OIG Warns CMS/Medicare: Watch for Inappropriate Payments for Transforaminal Epidural Steroid Injections

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

http://www.oig.hhs.gov/oei/reports/oei-05-09-00030.pdf

Thirty-four percent of transforaminal epidural injection services allowed by Medicare in 2007 did not meet Medicare requirements, resulting in approximately $45 million in improper payments.  Medicare allowed an additional $23 million in associated facility claims for transforaminal epidural injections performed in error. In addition, services provided in offices were more likely to have a documentation error than those provided in ambulatory surgical centers or hospital outpatient departments.

Transforaminal epidural injections are a type of interventional 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.

Medicare Part B physician payments for transforaminal epidural injections increased from $57 million in 2003 to $141 million to 2007. This represents an increase of almost 150 percent.

Medicare Part B contractors are responsible for implementing program safeguards to reduce payment error.  To safeguard payments, they may create local coverage determinations (LCD), implement electronic edits, or conduct medical review.

We found that in 2007, 9 of 14 contractors had an LCD for transforaminal epidural injection services, but reported limited use of other safeguards. Only one contractor enforced all of its LCD requirements with edits. No contractor staff reported performing a medical review.

Based on the results of our review, we recommended that CMS conduct provider education, directly and through contractors, about proper documentation and strengthen program safeguards to prevent improper payment for transforaminal epidural injection services.  In addition, we recommended that CMS take appropriate action regarding the undocumented, medically unnecessary, and miscoded services identified in our sample.

CMS concurred with our recommendations and outlined steps to improve its oversight of payments for transforaminal epidural injection services.