Ensuring Accurate Billing and Documentation for Lumbar Epidural Steroid Injections

Epidural steroid injections (ESIs), sometimes referred to as Lumbar Epidural Injections (LEIs), are a minimally invasive procedure used to treat pain and inflammation in the spine. During an ESI, a corticosteroid medication is injected into the epidural space, which is the area surrounding the spinal cord and nerve roots. This medication helps to reduce inflammation and pain, providing relief for patients with conditions such as herniated discs, spinal stenosis, and radiculopathy. ESIs are typically performed by pain management specialists, anesthesiologists, and physiatrists. The billing code for an ESI depends on the specific type of injection performed, but the most common codes are 62322, 62323, and 62325.

Epidural steroid injections (ESIs) can be a valuable tool for managing pain, but ensuring accurate billing and documentation is crucial for proper reimbursement.

The amount that can be billed for an epidural steroid injection (ESI) varies depending on several factors, including:

  • Location: The geographic location where the procedure is performed can affect the reimbursement rate.
  • Facility: Whether the procedure is performed in a hospital, ambulatory surgery center, or office setting can also impact the cost.
  • Provider: The type of provider performing the injection (e.g., physician, nurse practitioner) and their level of experience can influence the fee.
  • Type of injection: Different types of ESIs (e.g., interlaminar, transforaminal) may have different reimbursement rates.
  • Insurance coverage: Different insurance plans may have different coverage policies and reimbursement rates for ESIs.

 

It is important to note that Medicare and other insurance companies typically only cover ESIs if deemed medically necessary. This means the patient must have a specific diagnosis and meet certain criteria, such as having tried and failed conservative treatments.

Medicare Administrative Contractors (MACs), like Novitas, Noridian, CGS Administrators, and others, play a vital role in ensuring the appropriate use of healthcare services and resources. To meet MAC standards and facilitate smooth claim processing, it’s essential to provide comprehensive documentation that demonstrates the medical necessity and effectiveness of ESIs.

If an audit identifies an ESI without the required documentation, organizations are responsible for repaying the reimbursement. For some organizations with pain and orthopedic specialties, this can result in hundreds of thousands to millions of dollars in Medicare refunds.

Here’s what you need to include in your documentation:

  1. Specific Diagnoses: The Local Coverage Determination (LCD) outlines specific diagnoses for which ESIs are considered medically necessary. These include lumbar, cervical, or thoracic radiculopathy, radicular pain, neurogenic claudication, post-laminectomy syndrome, and acute herpes zoster-associated pain.
  2. Severity of Pain and Functional Impairment: Documentation must show that the pain is severe enough to significantly impact the patient’s quality of life or function. This can be demonstrated through objective pain scales (e.g., Numerical Rating Scale) and functional assessments (e.g., Oswestry Disability Index).
  3. Failure of Conservative Care: The patient must have tried and failed to respond to at least four weeks of conservative care, such as physical therapy, medication, or chiropractic manipulation.
  4. Image Guidance: ESIs must be performed under image guidance (CT or fluoroscopy) with contrast to ensure proper needle placement.
  5. Patient-Reported Outcomes: Documenting patient-reported outcomes (PROs) is crucial for demonstrating the effectiveness of ESIs and justifying repeat injections.

 

How Health Note Can Help:

Health Note streamlines the collection and documentation of PROs prior to the visit. Empowering physicians to consistently collect and document necessary information automatically in many cases.

With Health Note, you can:

  • Send automated PRO questionnaires to patients before ESIs to collect data on pain levels, functional limitations, failure of conservative care, and quality of life.
  • Update physician notes in the EHR with these PROs

By using Health Note, you can ensure that your documentation meets all the requirements for billing ESIs and facilitates efficient claim processing. Contact us today to learn more and develop a custom ROI that incorporates many more opportunities to improve revenue integrity and documentation compliance.

"We have detected an upward trend in the inappropriate billing of anesthesia services with ESI and facet joint injections."