the source of pain in the presence of multi-level nerve root compression
To identify the level of pathology at a previous operative site
It might be necessary to perform injections at two different nerve root levels on the same date of service. When multiple levels of nerve root compression or stenosis is suspected to be responsible for the patient’s symptoms, presence of the compression or stenosis on imaging studies should be documented in the medical record.
Therapeutic transforaminal epidural injections are appropriate for the following purposes:
Corticosteroid can be added as a therapeutic measure. Injections for therapeutic reasons can be of greater volume. The transforaminal injection can be performed for diagnostic, therapeutic or both purposes.
Radicular pain resistant to more conservative measures or when surgery is contraindicated.
Post-decompressive radiculitis or post surgical scarring
Monoradicular pain, confirmed by diagnostic block in which a surgically correctible lesion cannot be identified
Treatment of acute herpes zoster or post herpetic neuralgia
General Indications and Limitations
Epidural (interlaminar/translaminar or caudal) and transforaminal epidural corticosteroid injections should not exceed a series of three, per spinal region, within a six-month period when used as treatment for a pain disorder other than treatment for cancer pain. These may be performed at intervals of one week or greater. With each subsequent injection the medical record should clearly document the interval effects from the prior injection(s). Appropriate reasons for a repeat injection are: (a) significant improvement in the patient’s symptoms from the prior injection, even if relapsed, or (b) carefully documented technical reasons that it is appropriate to repeat the procedure even if no prior improvement and (c) patients with persistent pain in whom the imaging findings suggest that the pathology should respond to corticosteroid injection. In the absence of a compelling technical reason, it is not appropriate to repeat a procedure a third time if there has been no improvement from the two preceding.
If corticosteroids are used, consideration should be given to the potential complications of repetitive corticosteroid administration.
Many of these procedures, such as those in the peri-operative period, may not require fluoroscopy.
For treatment of chronic pain, the standard of care is that these procedures be performed under fluoroscopic or CT guided imaging. Therefore injections for chronic pain performed without imaging guidance will be considered not medically necessary.
Fluoroscopic guidance must be utilized in the performance of single nerve root/transforaminal injections to ensure the precise placement of the needle and medications injected.
Anti-spasmodic drugs administered intrathecally (e.g., baclofen) to treat chronic intractable spasticity are addressed in the Infusion Pump NCD Pub. 100-3 Sec. 280.14. The CPT description of procedure codes 62310, 62311, 62318 and 62319 include anesthetic, antispasmodic, opioid, steroid, other solution; therefore the spasticity conditions are included in this LCD.
The complete LCD L34622 can be found at: http://www.wpsmedicare.com/j5macpartb/policy/active/local/
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