Knowledge Base Article

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.