Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

INAPPROPRIATE MEDICARE

PAYMENTS FOR

TRANSFORAMINAL EpIDURAL

INJECTION SERVICES

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Daniel R. Levinson

Inspector General

August 2010

DEI -05-09-00030
Office of Inspector General

http://oig.hhs.gov

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as

amended, is to protect the integrity of the Department of Health and Human Services

(HHS) programs, as well as the health and welfare of beneficiaries served b'y those

programs. This statutory mission is carried out through a nationwide network of audits,

investigations, and inspections conducted by the following operating components:

Offce of A udit Services

The Offce of Audit Services (OAS) provides auditing services for HHS, either by conducting

audits with its own audit resources or by overseeing audit work done by others. Audits

examine the performance of HHS programs and/or its grantees and contractors in carrying

out their respective responsibilities and are intended to provide independent assessments of

HHS programs and operations. These assessments help reduce waste, abuse, and

mismanagement and promote economy and effciency throughout HHS.

Offce of Evaluation and Inspections

The Offce of Evaluation and Inspections COEI) conducts national evaluations to provide

HHS, Congress, and the public with timely, useful, and reliable information on significant

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI

reports also present practical recommendations for improving program operations.

Office of Investigations

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With

investigators working in all 50 States and the District of Columbia, 01 utilizes its resources

by actively coordinating with the Department of Justice and other Federal, State, and local

law enforcement authorities. The investigative efforts of 01 often lead to criminal

convictions, administrative sanctions, and/or civil monetary penalties.

Office of Counsel to the Inspector General

The Offce of Counsel to the Inspector General (OCIG) provides general legal services to

OIG, rendering advice and opinions on HHS programs and operations and providing all

legal support for OIG's internal operations. OCIG represents OIG in all civil and

administrative fraud and abuse cases involving HHS programs, including False Claims Act,

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG

also negotiates and monitors corporate integrity agreements. OCIG renders advisory

opinions, issues compliance program guidance, publishes fraud alerts, and provides other

guidance to the health care industry concerning the anti-kickback statute and other OIG

enforcement authorities.
.. EXECUTIVE SUMMARY

OBJECTIVE

1. To determine the extent to which Medicare Part B payments for

transforaminal epidural injections met Medicare requirements.

2. To determine what safeguards existed to ensure Medicare Part B

payments for transforaminal epidural injections met Medicare

requirements.

BACKGROUND

Medicare Part B physician payments for transforaminal epidural

injections increased from $57 milion in 2003 to $141 milion to 2007.

This represents an increase of almost 150 percent.

Transforaminal epidural injections are a type of inter ventiona i pain

management technique used to diagnose or treat pain. Transforaminal

epidural injections may be used to treat pain that starts in the back and

radiates down the leg, such as that from a herniated disc pressing on a

nerve. Two primary codes, 64479 and 64483, are used to bil a single

injection in the cervical/thoracic or lumbar/sacral areas of the spine,

respectively. Each primary code has an associated add-on code for use

when injections are provided at multiple spinal levels.

Medicare Part B contractors are responsible for implementing program

safeguards to reduce payment error. To safeguard payments,

contractors may create local coverage determinations (LCD), implement

electronic edits (hereinafter referred to as edits), or conduct medical

review.

We conducted a medical record review of a stratified random sample of

433 transforaminal epidural injection services performed in 2007. In

addition, we reviewed documents and conducted structured interviews

with contractor staff about program safeguards for transforaminal

epidural injections.

FINDINGS

Thirty-four percent of transforaminal epidural injection services

allowed by Medicare in 2007 did not meet Medicare requirements,

resulting in approximately $45 milion in improper payments.

Medicare allowed an additional $23 millon in improper facility

payments associated with physician services in error. Nineteen percent

oftransforaminal epidural injection services had a documentation error.

OEI.05.09.000JO INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES
EXECUTIVE SUMMARY

Documentation errors were more likely to occur in office settings.

Thirteen percent of transforaminal epidural injection services had a

medical necessity error. Eight percent had a coding error. Seven

percent had an overlapping error.

In 2007, 9 of 14 contractors had an LCD for transforaminal epidural

injection services, but reported limited use of other safeguards.

Nine of the fourteen contractors had an LCD for transforaminal

epidural injections. However, only one contractor enforced all LCD

requirements through edits.

No contractor staff reported performing a mep.ical review.

RECOMMENDATIONS

Based on the results of our review, the Centers for Medicare & Medicaid

Services (CMS) should:

Conduct provider education, directly and through contractors, about

proper documentation.

Strengthen program safeguards to prevent improper payment for

transforaminal epidural injection services. To improve program

safeguards, CMS could encourage contractors to examine

transforaminal epidural injection services provided in offces. CMS

could also encourage contractors to develop LCDs for transforaminal

epidural injections and develop additional edits enforcing LCD

requirements. Finally, CMS could encourage contractors to use medical

review to identify improper payments for transforaminal epidural

injection services.

Take appropriate action regarding the undocumented, medically

unnecessary, and miscoded services identified in our sample. We

wil forward information on these services to CMS under separate cover.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL

RESPONSE

CMS concurred with our recommendations and outlined steps to

improve its oversight of payments for transforaminal epidural injection

services. We did not make any changes to the report based on CMS's

comments.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 11
~ TABLE o F CONTENTS

EXECUTIVE SUMMARy...... .............................. 1

INTRODUCTION ..............".............................1

FIN DIN G S . . . . . . . . . . . . '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12

Thirty-four percent of transforaminal epidural injection services

allowed by Medicare in 2007 did not meet Medicare requirements,

resulting in approximately $45 milion in improper payments. .. 12

In 2007, 9 of 14 contractors had an LCD for transforaminal

epidural injection services, but reported limited use of other

safeguards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14

R E COM MEN D A T ION S ..................................... 18

Agency Comments and Office ofInspector General Response. . .. 19

A P PEN D I XES ............................................. 20

A: Detailed Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 20

B: Confidence Intervals for Selected Estimates. . . . . . . . . . . . .. 23

C: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25

A C K NOW LED G MEN T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27
.. NTRODUCTION

OBJECTIVE

1. To determine the extent to which Medicare Part B payments for

transforaminal epidural injections met Medicare requirements.

2. To determine what safeguards existed to ensure Medicare Part B

payments for transforaminal epidural injections met Medicare

requirements.

