Local Coverage Determination (LCD) for Surgery: Trigger Point Injections (L30066)

Transcription

1 Local Coverage Determination (LCD) for Surgery: Trigger Point Injections (L30066) Contractor Information Contractor Name Cahaba Government Benefit Administrators, LLC LCD Information Document Information LCD ID Number L30066 LCD Title Surgery: Trigger Point Injections Contractor's Determination Number AMA CPT/ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Oversight Region Region IV Original Determination Effective Date For services performed on or after 05/04/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 03/01/2010 Revision Ending Date

2 The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack the necessary information to process the claim. Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be reasonable and medically necessary, i.e., reasonable and necessary are those tests used in the diagnosis and management of illness or injury or to improve the function of a malformed body part. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Medicare National Coverage Determinations Manual (Pub ), Chapter 1, Section 30.3 addresses acupuncture. Medicare National Coverage Determinations Manual (Pub ), Chapter 1, Section addresses prolotherapy, joint sclerotherapy, and ligamentous injections. Medicare Program Integrity Manual (Pub ), Chapter 13, Local Coverage Determinations. Indications and Limitations of Coverage and/or Medical Necessity Indications An active trigger point has pain at rest, has pain on palpitation, has radiation of pain, and has a local twitch response. Trigger point injections are indicated in symptomatic trigger points. The history of onset of the painful condition and its presumed cause, location, duration, failed therapies and recommendations for injection therapy of each clearly delineated muscle must be in the patient s chart and made available to Medicare upon request. The goal is to treat the cause of the pain and not just the symptom of pain. Limitations 1. Trigger point injections accompanied by appropriate adjunctive care should provide moderate-to-long term benefits. There is no peer-reviewed literature to substantiate more than four trigger point injections in a year. 2. Acupuncture is not covered by Medicare. If acupuncture is billed using trigger point therapy codes (20552, 20553) it will be considered not reasonable and necessary.

3 3. Prolotherapy is not covered by Medicare. If prolotherapy is billed using trigger point therapy codes (20552, 20553) it will be considered not reasonable and necessary. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 999x Not Applicable Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes Not Applicable CPT/HCPCS Codes Inj trigger point 1/2 muscl Inject trigger points 3/> ICD-9 Codes that Support Medical Necessity The correct use of an ICD-9-CM code listed in the ICD-9 Codes that Support Medical Necessity section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD. ICD-9 codes must be coded to the highest level of specificity. Consult the Official ICD-9-CM Guidelines for Coding and Reporting in the current ICD-9-CM book for correct coding guidelines. This LCD does not take precedence over the Correct Coding Initiative (CCI). The diagnosis of trigger points does not have a specific ICD-9-CM code. In order to facilitate the providers to accurately pre-code the diagnosis, the following ICD-9-CM codes are being assigned for trigger points in specific muscle groups: For the following muscle groups use 720.1: Serratus anterior Serratus posterior Quadratus lumborum Longissimus thoracis

4 Lower thoracic iliocostalis Upper and lower rectus abdominis Upper lumbar iliocostalis Multi fidus External oblique McBurney's point SPINAL ENTHESOPATHY For the following muscle groups use 723.9: Trapezius (upper & lower) Sternocleido-mastoid (cervical & sternal) Masseter Temporalis Lateral pterygoid Splenii Posterior cervical Suboccipital UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK For the following muscle groups use : Scaleni Subscapularis Levatorscapulae Brachialis Deltoid (anterior & posterior) Middle finger extensor Infraspinatus/supraspinatus First dorsal interosseous Pectoralis (major & minor) Supinator Latissimus dorsi Rhomboid OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION For the following muscle groups use : Triceps Extensor carpi radialis Middle finger flexor OTHER ENTHESOPATHY OF ELBOW REGION For the following muscle groups use 726.5: Glutei, piriformis Adductor longus & brevis ENTHESOPATHY OF HIP REGION

