National Government Service (NGS), our local Medicare Administrative Contractor (MAC), is currently reviewing claims for trigger point injections and botulinum toxin injections. Let’s address trigger point injections first. NGS is finding a lack of documentation to support the medical necessity for the trigger point injection. An internal review of our documentation for trigger point injections found that improvements may be needed.
The decision to treat chronic pain by invasive or destructive procedures must be based on a thorough evaluation of the patient and include a systematic assessment of the location, intensity, and pathophysiology of the pain. A detailed pain history that includes prior treatment and response to treatment is essential. A detailed physical examination and review of all pertinent diagnostic tests is also needed.
In addition to documenting the assessment described above, the patient’s medical record must clearly reflect:
- Identification of the affected muscle(s)
- Reason for selecting the trigger point injection as a therapeutic option, and
- Whether it is being used as an initial or subsequent treatment for myofascial pain.
Repeat trigger point injections may be necessary when there is evidence of persistent pain. Generally, more than three injections of the same trigger point for the same muscle are not indicated. Evidence of partial improvements to the range of motion in any muscle area after an injection, but with persistent significant pain, would justify a repeat injection. The medical record must clearly reflect the medical necessity for repeated injections.
The NGS review of botulinum toxin (Botox) injections found that the documentation did not include a statement indicating that the condition being treated was unresponsive to conventional treatment previously tried and the significant disability and resulting impact on the patient’s function in order to support the medical necessity of the service.
Botox injections for patients with headache/migraine with chronic daily headaches (headache disorders occurring more than 15 days a month—in many cases daily with a duration of four or more hours—for a period of at least three months) who have significant disability due to the headaches, and have been refractory to standard and usual conventional therapy, may be covered. The etiology of the chronic daily headache may be chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on > 15 days per month, of which at least eight headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For continuing Botox therapy, the patients must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving Botox.
For coverage of Botox treatment, the medical record should include a relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. In addition, the following needs to be documented in the medical record:
- the medical necessity for the treatment
- a statement that the spastic condition has been unresponsive to conventional treatment
- a covered diagnosis
- dosage(s), site(s) and frequency(ies) of injection
- the medical necessity for associated electromyography when used; and
- description of the effectiveness of this treatment.
Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botox. When modifier JW is used to report that a portion of the drug is discarded, the medical record must clearly show the amount administered and the amount discarded.