BACKGROUND

Chronic pain affects more adults in the United States than diabetes,

heart disease, and cancer combined.1 Several organizations, including

the Department of Veterans Mfairs and the Joint Commission, have

recommended that physicians routinely assess pain in their patients.

Treatment varies depending on the type of pain and can range from

noninvasive to invasive, or interventional, techniques.2

Medicare paid over $2 bilion in 2007 for interventional pain

management services.3 Examples of inter ventiona i pain management

services include injections, nerve blocks, and spinal cord stimulation.

From 2003 to 2007, Medicare physician payments for transforaminal

epidural injections, a type of interventional pain management service,

increased by almost 150 percent.4 Physician payments for

transforaminal epidural injections increased from $57 milion in 2003 to

$141 milion in 2007.5 These payments represent approximately

i 1 percent of all Medicare physician payments for interventional pain

management services.6

1 American Pain Foundation, Pain Facts & Figures, July 8, 2009. Accessed at

http://www.painfoundation.org/ on February 1, 2010,

2 Noninvasive pain management techniques may include physical therapy; invasive, or

interventional, techniques may include injections near the source of pain,

3 Estimate based on Offce ofInspector General (OIG) analysis of physician claims for

interventional pain management procedure codes in a I-percent sample of the

2007 National Claims History (NCH) outpatient and physician/supplier fie,

4 Estimate based on OIG analysis of physician claims for transforaminal epidural

injection procedure codes in the following Medicare claims fies: (1) 2003 ¡-percent sample

ofNCH physician/supplier file and (2) 2007 IOO-percent NCH physician/supplier file,

5 Ibid,

6 Estimate based on OIG analysis of physician claims in the following Medicare claims

files: (i 2007 100-percent NCH physician/supplier fie and (2) I-percent sample of the

2007 NCH physician/supplier fie.

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EplOURAL INJECTION SERVICES 1
NTRODUCTION

The number of Medicare physician claims for transforaminal epidural

injection services increased by 130 percent from 2003 to 2007.7 Over

295,000 Medicare beneficiaries received transforaminal epidural

injection services in 2007.8

In addition, a number of investigations by OIG and the Federal Bureau

of Investigation (FBI) have found fraudulent activity related to

transforaminal epidural injections. In one joint OIG-FBI case, an Ohio

physician was convicted of multiple counts of health care fraud for

fraudulent interventional pain management procedures, including

transforaminal epidural injections.9 In a separate case in 2008, a

Maryland physician pled guilty to health care fraud after submitting

$1.75 millon in false claims to Medicare and other insurers. The false

claims were for transforaminal epidural injections and other

interventional pain management services. 

10

Transforaminal Epidural Injections

Transforaminal epidural injections may be used to treat back and leg

pain, including pain that starts from the back and radiates down the

leg, such as that from a herniated disc pressing on a nerve. For some

patients with chronic pain, transforaminal epidural injections of

medication into the back help to reduce inflammation and relieve pain.

A transforaminal epidural injection is given through the foramen

(plural "foramina") of the spinal column. The foramen is an opening in

a vertebra where the spinal cord nerve roots exit the spine. The spinal

column includes 24 levels of movable vertebrae that are divided, from

top to bottom, into cervical, thoracic, and lumbar regions. 11 Each level

of vertebrae has a pair offoramina, one on the left side and one on the

right side.12

7 Estimate based on OIG analysis of physician claims for transforaminal epidural

injection procedure codes in the following Medicare claims files: (1) 2003 I-percent sample

of NCH physician/supplier fie and (2) 2007 100-percent NCH physician/supplier file,

8 Based on OIG analysis of physician claims for transforaminal epidural injection

procedure codes in the 2007 100-percent NCH Medicare Part B physician/supplier fie.

9 D,S, Department of Justice, D,S, Attorney's Offce, Northern District of Ohio, Press

Release, June 9.2006. Accessed at http://www.usdoj,gov/on November 24,2009.

10 Sara Taylor, Doctor with Waldorf offce guilty offraud, Southern Maryland

Newspapers Online, February 27,2008. Accessed at http://www.somdnews.com/on

June 12,2009.

11 Henry Gray, Anatomy 

of the Human Body, II.,3. Accessed at http://www.bartleby.com

on July 28, 2010.

12 Ibid.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 2
NTRODUCTION

During a transforaminal epidural injection, the physician injects

medication through the foramen close to the affected nerve root in the

patient's back. This technique may enable the physician to inject the

medication as close to the source of pain as possible, reducing

inflammation and relieving the patient's pain. See Figure 1 for an

example of the target point, through the foramen, for a transforaminal

epidural injection.

Figure 1:

Transforaminal

Epidural

Injections

Source: The Pain Clinic, "Selective Transforaminal Nerve Root Blocks," Accessed at http://ww.painclinic.org/on

September 2. 2009,

Radiographic guidance. To reduce patient risk, many physicians use

radiographic guidance (such as live x-ray) to establish the placement of

the needle and avoid puncturing the spinal cord and vertebral arteries

that are located near the injection point. Some physicians perform the

procedure without radiographic guidance, which is referred to as a

"blind" injection. One study concluded that physicians "blindly"

performing epidural injections failed to correctly perform the injections

for 25 percent of cases.13 Even in cases where transforaminal epidural

injections have been administered with radiographic guidance,

13 G, El- Khoury, et al. Epidural Steroid Injection: A Procedure Ideally Performed with

Fluoroscopic Control Radiology, voL. 168 (2), pp. 554-557,

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 3
NTRODUCTION

complications resulting in stroke, paralysis, and death have been

documented. 

14

Frequencv of injections. The appropriate frequency oftransforaminal

epidural injections varies by patient. Typically, a patient receives an

initial injection, referred to as a diagnostic injection, which helps

confirm the suspected source of pain and determine whether the

transforaminal injection is successful at relieving the pain. If a patient

responds well and demonstrates pain relief, the patient receives a

second injection, referred to as a therapeutic injection, at a subsequent

visit. Therapeutic injections could continue at subsequent visits if a

patient continues to demonstrate sustained pain relief.

Setting and specialtv. Transforaminal epidural injections may be

performed in a variety of settings. Approximately 43 percent of the

injections were performed in offce settings, 29 percent in ambulatory

surgical centers (ASC), and 27 percent in hospital outpatient

departments.15 Less than 1 percent of transforaminal epidural

injections were performed in other settings.

