L29252-LCD

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Local Coverage Determination (LCD) for Paravertebral Facet Joint Blocks (L29252)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29252

LCD Title Paravertebral Facet Joint Blocks

Contractor's Determination Number 64490

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/04/2011

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three

(3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior

element biomechanical pain are

• The pain does not have a strong radicular component.

• There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.

A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. For purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g.. C4-5 or L2-3). It is further noted that there are two (2) facet joints at each level, left and right.

During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected. After the injection(s) have been performed, the patient is asked to indulge in the activities that usually aggravate his/her pain and to record his/her impressions of the effect of the procedure. Temporary or prolonged abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment may be prescribed in the future. Some patients will have long lasting relief with local anesthetic and steroid, others will require a denervation procedure for more permanent relief. Before proceeding to a denervation treatment the patient should experience at least a 50% reduction in symptoms for the duration of the local anesthetic effect.

Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat

the presumptive diagnosis. If the first set of procedures fail to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495).

Limitations

It is not expected that an epidural block, or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage will be extended for only one type of procedure during one day/session of treatment unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management.

Paravertebral blocks, facet joint injections, and medial branch blocks per “Current Procedural Terminology (CPT ) “ should be performed utilizing direct visualization with fluoroscopy and documented. Blocks performed without the use of fluoroscopy are considered not medically necessary. Per “CPT” Imaging guidance (fluoroscopy CT) and any injection of contrast are inclusive components of 64490-64495.

The CMS manual System, Pub.100-08, Program Integrity Manual, Chapter 13, Section 5.1, outlines that “reasonable and necessary” services are “ordered and /or furnished by qualified personnel.” Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 64490 (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR

THORACIC; SINGLE LEVEL

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 64491 (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR

THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 64492 (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR

THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR

PRIMARY PROCEDURE)

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 64493 (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR

SACRAL; SINGLE LEVEL

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 64494 (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR

SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 64495 (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR

SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR

PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity

719.48 PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES

721.0 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY

721.2 THORACIC SPONDYLOSIS WITHOUT MYELOPATHY

721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY

721.41 - 721.42 SPONDYLOSIS WITH MYELOPATHY THORACIC REGION - SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION

722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION

722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION

722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.1 CERVICALGIA

724.1 PAIN IN THORACIC SPINE

724.2 LUMBAGO

724.8 OTHER SYMPTOMS REFERABLE TO BACK

V58.61* LONG-TERM (CURRENT) USE OF ANTICOAGULANTS

* Use only as a supplemental code in addition to primary diagnosis, when anticoagulant therapy has been discontinued to facilitate therapeutic injections for pain management.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

N/A

General Information

Documentations Requirements

Medical necessity for providing the service must be clearly documented in the patient’s medical records.

Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

• Whether the block was a diagnostic or therapeutic injection

• Pre and postoperative evaluation of patient

• Patient education

• Subjective and objective responses from the patient regarding pain, including facet pain provocative maneuvers documented by pre and post operative measurement

According to ASIPP guidelines, a positive response to the paravertebral facet joint block is noted when a greater than 50% relief of pain is obtained.

Placement of the needle at the facet joint must be performed under the fluoroscopic guidance to ensure safety and accuracy of the injection procedure, and this must be documented in the patient’s medical record.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to prepayment review for medical necessity.

Diagnostic Phase

• Procedures performed during the diagnostic phase should be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region as defined in this LCD on any given date of service.

• A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the incidence of false positive responses due to placebo effect).

• Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.

Therapeutic Phase

• It is not expected that a patient would undergo a therapeutic block at more than three (3) levels (unilateral or bilateral) per anatomic region on any given date of service.

• It is not expected that patients would undergo repeat treatment at same anatomic region at less than 90-day intervals.

• It is also not expected that all patients will present with pain in both anatomical regions (cervicothoracic and lumbosacral), therefore the routine performance of facet joint/medial branch block (both diagnostic and therapeutic) to both regions may prompt a pre-payment review.

• Routinely exceeding the above parameters, by utilizing the procedure codes on the same beneficiary in unusual patterns may result in pre payment review.

• Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare. In certain circumstances a patient may present with both facet and sacroiliac problems. In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation. The medical record must clearly support both procedures. Medicare recognizes that this is not common and will monitor the frequency with which these codes are combined. Multiple procedure modifiers will apply to intraarticular sacroiliac injection.

Sources of Information and Basis for Decision

Boswell, M.V., Trescot, A. M., & et al. (2007). Interventional Guidelines: Evidence based practice guidelines in the management of chronic spinal pain. Pain Physician (10) 7-1111.

Manchikanti, L., Singh, V., Kloth, D., Slipman, C.W., Jasper, J., Trescot, A.M., Varley, K.G., Alturi, S.L., Giron, C., Curran, M.J., Rivera, J., Baha, A.G., Bakhit, C.E., and Reuter, M.W. (2001). Interventional techniques in the management of chronic pain. Pain Physician (1) 24-98.

Manchikanti, L., Singh, V. (2002). Review of chronic low back pain of facet joint origin. Pain Physician. 5(1) 83- 101.

Manchikanti, L., (2004). Principles of documentation, billing, coding and practice management for the interventional pain professional. American Society of Interventional Pain Physicians and Anesthesiology. Retrieved form the Internet on April 25, 2007 via ASIPP.org

Miller, R.D. (2005). Nerve blocks in Miller: Miller’s Anesthesia, 6th ed. Philadelphia: Churchill Livingstone.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2010

Revision History Number 3

Revision History Explanation Revision Number:3 Start Date of Comment Period:N/A

Start Date of Notice Period:11/01/2011 Revised Effective Date:10/04/2011

LCR B2011-108

October 2011 Connection

Explanation of Revision: Verbiage was revised to clarify the “Limitations” section of the LCD that fluoroscopy is an inclusive component of CPT Codes 64490-64495 and not paid separately. The revision is effective for claims processed on or after 10/04/2011 for dates of service on or after 01/01/2010.

Revision Number 2

Start Date of Comment Period:N/A Start Date of Notice Period:07/01/2011 Revised Effective Date 06/14/2011

LCR B2011-073

June 2011 Connection

Explanation of Revision: Based on an outside request to clarify our current training statement outlined in this

LCD, language under the “Limitations” section of the LCD has been deleted and replaced with a revised statement regarding the qualification and training. Revisions will be effective based on process date.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2010 Revised Effective Date:01/01/2010

LCR B2010- 006

December 2009 Update

Explanation of Revision: Annual 2010 HCPCS Update. Deleted CPT codes 64470, 64472, 64475 and 64476. Added

CPT codes 64490, 64491, 64492, 64493, 64494 and 64495. Contractor Determination Number was changed to 64490. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29252) replaces LCD L6146 as the policy in notice. This document (L29252) is effective on 02/02/2009.

11/15/2009 - CPT/HCPCS code 64470 was deleted from group 1 11/15/2009 - CPT/HCPCS code 64472 was deleted from group 1 11/15/2009 - CPT/HCPCS code 64475 was deleted from group 1 11/15/2009 - CPT/HCPCS code 64476 was deleted from group 1

Reason for Change