What Radiologists Need to Know about Epidural Steroid Injections for Pain Management

March 9, 2022

By Leslie Shisler, CPC, CIRCC, RCC, RCCIR, Manager, Corporate Coding

CMS has created new coverage policies and associated criteria for Epidural Steroid Injections for Pain Management, and because Zotec Partners keeps a finger on the pulse of radiology policies and documentation requirements, we have outlined must know information for radiologists.

Key Date Upcoming for Noridian Coverage Policy

All MAC policies (exception of Noridian) took effect on 12/5/2021 and 12/12/2021, respectively. However, the proposed Noridian coverage policy comment period will end soon, on 3/26/2022.

MAC / JurisdictionEffective Date
CGS (KY, OH)12/05/2021
NGS (CT, IL, ME, MA, MN, NH, NY, RI, VT, WI)12/05/2021
Palmetto (AL, GA, TN, VA, WV, NC, SC)12/05/2021
WPS (IN, IA, KS, MI, MS, NE)12/05/2021
First Coast (FL, PR, VI)12/12/2021
Novitas (AR, CO, DE, DC, LA, MD, MS, NJ, NM, OK, PA, TX)12/12/2021
Noridian JE & JF (CA, HI, NV, AK, AZ, ID, MN, ND, SD, OR, UT, WA, WY)Proposed

Because the coverage criteria and documentation requirements for epidural steroid injections are extensive, we’ve mapped the high points out below.

Stay on Top of These Coverage Criteria

  • Specific indications for coverage, utilization parameters, limitations, and medical necessity requirements are required.
  • Medicare distinguishes epidural steroid injections based on whether the procedure is diagnostic or therapeutic.
  • If/when a diagnostic transforaminal/selective nerve root block is performed, a KX modifier must be submitted on the claim.
  • An assessment of pre- and post-percent pain relief that is achieved immediately post-injection must be performed, and the same/consistent pain scale should be used for each encounter.
  • Transforaminal injections allow a maximum of two levels per session, per spinal region.
  • Caudal and interlaminar injections allow one level per session, per spinal region.
  • Percentage and duration of pain relief and frequency limitations will also affect coverage.

Documentation Requirements

  • The procedural report must clearly document the indications and medical necessityfor the block(s), along with thepre- and post-percent pain relief that is achieved immediately post-injection.
  • If either of the items above are missing from the documentation for Medicare patients, Zotec can send the reports back to the provider prior to billing to allow the required information to be added, if applicable.
  • If/when a transforaminal or selective nerve root block is diagnostic, this should be documented in the report by the provider to make the intent of the procedure clear so the -KX modifier can be applied.

Have more questions?

If you’d like more detailed information or to see our in-depth webinar recap, contact Ron Jackson with the radiology team at rjackson@zotecpartners.com.