Medicare Improperly Paid Physicians for More Than Five Spinal Facet-Joint Injection Sessions During a Rolling 12-Month Period

Facet-joint injections of an anesthetic with or without a steroid are used to diagnose or treat chronic neck and back pain. To address inappropriate billing for pain management tied to overuse of spinal facet-joint injections, the Medicare Administrative Contractors (MACs) developed a limitation of coverage.1 The coverage limitation allows physicians to be reimbursed, during a rolling 12-month period,2 for a maximum of five sessions3 in which facet-joint injections are delivered to the lumbar region of the spine (lumber spine) and a maximum of five sessions in which facet-joint injections are delivered to the cervical and thoracic regions of the spine (cervical/thoracic spine).4 (We refer to injection sessions in these two spinal areas during a rolling 12-month period as “selected facet-joint injection sessions.”) However, Noridian Healthcare Solutions, LLC (Noridian), one of the MACs, confirmed that a common error identified in audits it performed during calendar years 2016 through 2018 was that Medicare paid for more than five sessions in which facet-joint injections were delivered to the lumbar or cervical/thoracic spines during a rolling 12-month period. Therefore, we conducted this audit to determine whether Medicare made improper payments for selected facet-joint sessions in the MAC jurisdictions that had a coverage limitation from January 1, 2017, through May 31, 2019 (audit period).