A physician in any specialty can perform a transforaminal epidural

injection. However, in 2007, three types of specialists performed

86 percent of the transforaminal epidural injections.16 They are

anesthesiologists, pain management specialists, and rehabilitation

physicians. A variety of other physician specialists performed the

remaining 14 percent, including orthopedic surgeons, neurologists,

radiologists, and family practice physicians.

Medicare Requirements for Transforaminal Epidural Injections

General provisions of the Social Security Act (the Act) govern Medicare

reimbursement for all services, including transforaminal epidural

injections. Section 1862(a)(i)(A) ofthe Act states that Medicare wil

cover only services that are considered to be reasonable and necessary.

Reasonable and necessary services are those used in the diagnosis or

treatment of ilness or to improve the functioning of a malformed body

part.

14 Graham C. Scanlon, et aL. Cervical transforaminal epidural steroid injections: more

dangerous than we think? Spine, voL. 32 (l1), p. 1249.

15 OIG analysis of physician claims for transforaminal epidural injection procedure codes

in the 2007 100-percent NCH Medicare Part B physician/supplier fie,

16 Ibid.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 4
NTRODUCT o N

Providers must properly document medical care to support that it is

medically necessary. Section 1833(e) of the Act prohibits payment for a

claim that is missing necessary information. Further, Medicare

requires that providers keep documentation in the medical record to

support the claim submitted, including, but not limited to, provider

notes and test reports,1 Providers must submit this information to

Medicare upon request to support medical necessity.18

Providers must use uniform procedure codes to report all services,

including transforaminal injection services.19 The CPT codes and

descriptions for transforaminal epidural injections are listed in

Table 1,0 Two primary codes, 64479 and 64483, are used for a single

injection in the cervical/thoracic or lumbar/sacral regions of the spine,

respectively. Each primary code has an associated add-on code for use

when more than one level is injected. The add -on codes are 64480

(cervical/thoracic) and 64484 (lumbar/sacral).

Table 1: Transforaminal Epidural Injection CPT Codes and

Descriptions

CPT Code Description

64479

Injection; anesthetic agent and/or steroid, transforaminal epidural;

cervical or thoracic, single level

Injection; anesthetic agent and/or steroid, transforaminal epidural;

cervical or thoracic, each additional level

Injection; anesthetic agent and/or steroid, transforaminal epidural;

lumbar or sacral, single level

Injection; anesthetic agent and/or steroid, transforaminal epidural;

lumbar or sacral, each additional level

64480 (add on)

64483

64484 (add on)

Source: American Medical Association CPT descriptions, 2007,

17 CMS, Medicare Program Integrity ManuaL, Pub, No, 100-08. ch.3, § 11.1. The Manual

does not provide examples of the types of test reports required, Test reports for

transforaminal epidural injection services would likely include reports from diagnostic tests

that may identify whether the patient has a condition that is appropriately treated with

transforaminal epidural injections.

18 CMS, Medicare Program Integrity ManuaL, Pub. No. 100-08, ch.3, § 11.1.

19 Section 1848(c)(5) of the Act requires the Secretary of Health & Human Services to

develop a uniform coding system for all physician services, The American Medical

Association's Current Procedural Terminology (CPT) codes are a numeric coding system

consisting of descriptive terms that are used primarily to describe medical services and

procedures performed by physicians and other health care practitioners,

20 Although physicians may refer to transforaminal epidural injections as diagnostic or

therapeutic, both types of injections are reported using the same procedure code, Procedure

codes do not distinguish between diagnostic and therapeutic.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 5
NTRODUCTION

Medicare Part B Payments for Transforaminal Epidural Injections

Medicare reimburses physicians for transforaminal epidural injections

according to the Medicare Physician Fee Schedule.21 Medicare

reimburses ASCs and hospital outpatient departments for their facility

expenses separately from the payments made to physicians.

Physician Payments. The Medicare Physician Fee Schedule includes two

types of rates, based on setting: those paid to physicians for services

rendered in nonfacilities, such as their offices; and those paid to

physicians for services rendered in facilities, such as ASCs or hospitals.

Physician Fee Schedule rates for office services are generally higher

than those for facility services because they include payment for

practice expenses, such as building costs, administrative salaries, and

equipment. Medicare Physician Fee Schedule rates are adjusted to

account for geographic location. The base rates for physician payments

for transforaminal epidural injections in 2007 are listed in Table 2.22

Table 2: Medicare Physician Fee Schedule Base Rates, 2007

CPT code Office Facility

64479 $327.81

$151,21

$328.95

$156.90

$112.56

$73,52

$99,67

$62.15

64480

64483

64484

Source: Medicare Physician Fee Schedule. 2007,

Reimbursements for primary codes 64479 and 64483 are higher because

they include presurgical and postsurgical expenses related to the

procedure that the add-on codes, 64480 and 64484, do not.

Physician payments also vary based on the modifiers23 biled with the

CPT. For example, bilateral transforaminal epidural injections, which

are performed on both the right side and the left side of a vertebral

level, should be biled using modifier 50, which increases

reimbursement to 150 percent of the base rate.

21 Section 1848(a)(i) of 

the Act established the Medicare Physician Fee Schedule as the

basis for Medicare reimbursement for all physician services beginning in January 1992,

22 Base rates are national Medicare Physician Fee Schedule amounts with no adjustment

for geographic variation by locality,

23 Modifiers are two-digit codes biled in conjunction with the appropriate CPT code,

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 6
INTRODUCTION

Facilty Payments. Medicare reimburses ASCs and hospital outpatient

departments based on ASC payment groups and the hospital outpatient

prospective payment system, respectively. The base rates for facility

payments for transforaminal epidural injections in 2007 were $333 in

an ASC and $390,95 in a hospital outpatient department.24

Claims Processing and Program Safeguards

CMS is in the process oftransitioning its contracts with the private

organizations that process and pay Medicare claims, formerly known as

carriers. CMS is replacing carriers with Medicare Administrative

Contractors (MAC). MACs will process all Part A and Part B claims

within new jurisdictions covering all States. By 2011, MACs should be

operational in every State and the District of Columbia.

Carriers and MACs (hereinafter referred to as contractors) are

responsible for implementing program safeguards to reduce payment

errors. To safeguard payments, they may create local coverage

determinations (LCD)25, implement electronic edits (hereinafter

referred to as edits), or conduct medical review.

Leos. Contractors may develop their own coverage guidelines called

LCDs when no National Coverage Determination (NCD) exists.26 LCDs

vary by contractor and may result in different coverage in different

parts of the country.

