Changes in Facet Joint Injections Requirements for Jurisdiction J

on Tuesday, 07 May 2019. All News Items | Medicare Coverage

Staying Up to Date

A few weeks ago, our monthly coverage article addressed facet joint injections. In that article , as I always do, I stressed the importance of verifying the requirements of the Local Coverage Determination (LCD) for your particular Medicare Administrative Contractor (MAC) jurisdiction. This is important because different MACs may have different coverage and documentation requirements for a particular service as described in their LCDs. Your medical records should support the requirements of your jurisdiction’s LCD. It is also important to keep up with revisions and new LCDs to know when requirements change. All of the MACs have a listserv that includes information on updated LCDs as well as a monthly publication that generally gives more details of the LCD revisions. I recommend providers sign up for their MAC’s listserv and watch for LCD revisions and updates. And did you know the specifics of each LCD revision are listed in a table at the end of the LCD?

Sometimes a MAC will retire one LCD and replace it with a new one – this would be the time to look for significant changes to the coverage and documentation requirements. And although it does not happen often, sometimes a jurisdiction may transition from one MAC to another. This happened in 2018 to Jurisdiction J (Alabama, Georgia, and Tennessee) when they transitioned from Cahaba GBA to Palmetto GBA. As part of this transition, Palmetto evaluated all of the LCDs for both Cahaba and Palmetto and made determinations of which LCDs to retire and which to keep for both of their Jurisdictions, J and M. This created a responsibility on Jurisdictions J and M providers to become familiar with any new LCDs, though since more Palmetto LCDs were retained than Cahaba LCDs, it is a larger burden on providers in Jurisdiction J.

One example is the Facet Joint Injection policy. Here at MMP, we compared the retired Facet Joint Injection Cahaba policy against the current Palmetto policy and identified over 15 significant differences between the two policies. Some of the differences noted are:

  • Palmetto requires moderate to severe pain while Cahaba required average pain greater than 6 on a numeric rating scale of 1-10;
  • Palmetto allows a maximum of 5 sessions per year including both lumbar IA and lumbar medial branch nerve block while Cahaba’s frequency was 6 lumbar sessions per year, specified as up to 2 diagnostic and 4 therapeutic for the first year, and up to 4 therapeutic facet injection sessions the second year;
  • Palmetto’s policy includes steroid dose restrictions while Cahaba’s did not address this;
  • Diagnostic facet joint injections are not allowed by Palmetto but were by Cahaba (Palmetto only allows diagnostic injections for medial branch nerve block technique); and
  • Cahaba did not allow therapeutic intra-articular facet joint injections whereas in the Palmetto LCD therapeutic injections are allowed for both intra-articular and medial branch nerve block technique.

For a pdf-formatted chart of all the differences between the two policies, click here. This will allow Jurisdiction J providers to 1) educate their physicians on any new and/or different coverage and documentation requirements and 2) audit their records through an internal or contracted audit against the new Palmetto requirements to verify compliance with the Palmetto LCD. As with all things Medicare, it is always a challenge to stay up to date.

Updates of new, retired, and draft LCDs posted on Medicare's Coverage Database website since last month are listed in the table below.

 

Palmetto JJ and JM Coverage Updates

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37859  MolDX: myPath Melanoma Assay  4/29/2019 N/A  N/A  3/8/2019 New
L37870  MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer  4/8/2019 4/8/2019 N/A  3/18/2019 New
L37602  MolDX: MDS FISH  4/8/2019 N/A  N/A  2/15/2019 New
L34412  Cardiac Rehabilitation  10/1/2015 2/4/2019 4/5/2019 4/5/2019 New
A56396  Billing and Coding: Lumbar Spinal Fusion  5/6/2019 5/6/2019 N/A 3/13/2019 New
A56390  Billing and Coding: Lumbar Artificial Disc Replacement  5/6/2019 5/6/2019 N/A 3/13/2019 New
A56431  Billing and Coding: Topical Oxygen Therapy  5/6/2019 5/6/2019 N/A 3/28/2019 New
A56419  Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna™)  5/6/2019 5/6/2019 N/A 3/22/2019 New
A56506  Billing and Coding: Noncovered Services other than CPT® Category III Noncovered Services  5/5/2019 5/5/2019 N/A 4/11/2019 New
A56480  Billing and Coding: Non-Covered Category III CPT Codes  5/3/2019 5/5/2019 N/A 4/4/2019 New
A56503  Billing and Coding: Blepharoplasty, Eyelid Surgery, and Brow Lift  4/18/2019 4/18/2019 N/A 4/10/2019 New
A56476  Billing and Coding: Cardiac Radionuclide Imaging  4/11/2019 4/11/2019 N/A 4/1/2019 New
A56432  Billing and Coding: Infliximab  4/11/2019 5/5/2019 N/A 4/3/2019 New
A56468  Billing and Coding: Ambulance Services  4/4/2019 4/4/2019 N/A 3/26/2019 New

IDTitleComment Start DateComment End DateFinalStatus
DL38033  Cervical Disc Replacement  5/6/2019 6/20/2019 No  Draft
DL38026  Corneal Hysteresis  5/6/2019 6/20/2019 No  Draft
DL38037  Lab: Drug Interaction Testing  5/6/2019 6/20/2019 No  Draft
DL38035  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease  5/6/2019 6/20/2019 No  Draft
DL38029  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Unfavorable Intermediate Risk Disease  5/6/2019 6/20/2019 No  Draft
DL38043  MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Solid Tumors  5/6/2019 6/20/2019 No  Draft
DL38045  MolDX: Next-Generation Sequencing for Solid Tumors  5/6/2019 6/20/2019 No  Draft
DL38047  MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies  5/6/2019 6/20/2019 No  Draft
DL38051  MolDX: Pigmented Lesion Assay  5/6/2019 6/20/2019 No  Draft
DL38041  MolDX: Prospera  5/6/2019 6/20/2019 No  Draft
DL38039  MolDX: TruGraf Blood Gene Expression Test  5/6/2019 6/20/2019 No  Draft

 

 

 

CGS J15 Coverage Updates

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37834  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease  4/29/2019 N/A  N/A  3/5/2019 New

IDTitleComment Start DateComment End DateFinalStatus
DL38057  Drug Interaction Testing  5/7/2019 6/21/2019 No  Draft
DL38055  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease  5/7/2019 6/21/2019 No  Draft
DL38077  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Unfavorable Intermediate Risk Disease  5/7/2019 6/21/2019 No  Draft
DL38065  MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Solid Tumors  5/7/2019 6/21/2019 No  Draft
DL38067  MolDX: Next-Generation Sequencing for Solid Tumors  5/7/2019 6/21/2019 No  Draft
DL38070  MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies  5/7/2019 6/21/2019 No  Draft
DL38111  MolDX: Pigmented Lesion Assay  5/7/2019 6/21/2019 No  Draft
DL38059  MolDX: Prospera  5/7/2019 6/21/2019 No  Draft
DL38053  MolDX: TruGraf Blood Gene Expression Test  5/7/2019 6/21/2019 No  Draft

 

 

 

First Coast JN

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A56486  Laboratory Panels – Coding and Billing  4/11/2019 N/A N/A 4/5/2019 New

 

 

 

National Government Services J6 and JK

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L36376  Genomic Sequence Analysis Panels in the Treatment of Non-Small Cell Lung Cancer  4/1/2016 N/A  3/31/2019 3/31/2019 Retired 

 

 

 

Noridian JE

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37822  MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test  4/16/2019 N/A  N/A  2/22/2019 New
L36314  MolDX: Breast Cancer Index? Genetic Assay  10/1/2015 1/1/2019 4/15/2019 4/15/2019 Retired 

 

 

 

Noridian JF

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37824  MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test  4/16/2019 N/A  N/A  2/22/2019 New
L36316  MolDX: Breast Cancer Index?; Genetic Assay  10/1/2015 1/1/2019 4/15/2019 4/15/2019 Retired 

 

 

 

Novitas JH and JL

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A56268  Coding Article for Sclerotherapy and Endovenous Non-Thermal Treatment of Varicose Veins  5/7/2019 5/7/2019 N/A 1/25/2019 New
A56505  Billing and Coding: Transesophageal Echocardiography (TEE)  4/25/2019 N/A N/A 4/18/2019 New
A56433  Billing and Coding: Hemophilia Factor Products  4/25/2019 N/A N/A 4/18/2019 New
A56473  Billing and Coding: Laboratory Panels  4/11/2019 N/A N/A 4/5/2019 New
A56440  Billing and Coding: eVox® System and Other Electroencephalograph Testing for Memory Loss  4/4/2019 N/A N/A 3/29/2019 New

 

 

 

WPS J5 and J8

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37913  MolDX: Breast Cancer Index™ (BCI) Gene Expression Test  4/15/2019 N/A  N/A  2/19/2019 New
L37921  MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer  4/15/2019 4/15/2019 N/A  4/16/2019 New
L36785  MolDX: Breast Cancer Index? Genetic Assay  2/16/2017 1/1/2019 4/14/2019 4/14/2019 Retired 
L34436  Posterior Tibial Nerve Stimulation (PTNS)  10/1/2015 4/1/2018 4/14/2019 4/14/2019 Retired 
A56334  MolDX: Oncotype DX® Genomic Prostate Score Coding and Billing Article  4/15/2019 N/A N/A 2/19/2019 New
A56332  MolDX: Bladder Tumor Marker FISH Billing and Coding Guidelines Update  4/15/2019 N/A N/A 2/19/2019 New
A56335  Coding Article for MolDX: Breast Cancer Index™ (BCI) Gene Expression Test LCD L37913  4/15/2019 N/A N/A 2/19/2019 New
A56333  Coding article for MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer LCD L37921  4/15/2019 N/A N/A 2/19/2019 New
A56331  Posterior Tibial Nerve Stimulation (PTNS) Billing & Coding Guidelines  4/15/2019 N/A N/A 2/18/2019 New

IDTitleComment Start DateComment End DateFinalStatus
DL38162  Laboratory: Drug Interaction Testing  4/25/2019 6/9/2019 No  Draft
DL38164  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease  4/25/2019 6/9/2019 No  Draft
DL38018  MolDX: DecisionDX-Melanoma  2/21/2019 4/7/2019 No  Draft
DL38168  MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Solid Tumors  4/25/2019 6/9/2019 No  Draft
DL38158  MolDX: Next-Generation Sequencing for Solid Tumors  4/25/2019 6/9/2019 No  Draft
DL38176  MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies  4/25/2019 6/9/2019 No  Draft
DL38178  MolDX: Pigmented Lesion Assay  4/25/2019 6/9/2019 No  Draft
DL38174  MolDx: Prospera  4/25/2019 6/9/2019 No  Draft
DL38160  MolDX: TruGraf® Blood Gene Expression Test  4/25/2019 6/9/2019 No  Draft
DL38166  MolDX:Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Unfavorable Intermediate Risk Disease  4/25/2019 6/9/2019 No  Draft

 

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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