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Medical Coding News Archives

Facet-Joint Injections Often Don’t Meet Payment Requirements

February 24, 2009:

A recent review of facet-joint injections performed in 2006 revealed that approximately 63 percent of these services did not meet Medicare guidelines and resulted in an estimated $96 million dollars in improper payments to providers and $33 million to facilities. These injections are a type of interventional pain management technique used to diagnose or treat back pain.

The Office of Inspector General (OIG) issued a report entitled “Medicare Payments for Facet Joint Injection Services” in which it describes the findings after it reviewed a stratified random sample of 646 facet-joint injection services (CPT codes 64470–64476) performed in 2006 as well as interviewing staff from 15 Medicare contractors. After reviewing the claim and medical record data, the OIG found that:

  • 38 percent had medical record documentation errors:
    • 27 percent of the facet-joint injection services were completely undocumented
    • 11 percent of the injection services were insufficiently documented
  • 31 percent had coding errors:
    • More then half the coding errors were the result of inappropriate add-on code use.
    • More than 60 percent were the result of the inappropriate use of the bilateral modifier 50.
    • 14 percent of these claims had overlapping, multiple coding errors.

As a result of its findings, the OIG has recommended that CMS and its contractors:

  • Strengthen program safeguards to prevent improper payments for facet-joint injections by having contractors include the following in their local coverage determinations:
    • established frequency limits
    • establish automated edits where imaging guidance is required
  • Clarify billing instructions for bilateral services
  • Review claims data, particularly for services performed in the office setting.

Deborah C. Hall
Clinical/Technical Editor


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