LCDs help to safeguard Medicare services by defining whether services

are reasonable and necessary and therefore covered by Medicare.

Among other reasons, contractors may develop LCDs to address

problems presenting a significant risk to the Medicare Trust Fund or a

patient's access to care.27

LCDs typically cover the following topics: (1) indications and

limitations of coverage and/or medical necessity, (2) covered diagnosis

codes supporting medical necessity, (3) documentation requirements,

and (4) utilization requirements.

24 Ambulatory Surgical Center Approved Healthcare Common Procedure Coding System

(HCPCS) Codes and Payment Rates, 2007, and Hospital Outpatient Prospective Payment

Rates, 2007,

25 CMS, Medicare Program Integrity ManuaL, Pub, No, 100-08, ch,13, § 1.3.

26 NCDs, issued by CMS, govern how Medicare wil cover specific services, procedures, or

technologies at a national leveL.

27 CMS, Medicare Program Integn'ty ManuaL, Pub, No. 100-8, ch, 13, § 4,

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EplOURAL INJECTION SERVICES 7
INTRODUCTION

Edits. Contractors may implement edits to prevent improper payments.

These edits are part ofthe claims-processing system that automatically

pays all or part of a claim, denies all or part of a claim, or suspends all

or part of the claim for manual review.

CMS encourages contractors to develop edits to enforce criteria in an

LCD.28 Once a contractor develops an edit, it must annually evaluate

the edit for effectiveness. CMS considers an edit effective when it has

a reasonable rate of denials, a reasonable dollar return on the cost of

operation, or potential to avoid significant risk to beneficiaries.29

Medical review. Contractor staff may request and review medical

records to address program vulnerabilities related to coverage and

coding. CMS requires contractors to analyze data in order to target

medical review activities at identified problem areas and prioritize

medical review resources.

Related Report

A recent OIG study found problems with another type of interventional

pain management service, facet joint injections. OrG found that

63 percent of facet joint injection services allowed by Medicare in

2006 did not meet Medicare requirements, resulting in approximately

$96 million in improper payments. 30

METHODOLOGY

To determine the extent to which payments for transforaminal epidural

injections met Medicare requirements and what safeguards existed, we

(1) conducted a medical record review ofa sample of Medicare claims

from 2007, (2) reviewed CMS and contractor policies related to

safeguarding transforaminal epidural injection services, and

(3) conducted structured telephone interviews with contractor staff.

Scope

We focused our review on Medicare physician claims for transforaminal

epidural injections. Unless otherwise stated, all estimates refer to

physician payments.

28 CMS, Medicare Program Integrity ManuaL, Pub. No. 100-08, ch, 13, §§ 5.3 and 10.

29 CMS, Medicare Program Integrity ManuaL, Pub, No. 100-08, ch.3, § 5.1.1.

30 OIG, Medicare Payments for Facet Joint Injection Services, OEI 05-07-00200,

September 2008.

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EplOURAL INJECTION SERVICES 8
INTRODUCTION

Sample Selection

The population from which we sampled consisted of all 2007 allowed

physician servces in the NCH physician/supplier file for transforaminal

epidural injection CPT codes 64479,64480,64483, and 64484. We

restricted our population to Medicare physician services biled in offces,

ASCs, or hospital outpatient departments as 99 percent oftransforaminal

injection servces were biled in these settings,s1 We excluded claims that

were less than $15 to avoid performing medical record review on low dollar

claims,s2 The population consisted of approximately 800,000 claims and

$141 milion in allowed physician payments. From this population, we

selected a stratified random sample of 440 Medicare physician line item

claims,33 stratifying by place of service reported on the claim (offce or

facility) and the Medicare-allowed amount. See Appendix A for further

details on the sample selection, data collection, and data analysis.

Data Collection

Afer excluding 2 services from the 440 in our sample because of

ongoing OIG investigations, we requested, by mail, complete medical

records from physicians for 438 sampled services. We classified

providers for five services as nonresponders,s4 Thus, we based our

analysis on the remaining 433 line items. This represents a 99.percent

response rate.

In June and July 2009, we conducted structured telephone intervews

with staff at the 11 contractors that were processing Medicare Part B

claims at that time. Between 2007 and 2009, the number of contractors

processing Medicare Part B claims was reduced from 14 to 11. These

11 contractors that we interviewed covered the entire country at the

time ofthe interviews.

During each interview, we asked contractor staff for information about

program safeguards in place in 2007, the time frame associated with our

analysis. Specifically, we clarified our understanding of the LCDs and

31 Based on OIG analysis of physician claims for transforaminal epidural injection

procedure codes in the 2007 IOO.percent NCH Medicare Part B physician/supplier fie.

32 These claims represented less than I percent of the population.

33 Multiple line items may be biled within a single claim, Hereinafter, line items wil be

referred to as services,

34 A nonresponder is defined as a provider with whom no successful contact was made

after at least three written contacts and two phone calls. Providers with whom successful

contact was made who did not return the requested medical records were not counted as

nonresponders, but rather as having a documentation error.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 9
INTRODUCTION

inquired about what edits they had in place associated with the LCDs.

Because CMS requires the outgoing contractors to inform the incoming

contractors of edits on LCDs, we were able to obtain written

confirmation from the 11 contractors that we interviewed about the

program safeguards used by all 14 contractors operating in 2007. Thus,

we report on information from all 14 contractors operating in 2007.

We collected and reviewed all 30 LCDs for transforaminal injections in

place in 2007. LCDs are published on the CMS Web site. We requested

and received from contractor staff written confirmation of the correct

LCDs in all States for 2007.

To understand how program safeguards may have changed since 2007,

we also consulted with all contractors about 2009 safeguards, including

LCDs and edits.

Medical Record Review. We used a medical record review contractor to

conduct the medical record review. The reviewers included three

board -certified physicians with interventional pain management and

transforaminal epidural injection experience and one certified

professional coder. One physician and the coder reviewed each of the

medical records.

The reviewers determined whether the service was adequately

documented and medically necessary and whether the appropriate CPT

code and modifier(s) were used. Reviewers based their determination

on a review of the medical record and their professional judgment.

