|LCD for Pain Management (L28529)|
|Contractor Type |
|Oversight Region||Region I, II, III, V||Original Determination
Effective Date ||For services performed on or after
01/01/2009 ||Original Determination
Ending Date ||Revision Effective
Date ||For services performed on or after
10/01/2010 ||Revision Ending
Date ||Indications and Limitations
of Coverage and/or Medical Necessity ||Abstract:|
Acute pain is elicited by the injury of body tissues and activation of nociceptive transducers at the site of local tissue damage. This type of pain is often a reason to seek health care, and it occurs after trauma, surgical interventions, and some disease processes.
Chronic pain has been defined as "persistent or episodic pain of duration or intensity that adversely affects the function or well-being of the patient, attributable to any nonmalignant etiology" ("Practice Guidelines for Chronic Pain Management: A Report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section"). In addition, the pain has been refractory to repeated attempts at medical management and usually has been present for at least three to six months.
Pain associated with cancer includes pain associated with disease progression as well as treatments. Pain associated with cancer can have multiple causes—namely, disease progression, treatment (e.g., neuropathic pain resulting from radiation therapy), and co-occurring diseases (e.g., arthritis). Regardless of whether the pain associated with cancer stems from disease progression, treatment, or a co-occurring disease, it may be either acute or chronic.
Spinal pain generates from multiple structures in the spine. Certain conditions may not be detectable using currently available technology or biochemical studies. However, for a structure to be implicated, it should have been shown to be a source of pain in patients, using diagnostic techniques of known reliability and validity. The structures responsible for pain in the spine, include but are not limited to, the vertebral bodies, intervertebral discs, spinal cord, nerve roots, facet joints, ligaments, muscles, atlanto-occipital joints, atlanto-axial joints, and sacroiliac joints.
Postlaminectomy syndrome or pain following operative procedures of the spine, sometimes known as failed management syndrome, is becoming an increasingly common entity in modern medicine. Other spinal conditions causing pain include various degenerative disorders such as spinal stenosis, spondylolysis, spondylolisthesis, degenerative scoliosis, idiopathic vertebrogenic sclerosis, diffuse idiopathic spinal hyperostosis, and segmental instability. Degenerative conditions other than disc disruption and facet arthritis may contribute to approximately 5% to 10% of spinal pain.
Neural blockade is one technique used in chronic pain management. Neural blockade is the interruption of neural transmission by the injection of a local anesthetic agent or other drug. Nerve block therapy can be used to answer specific questions resulting from a careful evaluation of the patient's pain problem and to gain insight into the underlying problem causing the pain. Success of the nerve block is determined by the adequacy of interruption of nerve function, and the effect of that blockade on the patient's pain. The goal of chronic pain management is to achieve optimal pain control, recognizing that a pain-free state may not be achievable; minimize adverse outcomes; enhance functional abilities and physical and psychological well-being; and enhance the quality of life for patients with chronic pain.
The decision to treat chronic pain by invasive or destructive procedures must be based on a thorough evaluation of the patient and include a systematic assessment of the location, intensity, and pathophysiology of the pain. A detailed pain history that includes prior treatment and response to treatment is essential. A detailed physical examination and review of all pertinent diagnostic tests is also needed. This local coverage determination documents National Government Services indications and limitations for pain management treatment.
Indications and Limitations for Specific Types of Injections
TRIGGER POINT INJECTIONS
Trigger point injection is one of the many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Production of a referred pain pattern differentiates myofascial pain syndrome from tender points and fibromyalgia. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); and each of these single muscle syndromes is responsive to appropriate treatment, which includes injection therapy. Injection is achieved with needle insertion and the administration of agents such as local anesthetics.
The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical features are present most consistently, and are helpful in making the diagnosis:
Only one trigger point injection procedure (CPT codes 20552 or 20553) should be reported on any particular day, no matter how many sites or regions are injected.
The local anesthetic administered in conjunction with trigger point injections is included in the practice expense for these procedures.
Trigger point injections used on a routine basis, e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes are not considered medically necessary.
Only injections of local anesthetics and corticosteroids are covered. Injections consisting of only saline and/or botanical substances are not supported in the peer-reviewed literature and are not considered medically necessary.
