RFA frequency

[Greenbayslacker]

Straight Medicare insurance. I did a medial branch RFA for a patient one year ago at THREE levels (billing told me I could) that worked well, >50% pain relief for over a year. Later came to find out that we did not get reimbursed for the third level.

Fast forward a year, I repeat the RFA but only at two levels given our prior denial. Patient reports unsatisfactory pain relief. I looked over the previous and current fluoro images and the needle placement is nearly identical.

My question is this... can I repeat the RFA at the third level? LCD guidelines state that only two RFA sessions can be performed per 12 months. But there is no "frequency" stated (i.e. it does not say "one RFA every six months"). In theory I should be able to preform another RFA, but the patient would then be done with RFA's for a whole year.

Appreciate the input as I am relatively new to navigating insurance restrictions.

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[Baron Samedi]

You bill per facet joint, not per medial branch. If you are ablating the L3, L4, L5 MB/DR, you are treating the L4-L5 and L5-S1 facet joints, hence two levels.

 

[Greenbayslacker]

You bill per facet joint, not per medial branch. If you are ablating the L3, L4, L5 LB/DR, you are treating the L4-L5 and L5-S1 facet joints, hence two levels.

I understand that. The first RFA I did was three levels (four needles/medial branches). The second RFA was a standard two levels.

I am more asking about the rules regarding timing of doing another RFA.

 

[Tramadeezy]

My understanding is each region (C/T/L) can only be repeated every 6 months.

 

[Ferrismonk]

You CAN ablate the 3rd level (one joint), but then you cannot do another RF in the lumbar region for another year.

For clarification:
You cannot do the SAME levels for at least 6 months.
Cervical and thoracic count as the same region.

 

[sdnuser001]

My understanding is each region (C/T/L) can only be repeated every 6 months.

Source for this?

 

[Greenbayslacker]

I'd like to see a source as well. Medicare states "Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months." Nothing about 6 months.

 

[MitchLevi]

Make it simple: Two RFA's per year, at least 6 months apart.

 

[Greenbayslacker]

Make it simple: Two RFA's per year, at least 6 months apart.

Again where is the "6 months" limitation coming from?

 

[MitchLevi]

Again where is the "6 months" limitation coming from?

Convention.

 

[oneforfighting]

Taken from the LCD:

"Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.

Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months."

 

[Dr. Ice]

Again where is the "6 months" limitation coming from?

Proper lesioning should create at least 6 months of pain relief, otherwise the lesioning was not done well

 

[oneforfighting]

You CAN ablate the 3rd level (one joint), but then you cannot do another RF in the lumbar region for another year.

For clarification:
You cannot do the SAME levels for at least 6 months.
Cervical and thoracic count as the same region.

"One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal."

Nothing in the LCD states that you cannot do another RF in the lumbar region for another year if you do 3 levels.

 

[Laryngospasm]

My understanding was if you do bilateral you can do every six months.. if you separate out then you can only do every year.

 

[Greenbayslacker]

Proper lesioning should create at least 6 months of pain relief, otherwise the lesioning was not done well

That is irrelevant to the question at hand.

 

[SSdoc33]

dont RF the same nerve > once every year. you should be re-burning at 6 months. it should be around once/year

 

[SSdoc33]

Proper lesioning should create at least 6 months of pain relief, otherwise the lesioning was not done well

this is correct

 

[drrosenrosen]

You can also do three levels and have pt sign an ABN and pay for the third level. Doesn't help for now but going forward that could be an option

 

[Dr. Ice]

That is irrelevant to the question at hand.

It’s not irrelevant if the procedure works for more than 6 months for the patient

 

[RoloTomassi]

Pretty sure you can do a repeat now and get reimbursed but you have to document 6 months benefit from the levels you did in the past because obviously the recent one didn't give that duration. Then stay clear for a year. Then document why you have to do 3 levels next time. That's what I'd do but can't guarantee

 

[Greenbayslacker]

It’s not irrelevant if the procedure works for more than 6 months for the patient

The procedure (3 level RFA) worked for >1 year.
Now, I am looking to re-RFA the 3rd level one year later, and trying to figure out how to make sure it is reimbursed.
The question is, after doing a two-level RFA, can I do an RFA at the third level (which previously helped >1 year)? It would be within six months of the two-level RFA, however it would only be two RFA's in one year, which still falls within the LCD guidelines as acceptable.

Sorry if I sounded flippant, but this is more of an insurance/billing question rather than technique/clinical acumen.

 

[GoBeers]

The procedure (3 level RFA) worked for >1 year.
Now, I am looking to re-RFA the 3rd level one year later, and trying to figure out how to make sure it is reimbursed.
The question is, after doing a two-level RFA, can I do an RFA at the third level (which previously helped >1 year)? It would be within six months of the two-level RFA, however it would only be two RFA's in one year, which still falls within the LCD guidelines as acceptable.

Sorry if I sounded flippant, but this is more of an insurance/billing question rather than technique/clinical acumen.

it says two RFAs in one year. I agree with your guess that the way you are describing it technically should count.

Next time just do unilateral 3 level one week, then contralateral side 10 days later and call it a day. just hope that these last a full year.

 

[Quixotic2501]

If you're feeling nice: treat joints L3-4 and L5-S1. Capture L4-5 as collateral. Bill only the two joints.

 

[callmeanesthesia]

The procedure (3 level RFA) worked for >1 year.
Now, I am looking to re-RFA the 3rd level one year later, and trying to figure out how to make sure it is reimbursed.
The question is, after doing a two-level RFA, can I do an RFA at the third level (which previously helped >1 year)? It would be within six months of the two-level RFA, however it would only be two RFA's in one year, which still falls within the LCD guidelines as acceptable.

Sorry if I sounded flippant, but this is more of an insurance/billing question rather than technique/clinical acumen.

You need to read the LCD carefully to understand the wording, and document that the third level is medically necessary because the patient had inadequate relief from two level procedure and adequate relief from 3 level procedure. Your billers will need to file an appeal to get it paid. For now, you can do the third level but they’ll have to wait almost a year for repeat. Could consider a “TPI” into the facet joints to buy them a few months then repeat with all 3 levels.

 

[Asclepius186]

You can do 2 RFA sessions of up to 2 joints at a time per calendar year. So, to answer your question, you can absolutely do a 2 joint RFA and 2 weeks later do a third joint. The only timing limitation here would be the 10 day global period I believe. All should be paid. Then no more RF in lumbar until one year.

Similarly, some people do only unilateral RF (right then left) but then you can only treat those 2 joints. But they have maximized their billing.

 

[sdnuser001]

The procedure (3 level RFA) worked for >1 year.
Now, I am looking to re-RFA the 3rd level one year later, and trying to figure out how to make sure it is reimbursed.
The question is, after doing a two-level RFA, can I do an RFA at the third level (which previously helped >1 year)? It would be within six months of the two-level RFA, however it would only be two RFA's in one year, which still falls within the LCD guidelines as acceptable.

Sorry if I sounded flippant, but this is more of an insurance/billing question rather than technique/clinical acumen.

I am in a somewhat similar situation as you and had my biller call the patients insurance. They said there is no minimum amount of time you have to wait between the RFA sessions as long as it's medically necessary. This is prob insurance dependent

 

[MitchLevi]

I am in a somewhat similar situation as you and had my biller call the patients insurance. They said there is no minimum amount of time you have to wait between the RFA sessions as long as it's medically necessary. This is prob insurance dependent

Haha. Complete BS. What is the definition of medically necessary? I assure you there's a timeline in the definition.

You're not medically necessary 3 weeks after the previous RFA.

Your biller spoke with a high school graduate reading from a template.

 

[Ducttape]

I understand that. The first RFA I did was three levels (four needles/medial branches). The second RFA was a standard two levels.

I am more asking about the rules regarding timing of doing another RFA.

i have to repeat: next time, ask for 2 levels that are separated. you can do all 4 levels in that situation with no fear of not getting paid.

for example, L34 and L5S1.

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and yes, add the 3rd level, but then no RFA for any level of that section of spine for 12 months.

and you cant RF the same levels within 6 months because you did not prove the previous RFA lasted 6 months.

I am in a somewhat similar situation as you and had my biller call the patients insurance. They said there is no minimum amount of time you have to wait between the RFA sessions as long as it's medically necessary. This is prob insurance dependent

you should not RFA within the global period of the previous RFA.

if you are RFA'ing within 10 days of the first, you havent given the first RFA enough time anyways.

 

[cowboydoc]

This is why we’re having these silly conversations.

 

[Dr. Ice]

This is why we’re having these silly conversations.

View attachment 379642

How are these getting approved by private carriers or not audited by Medicare?

What’s so funny/tragic for me is that I’ve been following the rules before the rules were made. I’ve never had anyone come back to do one side at a time for lumbar rfa in the last 14 years. Yet docs keep having patients come back for multiple visits to have a procedure done which at best lasts 18 months. I recently once set a patient up for bilateral rfa, then he went for a second opinion and that doc wanted to do one side at time, then he wanted to come back to me and finally I was like no..go to that other doc. I understand that you may not get the system, but I’m not trying to screw you dude..the guy down the street who is clearing way more than me financially is..but you can go back to him.

 

[bedrock]

This is why we’re having these silly conversations.

View attachment 379642

Im not sure how these get authorized outside of PI.

Multiple insurances will allow unilateral 3 joint RFA , BCBS, Cigna, Aetna, UHC. Anthem BC does not.

But I’ve never seen a patient get authed for more than 3 joints. Admittedly, I have never asked for more than 3 joints, however I’ve read the LCDs and no insurance seems to allow more than 3 joints.

 

[Taus]

Im not sure how these get authorized outside of PI.

Multiple insurances will allow unilateral 3 joint RFA , BCBS, Cigna, UHC. Anthem does not.

But I’ve never seen a patient get authed for more than 3 joints. Admittedly, I have never asked for more than 3 joints, however I’ve read the LCDs and no insurance seems to allow more than 3 joints.

PI shenanigans

 

[MitchLevi]

Bill a few levels, do a few for free.

 

[RoloTomassi]

IV conscious with propofol? 5 joint levels only 5 nerves? All sorts of funny business

 

[cowboydoc]

IV conscious with propofol? 5 joint levels only 5 nerves? All sorts of funny business

Exactly! This looks like the level of nonsense that leads to a real injury, not just some questionable billing practices.

 

[mdo1738]

This is why we’re having these silly conversations.

View attachment 379642

“Moderate” sedation which would otherwise be known as room air general anesthetic in that case.

ETA: sorry, nasal cannula general anesthetic it appears, sooo much better 😂