"

Data Analysis

To determine the extent to which payments for transforaminal epidural

injections met Medicare requirements, we analyzed the results of the

medical review. We determined the percentage of physician services

that did not meet Medicare requirements. We also calculated the

projected physician 'dollars associated with these services. We then

compared physician office error rates to facility (ASC and hospital

outpatient department) error rates. Finally, we used the NCH files,

containing ASC and hospital outpatient department facility payments,

to match to the associated physician service found to be in error and

then projected the identified facility dollars paid .in error.

To determine what safeguards existed for transforaminal epidural

injections, we analyzed all documentation of program safeguards and

reviewed information collected during the contractor interviews. We

analyzed the number and type of LCD requirements that the contractor

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 10
INTRODUCTION

had in 2007. In addition, we analyzed the number and type of edits

each contractor had in 2007. We considered a contractor to have an

LCD or edit if it covered at least one State within the contractor's

jurisdiction at any time in 2007. To determine whether any safeguards

changed, we analyzed the LCDs and edits in 2009 and compared those

to the ones in place in 2007. Finally, we reviewed information collected

during the interviews to assess what other program safeguards

contractors had in place.

Comprehensive Error Rate Testing

CMS established the Comprehensive Error Rate Testing (CERT) to

calculate the Medicare fee-for-service paid claims error rate. As of 2009,

the CERT has not reported any specific information about

transforaminal epidural injections. This review was not designed to

reproduce or to review CERT findings.

Limitations

We were not able to calculate medical review error rates by contractor

to assess whether the contractor safeguards had an impact on error

rates. We were unable to do this because we did not stratify our sample

by contractor, so our sample size per contractor was too small to project

or compare error rates across contractors.

Standards

This study was conducted in accordance with the Quality Standards for

Inspections approved by the Council of the Inspectors General on Integrity

and Efficiency.

OEI-05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 11
.. FINDINGS

Thirty-four percent of transforaminal epidural

injection services allowed by Medicare in

2007 did not meet Medicare requirements,

resulting in approximately $45 milion in

improper payments

Medicare allowed approximately

$45 million in improper payments

to physicians for transforaminal

epidural injections in 2007. These

improper payments represent

32 percent of the $141 milion in

physician payments for

transforaminal epidural injections in 2007.

Thirty-four percent oftransforaminal epidural injection services did not

meet Medicare requirements. Table 3 shows the error rates and

associated payments for physician claims by error type. Confidence

intervals for projected error rates and payments are in Appendix B.

Table 3: Improperly Paid Medicare Transforaminal Epidural Injection

Services-Physician Claims, 2007

Sample Projected

Type of Error Services Allowed Services Allowed

Amount Amount

Documentation 87 $19,504 19% $29 milion

Medical Necessity 56 $12.109 13% $19 millon

Coding 35 $3.626 8% $6 milion

(Overlapping Errors) (30) ($6,161) (7%) ($9 milion)

Total 148 $29,078 34%" $45 milion

Source: OIG analysis of medical review results, 2009,

.Numbers do not always sum to total because of rounding,

Medicare allowed an additional $23 milion in associated facility claims

for transforaminal epidural injections in error in ASCs and hospital

outpatient departments. See Appendix A for further discussion of

estimates for associated facility claims. Although the focus of this

review is on physician claims, we also analyzed facility claims that were

submitted for the physician claims paid in error to provide additional

context. The remaining analyses focus on physician claims only.

Nineteen percent of transforaminal epidural injection services had a

documentation error

Medicare allowed approximately $29 milion for physician services that

were undocumented or insuffciently documented. Although some

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 12
FINDINGS

documentation errors may be the result of recordkeeping problems,

others may represent services not rendered. Records lacking

documentation to show that care was provided do not meet Medicare

requirements.

Ten percent of transforaminal epidural injection services were undocumented.

Medicare allowed approximately $14 milion for undocumented

transforaminal epidural injection services. For the majority ofthese

services, a record was submitted but contained no documentation of the

sampled service. In all other cases, the requested record was never

submitted.

Nine percent of transforaminal epidural injection services were insufficientlv

documented. Medicare allowed approximately $15 milion for

insufficiently documented transforaminal epidural injection services.

Most records were missing a description ofthe procedure as biled.

Some other records had a procedure note, but were missing details of

the procedure, such as the location and frequency of the injection. In

each case, the reviewer concluded that there was insufficient

documentation to support the service.

Documentation errors were more likelv to occur in office settngs.

Twenty-seven percent of transforaminal epidural injection services

provided in offices had a documentation error, compared to 13 percent of

transforaminal epidural injection services provided in facilities. See

Table 4 for error rates by setting and error type.

Table 4: Error Rates by Setting and Error Type for

Medicare Transforaminal Epidural Injection ServicesPhysician Claims, 2007

Type of Error Office Facility

Documentation' 27% 13%

Medical Necessity 18% 9%

Coding 8% 9%

Any Error 41%" 28%

Source: OIG analysis of medical review results, 2009,

'Statistically significant difference at the 95-percent confidence leveL.

'.Numbers do not sum to total because of overlapping errors,

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 13
FINDINGS

Thirteen percent of transforaminal epidural injection services had a medical

necessity error

Medicare allowed approximately $19 millon to physicians for

transforaminal epidural injection servces that medical reviewers

determined were medically unnecessary. In most instances, the record

contained no evidence of a condition that required a transforaminal

epidural injection. In some instances, the procedure was repeated at

close intervals with no evidence that it was relieving the patient's pain.

Eight percent of transforaminal epidural injection services had a coding

error

Medicare allowed $6 million to physicians in overpayments, net of

underpayments, for transforaminal epidural injection services that were

miscoded. The reviewer found primarily that physicians improperly

used add 'on codes and bilateral modifiers. In some instances, the

physicians performed less intensive procedures, but biled for

transforaminal epidural injections.

All but one ofthe miscoded services resulted in overpayment. The one

underpayment was a bilateral transforaminal epidural injection service

for which the provider biled only a unilateral service.

In 2007, 9 of 14 contractors had an LCD for

transforaminal epidural injection services, but

reported limited use of other safeguards

Contractors used LCDs primarily

to safeguard Medicare payments

for transforaminal epidural

injections. However, only one

contractor enforced all LCD requirements through edits. No contractors

performed medical reviews to safeguard services in 2007.

Nine contractors had an LCD for transforaminal epidural injections

Nine of the fourteen contractors had an LCD for transforaminal

epidural injection services in 2007. These LCDs covered 30 States.