INJECTION OF TENDON SHEATHS, LIGAMENTS, GANGLION CYSTS, CARPAL AND TARSAL TUNNELS
Injection into tendon sheaths, ligaments, ganglion cysts, tarsal or carpal tunnel is sometimes indicated to provide relief of pain and to reduce the inflammation in these structures when response to conservative measures has failed or is not indicated.
For the purposes of clarity the following descriptions are offered for each term:
Ligament - A band of tissue that connects bones.
Tendon - A fibrous cord of connective tissue attaching a muscle to a bone or other structure. A tendon sheath is the lining enclosing a tendon. It facilitates movement around the tendon.
Ganglion cyst - These knot like masses are non-cancerous and fluid filled cysts that arise from the ligaments, joint linings, or tendon sheaths.
Carpal tunnel - This is a passageway that runs from the forearm through the wrist. The median nerve and nine tendons pass through the tunnel.
Tarsal tunnel - A passageway on the medial side of the tarsus. The posterior tibial nerve passes through the tunnel.
Indications for Tendon Sheath, Ligament, Ganglion Cysts, Carpal and Tarsal Tunnel Injections:
Injection into tendon sheaths, their origins or insertions, ligaments, or ganglion cysts is indicated to relieve substantial pain and/or significant functional disability that results from inflammation or other pathological changes in those structures. Proper use of this modality should be part of an overall management plan including diagnostic evaluation in order to clearly identify and properly treat the primary cause.
Other conservative therapy has not provided acceptable relief, is contraindicated, or not appropriate.
There is a reasonable likelihood that injection will significantly improve the patient's pain and/or functional disability.
Injection of a carpal tunnel may be indicated for the patient with mild to moderate symptoms when pharmaceutical and other conservative measures have failed or are not otherwise indicated.
Injection of the tarsal tunnel may be indicated for conservative management of tarsal tunnel syndrome.
Limitations for Tendon Sheath, Ligament, Ganglion Cysts, Carpal and Tarsal Tunnel Injections:
When a given specific tendon, ligament, tunnel, or cyst is injected, it will be considered one injection service regardless of the number of injections administered at that specific anatomical location on a single date of service.
EPIDURAL AND INTRATHECAL INJECTIONS: INTERLAMINAR AND CAUDAL AND TREATMENT OF SPASTICITY
Epidural and intrathecal (epidural and subarachnoid) injections are utilized for acute and chronic pain, cancer pain management, and treatment of spasticity. Epidural and intrathecal injections are utilized both for diagnostic and therapeutic purposes.
Indications for Diagnostic and Therapeutic Epidural and Intrathecal Injections:
Diagnostic interlaminar/translaminar or caudal epidural steroid injections are seldom used. Although the medication injected can sometimes be confined to a limited area, bilateral effects and spread of injectate to adjacent levels often occurs. Diagnostic injections can easily be performed with transforaminal epidural injections if meticulous technique and a low volume of injectate are used. For diagnostic purposes, a transforaminal epidural injection is performed with meticulous technique and low volume of injected local anesthetic.
Intrathecal diagnostic injections are also used to determine the dose of opioid for pain control, or that no opioid will be effective in any dose, as well as to determine a patient's response to baclofen, clonidine, local anesthetic, and other medications.
Therapeutic intrathecal (subarachnoid) injections and infusions of opioid, local anesthetic, clonidine, and other medications may be used for the treatment of acute or chronic pain, cancer pain, and baclofen for intractable spasticity. Both epidural and intrathecal injections may be used for the following:
Indications for Transforaminal Epidural Injections:
Transforaminal epidural injection is selective block of the cervical/thoracic, lumbar, or sacral nerve roots with proximal spread of contrast/local anesthetic through the neural foramen to the epidural space. With the aid of fluoroscopic or computed tomography (CT) imaging, the needle tip is placed within or adjacent to the lateral margin of a neural foramen, and contrast material is injected to obtain a neurogram and visualize spread of the injected solution. A small volume of local anesthetic is injected (less than or equal to 1.0 ml) in order to perform a diagnostic, reproducible blockade of a specific nerve root. The diagnostic usefulness is lost if more than 1.0 ml of injectate is injected (the block becomes unreliable, since spread of anesthetic to adjacent levels and structures likely occurs). Steroid can be added as a therapeutic measure. Injections for therapeutic reasons can be of greater volume. The block can be performed for diagnostic, therapeutic, or both purposes.
