Update: Epidural Procedures For Pain Management And A Note On Anesthesia For These Services

As healthcare providers, it’s important to be aware of upcoming changes that could impact your practice through billing, claims, and insurance. Below is an important update on a proposed Local Coverage Determination (LCD) relevant for practices that perform epidural steroid injections (ESIs) to treat low back and neck pain. See our previous blog regarding potential changes to reimbursement for anesthesia sedation in paid management injections! 

For questions regarding the content below, or for anesthesia coding and billing support, contact us today! 

Epidural Procedures For Pain Management

DRAFT LCDs are being released for Epidural Procedures for Pain Management. As with the Facet Joint Intervention LCDs that went into effect this year, the MACs from all jurisdictions collaborated to create uniform LCDs for these procedures. This is a DRAFT without a defined release date at this point.

Even though this is a proposed LCD, providers should be aware of the upcoming changes. If your providers are interested in participating, this LCD’s comment period will end on July 24, 2021. Information regarding the comment period is found within the DRAFT policy below. 

In addition to providers performing these services listed below – your Anesthesia providers should also be made aware of these key takeaways. It is essential they review with their Pain Providers that may be requesting anesthesia for these services so that appropriate documentation is captured.

See the drafted LCD here. 

Below are the key takeaways from the DRAFT LCD for Epidural Procedures for Pain Management.

DRAFT LCD Coverage Indications

1. Epidural Steroid injection (ESI) will be considered medically reasonable and necessary when the following three requirements are met:

• • History, physical examination, and concordant radiological image-based diagnostic testing that supports one of the following:
    • Lumbar, cervical or thoracic radiculopathy and/or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis OR
    • Post-laminectomy syndrome, OR
    • Acute herpes zoster-associated pain.

AND Radicular pain is severe enough to cause a significant degree of functional disability or vocational disability measured at baseline using an objective pain scale*. A functional assessment scale must be performed at baseline if function is considered as part of the assessment.

AND Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster refractory to conservative management where a four (4) week wait is not required.

2. The ESIs must be performed under CT or fluoroscopy image guidance with contrast.

3. Transforaminal epidural steroid injections (TFESIs) involving a maximum of two (2) levels in one spinal region are considered medically reasonable and necessary. It is important to recognize that most conditions would not ordinarily require ESI at two (2) levels in one spinal region.

4. Caudal epidural steroid injections (CESIs) and interlaminar epidural steroid injections (ILESIs) involving a maximum of one level are considered medically reasonable and necessary.

5. It is considered medically reasonable and necessary to perform TFESIs bilaterally only when clinically indicated.

6. Repeat ESI when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief for at least three months and/or improvement in function measured from baseline using SAME scale* for at least three months.

7. The ESI injectants must include corticosteroids, anesthetics, anti-inflammatories and/or contrast agents.

8. The ESIs should be performed in conjunction with conservative treatments.

9. Patients should be part of an active rehabilitation program, home exercise program or functional restoration program.

DRAFT LCD Limitations

1. Injections performed without image guidance or by ultrasound are not considered medically reasonable and necessary.

2. The ESIs performed with biologicals, or other substances, not FDA designated for this use are considered not medically reasonable and necessary.

3. It is not considered medically reasonable and necessary to perform multiple blocks (ESIs, sympathetic blocks, facet blocks, trigger point injections, etc.) during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same session.

4. Use of General Anesthesia, Moderate Sedation, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and, therefore, is not considered medically reasonable and necessary. In exceptional cases, documentation must clearly establish the need for such sedation in the specific patient.

5. The ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, or cervicogenic headaches are considered investigational. They, therefore, are not considered medically reasonable and necessary.

6. The ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.

7. It is not considered medically reasonable and necessary for more than one spinal region to be injected in the same session.

8. It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.

9. It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than one (1) level during the same session.

10. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally.

11. It is not medically reasonable and necessary to perform ESIs in a series.

12. Steroid dosing should be the lowest effective amount and not exceed 40mg for methylprednisone, 10-20mg for triamcinolone acetate, and 10mg (10mg/mL) dexamethasone phosphate per session.

13. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months. Frequent continuation of epidural steroid injections over twelve (12) months may trigger a focused medical review. Use beyond twelve months requires the following:

• • Pain is severe enough to cause a significant degree of functional disability or vocational disability.
  • The ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline).
  • Rationale for the continuation of ESIs including, but not limited to, the patient is a high-risk surgical candidate, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months.
  • Communication with primary care provider regarding patients’ candidacy for prolonged repeat steroid use.

Indications for Anesthesia Services Based on the DRAFT LCD

As indicated, “ Use of General Anesthesia, Moderate Sedation and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore, is not considered medically reasonable and necessary. In exceptional cases, documentation must clearly establish the need for such sedation in the specific patient.” Referenced in the Draft LCD is a paper “Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group” The conclusions of the Work Group indicate “Excessive sedation should be avoided. It is preferable that a patient be able to respond adequately during a procedure.”

Review with your Anesthesia providers performing these services. Current ASA Codes utilized would be 01936 and 01935. New ASA codes will be released in 2022, and we will provide information as soon as they are available.

For any questions regarding these changes or anesthesia billing, contact us today!