Most commonly, these contractors had the following requirements in

their LCDs: (1) requiring that the procedure be performed only on

patients with acceptable diagnoses codes, (2) requiring that providers

use radiographic guidance for the procedure, (3) prohibiting multiple

pain management services on the same day, and (4) limiting the

frequency of the procedure. Less common requirements included

requiring more conservative treatments (such as physical therapy) prior

to trans foramina i epidural injections and allowing only experienced

providers to perform the procedure.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 14
FINDINGS

Among the four most common LCD requirements, contractors most

frequently required that providers perform the procedure only on

patients with acceptable diagnoses codes. All nine contractors with

LCDs listed this requirement in their LCD. In addition, eight of the

nine contractors required radiographic guidance in their LCD. Overall,

six of the nine contractors listed all four of the most common

requirements in their LCD.

Subsequent to our analysis period, the number of contractors with LCDs

decreased. In 2009, 7 contractors had LCDs covering 23 States.

Eight contractors did not enforce all of their LCD requirements with edits

Although, in general, contractor staff reported that edits were the best

way to enforce the requirements in their LCDs, only one contractor

enforced all LCD requirements with edits. Two contractors did not have

any edits. See Table 5 for a list of the most common LCD requirements

and corresponding edits by contractor.

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 15
FINDINGS

Table 5: 2007 Common LCD Requirements and Edits by

Contractor

Edit LCD Edit LCD Edit

2

.

.

.

.

3

4

5 . .

6

8 .

.

.

.

.

.

.

.

.

.

7

9

10

11

12

13

14

Source: OrG interviews and document review, 2009,

The most commonly used edits ensured that claims were paid only for

procedures performed on patients with acceptable diagnoses codes. Six

of the nine contractors listing acceptable diagnoses codes in the LCD

had corresponding edits. These edits were intended to automatically

check that physicians biled only acceptable diagnoses and deny claims

biled without acceptable diagnoses codes.

Contractors seldom used other edits to enforce requirements in their

LCDs. Only one ofthe eight contractors requiring radiographic

guidance in the LCD created a corresponding edit. Only one of the

seven contractors prohibiting multiple pain management services on the

same day had a corresponding edit. Only one of the six contractors with

frequency limits in the LCD developed a corresponding edit.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 16
FINDINGS

Contractors did not use edits to enforce less common requirements from

LCDs.

In some instances, contractors could not create edits because claims

lacked the required information to implement the edits. For example,

several contractors had LCDs that limited the frequency of injections

per spinal level, but claims did not capture which of the spinal levels in

the back were injected. Similarly, several contractors had LCDs with

different frequency limits for diagnostic and therapeutic injections, but

claims did not capture whether an injection was diagnostic or

therapeutic.

In other instances, claims captured the required information, but

contractors did not create edits to enforce LCD requirements. Most

contractors had an LCD requiring that providers use radiographic

guidance. Providers separately bil radiographic guidance on the

claims. However, only one contractor developed an edit related to

radiographic guidance.

Subsequent to our analysis period, the number of contractors with edits

decreased. In 2007, 7 of the 14 contractors had at least 1 edit covering

20 States. In 2009, only four contractors had edits enforcing their LCD

requirements. These edits covered seven States.

No contractors reported performing medical reviews

No contractor staff reported performing medical reviews for

transforaminal epidural injections in 2007.

Most contractor staff reported that they analyzed data for

transforaminal epidural injections, but did not find any outliers

warranting medical review. CMS requires that contractors analyze

data to prioritize the use of limited medical review resources.

Contractors might do a medical review if they notice outliers in the

data, such as one provider that bils substantially more than his peers.

Despite limited use of medical review, contractor staff reported that it is

a useful safeguard because it reveals problems not identifiable through

data analysis or edits. Staff from five contractors stated that medical

review is more comprehensive than either edits or data analysis. For

example, in 2009, one contractor performing a medical review for

transforaminal epidural injections found that providers were

administering too much steroid medication, a potentially dangerous

practice. The contractor staff reported that this problem was revealed

only through a detailed medical review.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 17
.. RECOMMENDATIONS

This report identifies problèms with Medicare payments for

transforaminal epidural injections. Thirty-four percent of

transforaminal epidural injection services in 2007 did not meet

Medica:re requirements, resulting in improper payments of

approximately $45 milion. Further, Medicare allowed an additional

$23 milion in associated facility claims for transforaminal epidural

injections in error. Transforaminal epidural injection services delivered

in offce settings were more likely to have a documentation error

compared to services delivered in facilities. Nine of fourteen contractors

had an LCD for transforaminal epidural injection services, but reported

limited use of other safeguards. No contractors performed medical

reviews for transforaminal epidural injection services in 2007.

This report is the second in a series on Medicare pain management

services. A 2008 OIG report found that 63 percent offacet joint

injections in 2006 did not meet Medicare requirements, resulting in

improper payments of $96 milion. The previous report found that facet

joint injections delivered in office settings were more likely to have an

error.

Based on the results of this body of work, CMS should:

Conduct provider education, directly and through contractors, about proper

documentation

Nineteen percent of transforaminal epidural injection services had a

documentation error. CMS should conduct provider education

regarding proper documentation to reduce future documentation errors.

CMS should also direct contractors to conduct provider education about

proper documentation for transforaminal epidural injection services.

Strengthen program safeguards to prevent improper payment for

transforaminal epidural injection services

To strengthen program safeguards, CMS could encourage contractors to:

Examine transforaminal epidural injection services provided in offices.

Both our current study and our 2008 facet joint injection study found

higher error rates for services performed in offices. Contractors could

examine services provided in offces to safeguard Medicare payments.

Develop LeOs for transforaminal epidural injections. Between 2007 and

2009, the number of States covered by an LCD for transforaminal

epidural injection services decreased from 30 to 23. Contractors that do

not have an LCD to define requirements for transforaminal epidural

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 18
RECOMMENDATIONS

injections may consider developing one. As noted in the limitations

section of this report, we were not able to assess whether contractor

safeguards, such as LCDs, had an impact on error rates. However,

LCDs may be helpful to control improper payments for other reasons,

such as establishing criteria for law enforcement action.

Develop additional edits enforcing LCD requirements for transforaminal

epidural injection services. Both our current study and our 2008 facet

joint injection study found that not all LCD requirements were enforced

by edits. In addition, between 2007 and 2009, the number of States

covered by at least 1 edit for transforaminal epidural injection services

decreased from 20 to 7. Contractors could strengthen current

safeguards for both transforaminal epidural injection services and facet

joint injection services by developing edits to enforce the requirements.