Transforaminal epidural injections are appropriate for the following diagnostic purposes:
Transforaminal epidural injections are appropriate for the following therapeutic purposes:
The facet, or zygapophysial, joints are paired diarthrodial articulations between posterior elements of adjacent vertebrae. Spinal facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain, 36% to 67% of patients with neck pain, and 34% to 48% of patients with thoracic pain (Boswell et al, 2007). Paravertebral facet joint/nerve block is utilized as a diagnostic tool to determine whether a specific facet joint is responsible for chronic spinal pain. The patient with this condition usually has moderate-to-severe back pain that does not have a strong radicular component, there is no associated neurologic deficit, the pain is typically aggravated by hyperextension of the spine, and there is typically tenderness to palpation of the spine at the level of the suspected joint. Back or neck pain is typically worse than leg or arm pain, respectively, e.g., pain is primarily axial, not radicular.
Facet joint arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of a joint, either by intra-articular injection of a small volume of local anesthetic (0.5 to 1.0 ml), or blockade of the medial branch nerves of the dorsal rami innervating the joint with a small volume of local anesthetic (0.5 to 1.0 ml). A single block has been implicated to be a source of false-positive results in 27% to 63% of patients in the cervical spine, 42% to 58% of the patients in the thoracic spine, and 17% to 47% in the lumbar spine (Sehgal et al 2007). The diagnosis can be made by a positive but differential response to local anesthetics of different durations of action injected on separate occasions.
After a needle is placed into the facet joint or adjacent to the target medial branch nerve under fluoroscopic or computed tomography (CT) imaging guidance, a small volume (0.5 to 1.0 ml) of a short or long-acting local anesthetic agent with or without steroid is injected. The patient is then asked to engage in activities that typically elicit or aggravate the pain. Relief of pain for a significant period of time suggests that facet joints were the source of the pain. Pre-procedural and post-procedural pain scores (numeric or Visual Analogue) should be documented, and then compared. If significant pain relief occurs after the injection (a positive response), the patient’s response should be monitored and documented with regards to the degree of pain relief, duration of pain relief, and improvement in functional status. A repeat block may be performed only if the patient’s pain returns and functional status starts to deteriorate. If significant relief is noted with improvement in functional status, but the pain returns after a period of relief, a second block may be performed at a later date with local anesthetic of a different duration of action in order to rule out a false-positive response.
If double-comparative paravertebral facet joint /nerve blocks provide significant pain relief lasting several weeks to months, therapeutic facet joint/nerve blocks may be considered. If double-comparative paravertebral facet joint/nerve blocks provide significant pain relief that is not long-lasting, facet joint denervation may be considered.
Indications for Paravertebral Facet Joint/Nerve Block:
Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first set of procedures fails to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495).
Fluoroscopic or computed tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by codes 64490-64495. For Paravertebral Spinal Nerves and Branches – Image guidance [fluoroscopy or CT] and any injection of contrast are inclusive components of 64490-64495.
Diagnostic Paravertebral Facet Joint/Nerve Block
Diagnostic paravertebral facet joint/nerve block is appropriate for the following conditions:
Therapeutic Paravertebral Facet Joint/Nerve Block
When a patient has relief of pain with controlled diagnostic blocks with a combined response from two blocks of several weeks to months, he/she may be considered a candidate for therapeutic facet joint/nerve nerve blocks. When a patient has relief of pain (positive response), but an insufficient duration of symptom relief, with controlled diagnostic blocks, he/she should be considered for a more definitive procedure such as denervation unless, of course, the diagnosis is in error.
Therapeutic facet joint/nerve block injections may be considered provided that:
Paravertebral facet joint denervation is the destruction of a paravertebral facet joint nerve by neurolytic agent (e.g., chemical, thermal, electrical, radiofrequency).Facet joint denervation may be considered if double-comparative paravertebral facet joint/nerve blocks do provide significant pain relief, but the pain relief is not long-lasting. This procedure involves placing a needle or radiofrequency cannula adjacent to each of the two, or more, medial branch nerves innervating the target joint(s).
Indications for Paravertebral Joint/Nerve Denervation:
Facet joint arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade as described above.
For those beneficiaries that are considered candidates for denervation, the medical record should reflect the failure of conservative therapy and that appropriate diagnostic paravertebral facet joint/nerve block studies have been performed. Studies should document the specific joint level(s) affected and that significant, but not long-lasting, pain relief has been obtained from the paravertebral facet joint/nerve blocks. Significant pain relief in this instance is defined as greater than or equal to (>/=) 80%-90% initially with the ability to perform previously painful maneuvers.
