A Resurgent Pattern
So, you’ve been doing quite well, following the directions and living up to expectations; but, all of a sudden, you start veering off course and coloring outside the lines. You’re going back to old habits. That is the place many providers are currently in when it comes to submitting cases associated with certain services.
Our Coronis Health team has noted in recent weeks a new uptick in the receipt of anesthesia records involving chronic pain injections. That is, a chronic pain physician performs a lumbar epidural steroid injection (LESI), a transforaminal injection or a facet joint injection, and you—the anesthesia provider—are being asked to provide anesthesia coverage for that injection procedure. Again, we are seeing more of these cases. Here is a direct quote from one of our key coding team members:
Recent reviews have identified an increase in inappropriate billing of anesthesia services during epidural steroid injections (ESI) and facet joint interventions for pain management.
Okay, so you’ve seen an increase in these types of cases. So what? The answer is that submitting such cases—especially to Medicare—can be fraught with all kinds of problems, as the section below will demonstrate.
A Problematic Practice
Hey, we get it! We understand the reason behind wanting to provide anesthesia coverage in these types of cases. The thinking is that this particular patient may pass out or may have certain anxieties or perhaps they have some mental challenges, and it would therefore be best to have an anesthesiologist or anesthetist present in the event the patient needs to be sedated or put fully under. The problem is that these services are rarely payable under Medicare.
Back in 2021, Medicare jurisdictions published a local coverage decision (LCD) entitled “Epidural Steroid Injections for Pain Management” (which includes interlaminar, transforaminal and caudal approaches). It contained the following language:
Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.
While Medicare has thus far refused to clarify which “exceptional and unique cases” would establish a medical necessity for the services of an anesthesia provider in an ESI case, the overall takeaway is that these services will rarely be reimbursed to anesthesiologists and anesthetists.
Similarly, Medicare published policy language in 2024 completely precluding payment for facet injections. The Medicare LCD on facet interventions states the following:
Use of moderate or deep sedation, general anesthesia and monitored anesthesia care (MAC) is not considered medically reasonable and necessary during facet injections. For RFA and facet cyst aspiration/rupture, the use of moderate anesthesia or MAC may be considered if medical necessity is clearly established. Documentation must explain the medical necessity for sedation and frequent reporting of these services together may trigger focused medical review.
So, if you are submitting claims for facet injection—regardless of the anesthesia technique—we will not submit them to Medicare due to the above LCD language.
Providers can submit appeals if they believe anesthesia was justified in exceptional cases, such as facet RFA, supported by detailed documentation. Even so, we believe the bar is set too high for many of these appeals to be successful. In addition, it should be noted that the Office of Inspector General (OIG), in a nationwide audit, revealed that Medicare could have saved $17.7 million if CMS oversight had prevented at-risk payments for anesthesia during spinal pain management procedures.
So, the upshot of all this is that anesthesia providers should take seriously the LCD limitations, as outlined above, ensure that their documentation supports medical necessity where truly present, and avoid the routine submission of anesthesia services associated with these procedures. Finally, it should also be noted that some commercial carriers are starting to follow CMS’s policies in this regard and are creating their own policies with similar limitations.