Medicare Targeting TENS & ESIs

-->December 11, 2012Billing & Compliance Alerts

    Medicare Targeting TENS & ESIs
    By Justin Vaughn, M.Div, CPC
    Vice President of Compliance


    As part of its ongoing efforts to ensure the medical necessity of covered services, Medicare has published two recent documents that will have a direct impact on the practices of chronic pain providers.  One of these documents deals with transcutaneous electrical nerve stimulation (TENS), while the other addresses epidural steroid injections (ESIs).  The pertinent details of these Medicare communications are provided below.

    Time Running Out for TENS

    On December 4, CMS published a revised Medicare Learning Network (MLN) Matters article in which it announced a change in coverage as it relates to TENS services.  While once covered, such services are now being phased out—at least as it concerns using a TENS unit for the treatment of chronic lower back pain (CLBP).  Specifically, CMS has determined that “the evidence is inadequate to support coverage of TENS for CLBP as reasonable and necessary.”  As a result, Medicare will only allow coverage of TENS in connection with CLBP when ALL of the following stipulations are met:
    There must be pain in the lower back existing for 3 months or longer;

    • Such pain must NOT be a manifestation of a clearly defined and generally recognizable primary disease (such as cancer); AND
    • The patient must be enrolled in an approved clinical study under “coverage with evidence development” (CED).  Please note that CED coverage expires June 8, 2015.

    As a result of these recently released restrictions on TENS coverage in connection with CLBP, you will want to make sure that the stipulations listed above are fully followed before you attempt to submit a claim to Medicare for this service.  For more details on this issue, please go to the CMS website and access MLN article # MM7836.

    Lack of Support for ESIs

    Wisconsin Physicians Service Insurance Corporation (WPS), the Medicare carrier for several Midwestern states, undertook a Comprehensive Error Rate Testing (CERT) review, and determined a significant incidence of insufficient documentation in connection with epidural injection services.  Specifically, the CERT audit revealed that, “in most cases, providers did not submit documentation of conservative therapies that were tried and failed prior to initiating the epidural injection treatment.”  According to the carrier’s local coverage determination (LCD) on epidural injections, this “conservative therapies” documentation requirement does not extend to acute scenarios, such as labor or post-op pain epidurals, but is applicable when submitting claims for epidural steroid injections (ESIs).

    Since at least one Medicare carrier has determined, via CERT review, that ESIs are not being sufficiently supported in the medical record, you can be sure that this issue will not only come under increasing scrutiny in the WPS states, but will become a target in other carrier jurisdictions, as well.  Therefore, it will behoove you to review your Medicare carrier’s epidural LCD (if extant) prior to administering ESIs to your patients.  Should documentation of the attempt and failure of conservative treatment be required, be sure to add that language to your procedure report when applicable.  If you do not, and you are selected for an audit, you may be asked to write a check to the government.

    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.