5 For the following muscle groups use : Soleus Gastroenemius ACHILLES BURSITIS OR TENDINITIS For the following muscle groups use : Tibialis anterior TIBIALIS TENDINITIS For the following muscle groups use : Peroneus longus & brevis Extensor digitorum & hallucis longus Third dorsal interosseous OTHER ENTHESOPATHY OF ANKLE AND TARSUS For the following muscle groups use : Rectus femoris Vastus intermedius Vastus medialis Vastus lateralis (anterior & posterior) Biceps femoral ENTHESOPATHY OF UNSPECIFIED SITE - EXOSTOSIS OF UNSPECIFIED SITE Diagnoses that Support Medical Necessity NA ICD-9 Codes that DO NOT Support Medical Necessity Any ICD-9-CM code that is not listed in the ICD-9 Codes that Support Medical Necessity section of this LCD. XX000* Not Applicable ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation NA Diagnoses that DO NOT Support Medical Necessity Any diagnoses that are not listed in the ICD-9 Codes that Support Medical Necessity section of this LCD. General Information Documentations Requirements 1. The patient s medical record must have:

6 A. Documentation of the physical findings leading to diagnosis of the trigger point. B. The involved muscle group(s) must be documented in the patient s medical record as well as the number of trigger points injected. A diagram with an "X" or other similar annotation is not adequate documentation. C. Documentation of the reason(s) for selecting this therapeutic option. 2. Diagnosis codes from the ICD-9-CM Codes that Support Medical Necessity section must be used to support the specific muscles injected. Generalized diagnoses like low back pain, lumbago, etc. will not be covered. 3. If a patient requires more than four (4) procedures of either CPT codes or during one year, a report stating the unusual circumstances and medical necessity for giving the additional injections must be documented in the patient's medical record and made available to Medicare upon request. 4. All coverage criteria must be clearly documented in the patient s medical record and made available to Medicare upon request. 5. Documentation must support CMS signature requirements as described in the Medicare Program Integrity Manual (Pub ), Chapter 3. Appendices NA Utilization Guidelines 1. More than four (4) trigger point injections in a year's time will not be covered by this Contractor. 2. If a patient requires more than four (4) procedures of either CPT codes or during one year, a report stating the unusual circumstances and medical necessity for giving the additional injections must be documented in the patient's medical record and made available to Medicare upon request. Sources of Information and Basis for Decision Alvarez D.J., Rockwell P.G., University of Michigan Medical School, Ann Arbor, Michigan; Trigger Points: Diagnosis and Management; Practical Therapeutics, Feb 15, 2002, Volume 65, Number 4, Borg-Stein, J., MD; Stein, Joel; Trigger Point and Tender Points One and the Same? Does Injection Treatment Help? Rheumatic Disease Clinics of North America; Volume 22, Number 2, May 1996, Ingber, Reuben S., MD; Position Paper on Trigger Point Injections (Fibromyalgia and Myofascial Pain News); Immunesupport.com; Treatment and Research Information,

7 Consultation with Cahaba GBA Part B CMDs from Alabama, Georgia and Mississippi. Consultations with the representatives to the Carrier Advisory Committee. Other Medicare Carriers LCDs. Advisory Committee Meeting Notes Start Date of Comment Period End Date of Comment Period Start Date of Notice Period Revision History Number #3 Revision History Explanation Revision 3 Revision Date: October 14, 2011 Effective Date: March 1, 2010 Template language in the ICD-9 Codes that Support Medical Necessity section was added regarding correct coding guidelines. Added to the Documentation Requirements: Documentation must support signature requirements as described in the Medicare Program Integrity Manual (Pub ), Chapter 3. (Change Request 6698) No change in coverage; effective 3/01/2010. Revision 2 Start Date of Notice Period: July 14, 2009 Effective Date: August 29, 2009 As part of the J10 MAC transition, LCD effective for contractor number Tennessee Part B. Revision 1 Start Date of Notice Period: June 17, 2009 Effective Date: August 1, 2009 As part of the J10 MAC transition, LCD effective for contractor number Georgia Part B. Original Start Date of Notice Period: March 20, 2009 Effective Date: May 4, 2009 As part of the J10 MAC transition, LCD effective for contractor number Alabama Part B. 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group 1

8 11/25/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group 1 (LCD approved 12/4/2012 for this update). Reason for Change Narrative Change Related Documents This LCD has no Related Documents. LCD Attachments There are no attachments for this LCD. All Versions Updated on 12/04/2012 with effective dates 03/01/ N/A Updated on 10/24/2011 with effective dates 03/01/ N/A Updated on 10/14/2011 with effective dates 03/01/ N/A Some older versions have been archived. Please visit the MCD Archive Site to retrieve them. Read the LCD Disclaimer Footer Links Get Help with File Formats and Plug-Ins Submit Feedback Department of Health & Human Services Medicare.gov USA.gov Web Policies & Important Links Privacy Policy Freedom of Information Act No Fear Act Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD