The What: Medicare Targeted Prob Audits (TPE) are a hot topic for practices right now.

The Who: CMS is instructing Medicare Administrative Contractors to (MAC) to conduct these TPE Audits.

The Why: WPS, which is jurisdiction 8, stated that over 70% of the practices they have audited failed the first round. Here is a look at where practices are coming up short.

Paravertebral Facet Joint Injections for CPT codes 64490-64495 has a trending claim error rate of 90%. The top reason for denial is documentation not meeting Local Coverage Determination (LCD) L38841 requirements for a diagnostic medial branch block (MBB).

Primary Cause of Denials

• Missing disability scale
• A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment).
• Lack of documentation
• Lack of pain lasting 3 months with documented failure to respond to non-invasive conservative management

Coverage Indications, Limitations, and/or Medical Necessity
Covered Indications Facet Joint Interventions
Facet Joint Interventions consist of four types of procedures: Intraarticular (IA) Facet Joint Injections, Medial Branch Blocks (MBB), and Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration:

Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL 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*
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
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.

Need To Know? It is important for you to know how to prepare for the TPE audits, and a terrific way is to start conducting your own audits. If you are not sure how to get started – let us help you. ConfirmaMD’s staff of prior authorization specialists are best in class. Schedule a quick call or reach us online at www.ConfirmaMD.com