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New Documentation Requirements for ESIs: How ModMed® Seeks to Help Pain Management Practices

doctors examining scans of a patient's lower back pain

FAQ with ModMed Pain Management Staff

This article was originally published on Sept. 7, 2022. 

In December 2021, a new local coverage determination (LCD) issued by nearly all Medicare administrative contractors (MACs) went into effect. For practitioners in Noridian jurisdictions (like California and Nevada), a similar LCD took effect on June 19, 2022. These LCDs significantly amended the documentation requirements necessary to receive full reimbursement for the administration of epidural steroid injections (ESIs).

What exactly changed in terms of required ESI documentation with the implementation of these LCDs?

Prior to December 2021, any pain management physician could schedule a series of epidural steroid injections and perform them if that physician believed it was the best course of treatment. It was considered a routine practice. Now, physicians will not be reimbursed by Medicare for administering a second injection without documenting and demonstrating medical necessity in a certain way. There are lots of specific details that need to be included to get a second, third and fourth injection covered by Medicare, and all of them must be maintained in the patient’s medical record.

The documentation must include patient identification information, dates of service, and responsible physician or practitioner signatures. Documentation must clinically support the chosen ICD-10-CM and CPT codes, with the procedural report spelling out indications and medical necessity for ESIs. Additionally, the report should include pre- and post- percent pain relief reported by the patient achieved post-injection.

You generally will need films with a minimum of two views that show final needle position and contrast flow. You also need to include the assessment, chief complaint, medical history, results of any relevant tests and/or procedures, and a signed and dated office visit record and/or operative report.

How has this affected coding and billing for ESI administration?

According to the LCD, it’s not medically necessary to perform caudal or interlaminar injections bilaterally. Therefore, CPT codes 62321 and 62323 aren’t bilateral procedures and can only be reported for one level per session.

Also, billing and coding articles issued by the MACs indicate that CPT codes 64479 and 64483 should be used to report a single level injection, while CPT codes 64480 and 64484 represent each additional level, so they should be reported separately in addition to the primary procedure when applicable.

How did you find out these changes were coming?

Dr. Aneesh Singla, our Medical Director of Pain Management, had seen a post on Linkedin from a concerned colleague. Dr. Singla told us he knew this could affect the revenue of our pain management customers, so he brought it to our attention right away, before the changes went into effect.

Who has been the hardest hit?

Basically, any interventional pain management physician who sees Medicare patients has probably been affected. They’ve had to handle major changes in the amount and quality of documentation needed for a treatment many considered to be routine practice. And these guidelines may trickle down into the commercial payers, since Medicare is often considered a “gold standard” when it comes to insurance reimbursements.

We knew we had to act proactively because many of our pain management physicians were going to be affected. What differentiates pain management from other specialties is the complexity of it. Pain is often a chronic condition, it’s fluid, and it can have many causes.

So what has ModMed done to address these changes?

First, we consulted with our on-staff medical directors. Our goal was to remove this mental obstacle for physicians and distill these changes into a less mentally exhausting format. That consultation led to the development of a new workflow within the software. The ESI workflow includes all seven new documentation requirements from the LCD, and allows the physician to select the appropriate criteria in order. By leveraging our medical directors’ experience, we’ve created a simple version of a criteria checklist that helps physicians obtain the level of reimbursement they’re actually entitled to.

What was the motivation to implement these changes?

The Medicare contractors have suggested that there is a patient safety angle to all of this. Unnecessary injections performed without considering alternatives may have devastating consequences for patient health over the long term. So it’s an effort by Medicare, and potentially commercial payers in the future, to establish that only those conditions that actually require ESIs are being treated with this procedure. Unfortunately, increasing reporting requirements like this can result in an additional administrative burden on pain management practices.

This isn’t the first time documentation requirements have changed, and it certainly won’t be the last. Have we learned anything that we can apply in the future?

When we talk to pain management practices, many of them say they’re searching for ways to handle these regulatory changes. If this is how physicians are feeling on a daily basis, we need to provide concrete ways to help. Otherwise, burnout will just get worse.

We’ve learned that being as proactive as possible is the key. That means doing our own research to keep on top of what’s going on in the industry. It also means keeping an open line of communication with our clients and our medical directors so that when we make a change, we can verify it’s really going to help.

Learn more about how ModMed can help your pain management practice succeed.

This blog is intended for informational purposes only and does not constitute legal or medical advice. Please consult with your legal counsel and other qualified advisors to ensure compliance with applicable laws, regulations, and standards.