Use medical review to identify improper payments for transforaminal

epidural injection services. Thirty-four percent of transforaminal

epidural injection services were paid in error. Thirteen percent were

medically unnecessary. Additional medical reviews may limit future

improper payments and protect beneficiaries from unnecessary services.

Take appropriate action regarding the undocumented, medically

unnecessary, and miscoded services identified in our sample

We wil forward information on these services to CMS under separate

cover.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL

RESPONSE

CMS concurred with our recommendations and outlined steps to

improve its oversight of payments for transforaminal epidural injection

services. We did not make any changes to the report based on CMS's

comments. For the full text of CMS's comments, see Appendix C.

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 19
.. APPENDIX-A

Detailed Methodology

Sample Selection

The population from which we sampled consisted of all the allowed

physician services in the Centers for Medicare & Medicaid Services

National Claims History (NCH) file for Current Procedural Terminology

(CPT) codes 64479, 64480, 64483, and 64484 performed in 2007. We

stratified the sample by place of service and dollar amount. We

stratified by place of service to compare rates by setting (office and

facility). Previous work found significantly different error rates

between these two settings. We further stratified by the dollar amount

of the claims to improve our ability to provide an overall estimate of the

dollars in error with an acceptable confidence interval. We randomly

selected 110 claims from each stratum for review, for a total of

440 claims. Table A-I shows the sampling stratification and population

of claims for CPT codes 64479, 64480, 64483, and 64484.

Table A-1: Sampling Stratification for Transforaminal Epidural

Injection Claims

Stratum Description Population Sampled Claims

1 - Offce ~ $325 103,987 110

2 - Offce 2: $15 to:S $325 242,074 110

3 - Facility (Ambulatory

Surgical Center (ASC) and ~ $100 149.362 110

Hospital Outpatient)

4 - Facility ASC and Hospital 2: $15 to:S $100 311,278 110 Outpatient)

Total 806,701 440

Source: Ofce of Inspector General (OIG) analysis of 2007 NCH physician/supplier file,

Data Collection

Medical Record Review. We used a medical record review contractor to

conduct the medical record review. We requested, by mail, complete

medical records and documentation from physicians for the services in

our sample. We specified that providers send the following materials, if

available: initial patient evaluation and exam, test results,

radiographic evidence of needle placement, and procedure notes. For

additional context, we also requested that providers furnish all

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 20
APPENDIX~A

documentation for all services provided to the beneficiary 4 months

before and 1 month after the sampled date of servce.

We requested the beneficiary's medical record from the provider

associated with the sampled claim. We used the Unique Physician

Identification Number validation fie and the National Provider

Identifier to obtain contact information for the provider when mailing

the request.

We allowed at least 7 weeks from the date of the initial request for the

sampled provider to fax or mail the records to the medical review

contractor. We made at least two additional written attempts followed

by two telephone calls to obtain the records. The last written request

was mailed by signature-required certified maiL.

Our response rate for this study was 99 percent. Of the 440 services

that we originally sampled, 2 services were removed because of ongoing

OIG investigations. Then we requested records for the remaining

438 sampled services. We classified five ofthese as nonresponders. We

classified two servces as nonresponders because we were unable to

locate the sampled provider, and we classified three servces as

nonresponders because the provider returned the record too late to be

reviewed. Our analysis was based on the 433 remaining services in the

sample for which we received a response.

Test Review. To test our review instrument and ensure uniformity

among the reviewers, we conducted a preliminary medical review of

20 servces. These servces were randomly sampled from the same

population where we drew our final sample. However, the preliminary

sample was chosen separately from the sample used for the final review.

We analyzed the results of the test review and discussed them with the

reviewers. The reviewers resolved inconsistencies in the results and

suggested changes to the review instrument. Some of the changes were

incorporated into the final review instrument as appropriate.

Data Analysis

Calculation of improper physician payments. We calculated the total

actual and projected dollars paid in error for these services. For

services that were not medically necessary, insuffciently documented,

or not documented, we counted the entire Medicare-allowed amount as

improper and projected the amount paid in error. For services with a

coding error, we determined whether Medicare overpaid or underpaid.

We then calculated the total net difference for all services with a coding

error and projected it to the population.

OEI-05.09-00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERYICES 21
APPENDIX A

We projected dollars in error and percentage of services in error to the

population of all transforaminal epidural injection services in 2007. We

removed any overlap in sampled services that had multiple errors.

Calculation of improper faciltv payments. In addition, we calculated and

projected the facility payments associated with physician services that

were performed in facilities and did not meet documentation or medical

necessity requirements. For services performed in ASCs and hospital

outpatient departments, we used the NCH Part B file and the hospital

outpatient file, respectively, and matched facility claims to physician

claims using the dates of service, CPT, and beneficiary identification.

Afer matching the claims, we projected the facility dollars paid in error.

Our estimate of facility dollars associated with physician services in

error is conservative. First, we excluded physician services in error

because of incorrect 'coding. It would have required a coding review of

the facility claim to determine the amount in error on the facility claim,

which was beyond the scope of our study. Second, among the errors

that we did attempt to match, we were not able to find all matching

facility claims. We were able to match only 69 percent of sampled

physician services performed in facilities and having a documentation or

medical necessity error to their associated facility payment.

OEI.05.09.000JO INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 22
.. APPENDIX B

Confidence Intervals for Selected Estimates

Table B-1: Estimates of All Errors

Estimate Description Point Estimate 95-Percent Confidence Interval

Percentage of services with any error 33.9% 29.1 %-38,7%

Percentage of services with any documentation error 19,2% 15.4%-23.0%

Percentage of services with no documentation' 9,8% 6.8%-12,7%

Percentage of services with insuffcient documentation 9.4% 6.6%-12.4%

Percentage of services that were not medically necessary 12,9% 9,6%-16,3%

Percentage of services coded incorrectly 8.3% 5.5%-11,2%

Percentage of services with overlapping errors 6.6% 4.1%-9.0%

Percentage of amount allowed in error among all allowed 31.7% 27.0%-36.4%

amounts for transforaminal epidural injection services

Source: Ofice of Inspector General (OIG) analysis of medical review results, 2009,

Table B-2: Estimates of Improper Physician Payments Associated With All Errors

Estimate Description Point Estimate 95-Percent Confidence Interval

Amount allowed for services with any error $44,833,417 $38,188,484-51,478,349

Amount allowed for services with any documentation error $28,895,365 $22,934,192-$34,856,538

