Doctors Beware: Facet Joint Injections Still Trip Up Medicare

Doctors offering facet joint injections to Medicare patients need to be aware that the coding and billing of such treatments continues to trip up Medicare. A case in point was recently reported by the American Society of Anesthesiologists. It relates to billing and coding through the well-known Noridian portal.

Apparently, the HHS believes Noridian made upwards of $4.2 million in improper payments to physicians for 2016 through 2018. These improper payments were allegedly for facet joint injection treatments that, for one reason or another, did not qualify for Medicare coverage.

A Failure to Comply

The HHS report cites a failure to comply on multiple points. Furthermore, it suggests that Noridian both attempt to recover the money and better educate physicians and their billing department about the proper way to bill for the treatment. Failure to comply issues related to:

  • Pain – Some patients allegedly lacked a history of moderate to severe pain for three months, combined with loss of function.
  • Spinal Levels – Facet joint injections did not meet federal requirements for spinal level reporting. Records contradicted the requirements.
  • Therapeutic Injections – Treatments did not comply with therapeutic requirements, particularly those that were given despite not offering at least three months of pain relief.
  • Limited Coverage – Some treatments did not comply with limitation-of-coverage requirements.

It is not clear whether or not doctors improperly administered facet joint injections in relation to Medicare requirements. If not, the issues may be more billing and coding than anything else. Yet without proper guidance, it is difficult to determine what the issue actually is.

A Matter of Coverage

For the record, facet joint injections are pretty standard procedure at pain clinics throughout the country. Clinics like Weatherford, Texas-based Lone Star Pain Medicine call for the injections to treat chronic back pain caused by facet joint syndrome and other conditions. The issue here is not a matter of safety or efficacy. It is one of the coverage.

Medicare and Medicaid offer limited coverage for certain types of medical procedures. Their coverage for facet joint injections varies quite a bit. Variation is reflected in medical coding and billing. And unfortunately, nothing about Medicare or Medicaid is easy to navigate. It is understandable that doctor’s offices and clinics would struggle to keep all of their ducks in a row.

Even more disturbing is the fact that HHS is only discovering the problems now. Remember, the payments mentioned in the Noridian report are from the 2016-2018 coverage years. We are talking 3 to 5 years ago. They are just figuring it out now?

A Much Bigger Problem

When you consider it takes HHS so long to identify a problem and suggest workable solutions, it becomes apparent that there is a much bigger issue in play here. Admittedly, doctors billing for facet joint injections that do not meet Medicare requirements is problematic and needs to be corrected. But if it takes HHS this long to identify potential errors, maybe their system is broken.

It could also be that requirements are more complicated than they need to be. That is always a possibility when you are talking about the government, especially when it comes to things like Medicare, Medicaid, and other social assistance programs. If there is a way to unnecessarily complicate something, government bureaucrats will figure out how to do it.

In the meantime, it is important that doctors and clinics ensure that they are billing and coding facet joint injections properly. The last thing they want is to be contacted by Medicare five years down the road, looking for a refund on payments that have long since been spent.

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