Injection Series: Part II – Facet Joints (Paravertebral)

Facet Joint Injections
Facet joint injections are frequently used to diagnose and treat facet joint pain, also known as lumbar spondylosis or zygapophyseal joint pain. These injections, which include both anesthetic and corticosteroid medications, can offer relief for two to four months or more.

CMS LCD Coverage criteria:

Must meet ALL of the following criteria:

1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale; AND*
2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated), AND
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst), AND
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient’s pain, including but not limited to fracture, tumor, infection, or significant deformity. 

Providers must document baseline pain, reassess pain after each diagnostic procedure using the same scale, and obtain a baseline disability score for functional assessment when the patient qualifies for treatment.

Medicare’s top TPE denials for facet joint injections are as follows:

Medical Necessity –

The documentation lacked evidence to support the requirements of the Novitas Local Coverage Determination (LCD) because the documentation lacked pain level, prior conservative therapy and/or effectiveness of treatment.

Insufficient Documentation –

The provider did not submit documentation to Novitas in a timely manner to support the services billed to Medicare.

The submitted documentation failed to support the services billed on the claim.

After receiving the additional development request, the provider determined that the service was billed to Medicare in error.

Injection Series:  Part III – Trigger Points

Resources:

Novitas TPE:  Facet Joint Injections and Checklist

CDI Facet Joint Injections Tip Sheet