Amount allowed for services with no documentation $14,005,827 $9,505,141-$18,506,513

Amount allowed for services with insuffcient documentation $14,889,538 $10,360,675-$19,418,401

Amount allowed for services that were not medically $18,831,045 $13,779,543-$23,882,548

necessary

Amount allowed for services coded incorrectly $6,248,458 $3,829,614-$8,667,303

Amount allowed for services with overlapping errors $9,141,452 $5,352,508-$12,930,395

Source: OIG analysis of medical review results, 2009,

o E 1.0 5-09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 23
A P PEN D x B

Table B-3: Estimate of Improper Facilty Payments Associated With Any Error

Source: OIG analysis of medical review results, 2009,

Table B-4: Estimates of Errors by Setting and Type

Error Type Setting Point 95-Percent Confidence Interval Estimate

,

Offce 27.0% 20.5%-33,5%

Docum entation

Facilty 13.3% 8.6%-18,0%

Offce 17.7% 12.1 %-23,3%

Medical Necessity

Faciliy 9,3% 5,1%-13.4%

Offce 8.0% 4.0%-12,0%

Coded Incorrectly

Facility 8.6% 4.6%-12,6%

Offce 41.3% 34.1 %-48.4%

Any Error

Facility 28,3% 22.0%-34.7%

Source: OIG analysis of medical review results, 2009,

OEI.05.09.00030 INAPPROPRIATE MEOICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 24
.. A P PEN 0 x c

Agency Comments

,pVICea"lf

l4 DEPARTM DF HEALTH & HUMAN SERVICES

Centers for Medicare & Mediceid Servces

Off!iof the A¡lministrator

wasl\ton. dç 2%91 :~ ~ .~ ''\

~~ .~~ ~) C\, _ ''' i;~ e," i: ~ \ '\

-i ~ (' ~ 0 DATE: MAY 1 02010

TO:

FROM:

SUBJECT: Offce of Inspector General (OIG) Draf Report: "Inappropriate Medicare

Payments for Transforaminal Epidural Injection Services" (OEI-05-09-00030)

Thank you for the opportunity to review and comment on the Offce of Inspector General's

(OIG) draft report, "Inappropriate Medicare Payments for Transforaminal Epidural Injection

Services." The Centers for Medicare & Medicaid Services (CMS) appreciates the time and

resources the OIG has invested to determine the extent to which Medicare Par B payments for

transforaminal epidural injections met Medicare requirements.

Transforaminal epidural injections are a pain management technque used to diagnose or treat

pain. The OIG conducted a medical record review of a stratified random sample of 433

transforainal epidural injections performed in 2007. The OIG determined that thirty-four

percent of trans foraina i epidural injection services allowed by Medicare in 2007 did not meet

Medicare requirements. In addition, OIG reported that nine out offoureen CMS contractors had

a Local Coverage Determination (LCD) for transforaminal epidural injection services but only

one contractor enforced all LCD requirements with edits.

The CMS appreciates the work of OIG on this issue and wi1 work to improve our oversight of

these payments in the future. As a result of its findings,'the om made the following

recommendations:

OIG Recommendation

Conduct provider education, directly and though contrctors, about proper documentation.

eMS Response

The CMS concurs with ths recommendation. CMS wil direct contractors to conduct provider

education about proper documentation for transforaminal epidural injections especially provided

in offces. CMS wil issue a Medicare Learing Network Matters Arcle on this topic related to

documentation requirements and expectations.

o E I. 05-09.000 30 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 25
A P PEN 0 x c

Page 2 - Daniel R. Levinson

OIG Recommendation

Strengthen progr safeguards to prevent improper payment for tranforaminal epidural

injection services.

CMS Response

Examine transforaminal epidural injection services provided in offices.

The CMS concurs. To strengten program safeguards, CMS wil instrct the appropriate

Medicare contractors to review their claims data for transforaminal epidural injection servces

paricularly in the offce, due to higher error rates in that setting.

Develop LCDs for transforaminal epidural injection services.

The responsibilty to determine whether or not to develop an LCD lies with the Medicare

Administrative Contractors (MACs). CMS wil shar the results of the OIG report with the

Medicare contractors, who may develop policies under their own authority and based on CMS

manual instrctions.

Develop additional edits enforcing LCS requirements for trasforamnal epidural injection

services.

The CMS concurs. CMS wil instrct contractors to examine whether sufficient edits are in

place to enforce LCDs.

Use medical review to identify improper payments for tranforaminal epidural injection services.

The CMS concurs. CMS will instruct the MACs to tae appropriate action consistent with their

individual prioritized medical review strategy. MACs use their medical review strtegies to best

focus their resources relative to other vulnerabilties.

OIG Recommendation

Take appropriate action regarding the undocUIented, inedically unnecessar, and miscoded

services identified in our sample.

CMS Response

The CMS concurs. CMS wil share the OIG report and any additional claim information received

with the appropriate Medicare contractors. CMS will instruct them to consider the issues

identifed in this report and the additional claim information when prioritizing their Medicare

review strategies.

The CMS requests that OIG fuish the necessary data, including Medicare contractor numbers,

provider numbers, claims inormation including the paid date, HlC numbers, etc. to accomplish

our review. In addition, CMS requests that Medicare contractor-specific data be wrtten to

separate CD-ROMs or separate hardcopy worksheets to better faciltate the transfer of

information to the appropriate contractors,

The CMS appreciates the O!G's effort and insight on this report. CMS looks forward to

continualy working with OIG on issues related to waste, fraud and abuse in the Medicare

program.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 26
.. ACKNOWLEDGMENTS

This report was prepared under the direction of Ann Maxwell, Regional

Inspector General for Evaluation and Inspections in the Chicago

regional office, and Thomas Komaniecki, Deputy Regional Inspector

General.

Laura Kordish served as the team leader for this study and Beth

McDowell served as the lead analyst. Other principal Offce of

Evaluation and Inspections staff from the Chicago regional offce who

contributed to the report include Lisa Minich and Lauren Rosapep;

central offce staff who contributed include Sandy Khoury and Megan

Ruhnke.

OEI.05.09.00030 INAPPROPRIATE MEDICARE PAYMENTS FOR TRANSFORAMINAL EpIDURAL INJECTION SERVICES 27