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Ohio Part B Carrier
Paravertebral Facet Joint Injections: Medical Necessity Denials

Denial Reason, Reason/Remark Code(s)

  • CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD
  • CPT codes 64470-64476

Resolution/Resources

  • Use the appropriate modifier to designate whether services are unilateral (specify which side of the joint) or bilateral
    • Unilateral blocks: submit HCPCS modifier RT or LT
    • Bilateral blocks: submit CPT modifier 50
  • Submit additional information in Loop 2300, or 2400, NTE, 02 for electronic claims, or as attachments when paper claims are submitted, in the following situations:
    • Multiple spinal levels are injected: identify the specific levels (e.g., T11-12, L2-3, L4-5, and L5-S1)
    • Multiple sets of paravertebral facet joint injections are performed for a beneficiary over a period of time: submit documentation to explain the reason for the number of injections relative to the patient’s condition
    • When the beneficiary’s pain is controlled by facet blocks, explain why a more permanent method of control, such as neurolysis, was not used
  • Jurisdiction 1: Refer to the 'Paravertebral Facet Joint Block and Facet Joint Denervation' LCD/NCD: www.PalmettoGBA.com/j1b/LCD/NCD 
  • Ohio and West Virginia: Refer to the 'Paravertebral Facet Joint Block' Local Coverage Determination (LCD) and Coverage Article for information on covered conditions and applicable frequency limitations.
  • South Carolina: Refer to the 'Paravertebral Facet Joint Block' Local Coverage Determination (LCD) and Coverage Article for information on covered conditions and applicable frequency limitations: www.PalmettoGBA.com/bsc/LCD

Advance Beneficiary Notice Information

  • If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an Advance Beneficiary Notice (ABN) prior to performing these tests
  • ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'
  • If you utilize ABNs, they must be issued in advance. Maintain the original in the patient's medical record. Provide the patient with a copy of the signed notice.
  • ABNs must be issued using the standard CMS form. Access the ABN and other background information from the CMS Web site: www.cms.hhs.gov/BNI/01_overview.asp.
  • If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Modifier Lookup tool by selecting 'Browse by Topic' on the left side of this Web page for more information on HCPCS modifier GA.  

Resource

  • MLN Matters Article #MM6518 (PDF, 70 KB): Appropriate Use of CPT Modifier 50 and Add-On Current Procedural Terminology (CPT) Codes for Facet Joint Injection Services 

 

last updated on 12/29/2009
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