New CMS Notices Target Pain Management Services
By: Justin Vaughn, M.Div, CPC, Director of Compliance

7/20/2011

CMS has begun issuing notices to pain management goups across the country that address government concerns of non-compliant claims submission.  The first of these notices involves audits, known as “Specialty Medical Reviews,” that will specifically target transforaminal epidural injections.  CMS has contracted with Strategic Health Solutions, LLC as the auditing entity relative to these procedures.  The genesis of these audits was the OIG’s prior determination that a significant number of transforaminal claims did not meet the LCD requirements of Medicare contractors, were miscoded, or were otherwise medically unnecessary.

Compliance attorney David Vaughn advises:  “If you get one of these audit requests, make sure to send both the H&P and/or progress note documenting the medical necessity rationale for initiating these injections, as well as the follow-up notes showing the efficacy of the injections.”

On another front, CMS has begun issuing CBRs (Comparative Billing Reports) to pain practices that prescribe back braces.  These CBRs provide the physicians with a comparison of their prescriptions of back braces with those of their peers—both in their state and in the nation as a whole.  CMS has identified orthotics as an area of increased utilization, and this is the government’s way of warning you that they will be auditing those who have a high incidence of orthotic prescriptions.

Attorney Vaughn notes that there must be (a) a signed order and, (b) a statement of the medical necessity, relative to each brace prescribed.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.