CERT Errors - Epidural and Transforaminal Epidural Injections

WPS Medicare received notice from the Comprehensive Error Rate Testing (CERT) Contractor, of errors assessed due to insufficient documentation for CPT code 64483 (Injection(s) s, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level). Included in the CERT contactor's comments for two different claim submissions, are the following comments:

Case 1

  • Missing documentation to support use of conservative therapies prior to administration of injection on 04/14/2011, and rendering physician's signature on the provided follow-up telephone call dated 04/22/2011. Of note, this record of phone call does report the beneficiary's current pain level and is signed by the CMA.

Case 2

  • Provider submitted copy of physician's order and procedure report for transforaminal epidural injection and eipdurography in support of billed services for 4/29/11. However, missing is documentation of medical necessity for the procedure, as required by LCD. Provider submitted a copy of the History and Physical; however, it was not signed by physician and the form did not include physical exam, assessment, or plan entries. A Pain Management Information form was submitted; however, the form was not signed, thus we are unable to determine that entries were those of billing physician.

If you perform and submit any services governed by this LCD to WPS Medicare, please be certain that the provider's documentation supports the services billed. When responding to a request for documentation, please include all relevant documentation to support the service billed, and the medical necessity of the service. To review Epidural and Transforaminal Epidural Injections, LCD L30481 in its entirety, please refer to the Local Coverage Determinations (LCD) Policy page.

Page Last Updated: Tuesday, 13-Dec-2011 17:21:57 CST