Limitations for Paravertebral Joint/Nerve Denervation:
The effects of denervation should last from six (6) months to one (1) year, or longer. In some instances, though, the effects may be permanent. Repeat denervation procedures at the same joint/nerve level will only be considered medically necessary when the patient had significant improvement of pain after the initial facet joint nerve destruction that lasted an appropriate period of time (greater than or equal to six months).
Pulsed radiofrequency for denervation is considered investigational and thus, not medically necessary.
SACROILIAC (SI) JOINT INJECTIONS
The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.
Indications for Sacroiliac (SI) Joint Injections:
Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed.
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by the intra-articular injection of a small volume of local anesthetics (2 to 3 ml) of different durations of actions. A positive response should demonstrate initial pain relief greater than or equal to (> /=) 80%-90% and the ability to perform previously painful maneuvers. Steroids may be injected in addition to the local anesthetic.
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be billed.
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic procedures have been performed.
Limitations for Sacroiliac (SI) Joint Injections:
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections would not be considered medically necessary.
ACUTE POST-OPERATIVE PAIN MANAGEMENT
Management of acute pain (obstetric, post-operative, or secondary to major trauma not requiring an operative procedure) in the hospital may be provided by several means: oral and parenteral administration of analgesics, intravenous patient controlled analgesia (PCA), and by the administration of epidural opiates or anesthetics.
Patient controlled analgesia is generally administered as an intravenous opiate infusion. The medication is available via an intravenous pump, and the patient can trigger the pump to deliver additional doses of medication based upon his/her individual threshold for pain, within the parameters programmed into the device.
Epidural analgesia may be provided by single injection or continuous infusion. It usually requires the placement of an epidural catheter, but may also be performed by a single injection. Epidural analgesia may be provided before or after a surgical procedure, but the advantage to pre-operative placement is that the patient is able to cooperate with the procedure, is not sedated from the operation and therefore is able to report any accompanying paresthesias, the catheter can be properly tested prior to surgery, and the patient will be able to receive pain medications via the epidural space prior to emergence from general anesthesia and may receive benefit from preemptive analgesia. Epidural anesthesia/analgesia commonly employs, in combination or as single agents: local anesthetics, opiates and opioids. Occasionally clonidine is used. Advantages of epidural analgesia include: less sedation, earlier mobilization, fewer respiratory complications, and preemptive analgesia. Catheters are usually left in place for three (3) days or less as the patients have usually recovered sufficiently to allow for removal. Patients with major abdominal or thoracic procedure may require longer infusion periods.
Indications for Acute Post-Operative Pain Management:
Epidural analgesia may be employed in obstetrical care and following major thoracic, intra-abdominal, radical pelvic cancer, aortic, retroperitoneal or orthopedic surgeries (hip and knee). It is seldom needed after laparoscopic surgeries for patients who are ambulated the same day.
Epidural analgesia may be employed for pain management in patients sustaining major non-operative trauma.
Reimbursement will be allowed for the initial insertion of the catheter by an anesthesiologist or CRNA on the date of surgery if performed for postoperative pain relief rather than as a measure for providing the regional block for surgical procedures.
Limitations for Acute Post-Operative Pain Management:
Except in special circumstances, payment for physician services related to patient controlled analgesia is included in the global fee paid to the surgeon. Routine management of PCA is not reimbursable to another physician or provider, and may not be billed as an anesthesia or evaluation and management (E&M) service. Prescription is part of the surgeon’s post-operative management and included in the global surgery.
Catheters placed in an operative site for infusion of a local anesthetic are included in the global surgical package.
Although the insertion of the epidural catheter is for the post-operative management of pain, the catheter may be utilized for the delivery of anesthetic during the surgical procedure if such use is only incidental to the general anesthesia. If it is used as the principal method of anesthesia, then it should be included as part of the surgical anesthesia care, and not separately billed. The catheter may be inserted prior to the onset of the surgical procedure (in the operating room) but this time should not be included in the time recorded for the anesthesia care for the surgery.
Anesthesia services provided by the performing surgeon are included in the global reimbursement for surgery, and neither the catheter placement (CPT code 62318 or 62319) nor the daily management of the administration of drugs is separately payable to the surgeon.
Daily management of epidural or subarachnoid drug administration is defined as a daily service and may only be billed by one provider other than the surgeon per day.
LIMITATIONS FOR ALL DIAGNOSTIC AND THERAPEUTIC PAIN MANAGEMENT SERVICES
Low back pain may also be associated with “myofascial pain syndrome” or a soft-tissue source of pain in which case no nerve root pathology exists, so interlaminar/translaminar, caudal, or transforaminal epidural injection would be ineffective. If the diagnosis is in question, the diagnosis of radiculopathy should be confirmed by electrophysiological studies, radiological studies, or a diagnostic transforaminal selective epidural/selective nerve root injection. A paravertebral joint/nerve or sacroiliac joint injection would also not be indicated for pain associated with “myofascial pain syndrome.”
Nerve blocks may be used for diagnostic and therapeutic purposes. Therapeutic blocks include the use of anesthetic, antispasmodic, and/or anti-inflammatory substances for the long-term control of pain. There is no role for a "series" of injections. Each injection should be individually evaluated for clinical efficacy (diagnostically and/or therapeutically). If complete, but only temporary pain relief occurs after the injections, another type of treatment needs to be considered.
Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare. In certain circumstances a patient may present with both facet and sacroiliac problems. In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation. The medical record must clearly support both procedures. Medicare recognizes that this is not common and will monitor the frequency with which these codes are combined. Multiple procedure modifiers will apply to intraarticular sacroiliac injection.
It is usually not appropriate to provide an interlaminar epidural/intrathecal injection, a transforaminal selective epidural (or selective nerve root injection), facet joint/nerve block, sacroiliac joint injection, lumbar sympathetic block, or other nerve block on the same day. Therefore, only one of these procedures is allowed on a given day, unless conditions are met as described immediately above for paravertebral and sacroiliac joints or one of the following conditions occur and are documented in the medical record.
The standard of care for all transforaminal epidural injections for paravertebral facet joint/nerve injection and denervation, and sacroiliac joint injections requires that these procedures be performed under fluoroscopic- or CT-guided imaging. Therefore, injections performed without imaging guidance will be considered inappropriate and not reasonable or necessary. The rationale for accepted medically necessary use of CT rather than fluoroscopy must be documented.
Failure to obtain appropriate response to blind interlaminar or caudal epidurals may indicate improper delivery of the drug and/or presence of a pain generator, which is non-responsive to epidural injection. Thus, subsequent epidural injections after a failed or inadequate response, if performed, should be under fluoroscopic visualization.
General anesthesia or monitored anesthesia care (MAC) is rarely, if ever required for injections addressed in this policy. In fact, general anesthesia is contraindicated for diagnostic blocks (Manchikanti et al 2005). Further, monitored anesthesia care or heavy sedation may provide false-positive results.
The CPT code 72275 (Epidurography, radiological supervision and interpretation) differs from CPT code 77003 in that it represents a formal recorded and reported contrast study that includes fluoroscopy. Epidurography should only be reported when it is reasonable and medically necessary to perform a diagnostic study. It may only be performed with a caudal or intrathecal approach and should not be billed for the usual work of fluoroscopy and dye injection that is integral to the epidural, paravertebral joint/nerve, or sacroiliac injection(s).
Until the pending scientific assessment of the technique has been completed and its efficacy has been established, Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made. Accordingly, acupuncture is not considered reasonable and necessary within the meaning of §1862(a)(1) of the Act. (CMS Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1: Section 30.3)
The medical effectiveness of Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents has not been verified by scientifically controlled studies. Accordingly, reimbursement for these modalities should be denied on the ground that they are not reasonable and necessary as required by §1862(a)(1) of the Act. (CMS Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1: Section 150.7)
CMS Publication100-08, Program Integrity Manual, Chapter 13, section 5.1 outlines that “reasonable and necessary” services are “ordered and /or furnished by qualified personnel.” Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty. If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered, sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit. Documentation of training must be available upon request.
Non-physician practitioners (NPs) may only perform procedures requiring radiologic imaging if their respective states allow such in their practice act and license the practitioner to use radiation.
For claims submitted to the fiscal intermediary Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.
Bill type codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier Part B MAC.
For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for pain management services as authorized by State law. (See Sections 1861[s] and 1862[a] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)