VIA DISC NP

Allograft Pain Management

Quest ion:

We need education on VIA DISCNP. We have a pain management physician wanting to perform this procedure in the operating room They state Medicare is the only payer that will pay for this. The Billing guide states that other payers may pay, based on medical necessity. Also, there are only four diagnosis codes listed for the procedures If the procedure code and diagnosis does not meet medical necessity, should an ABN be issued?

Also, on July 1, 2023, paravertrabal injections for traditional Medicare became effective to require PAs. Does tradiational Medicare require a PA for these procedures?

Answ er:

Coding- On January 1, 2021, Category III codes 0627T-0630T were assigned to report percutaneous lumbar spine injection of allogeneic cellular and/or tissue-based products with fluoroscopic or computed tomography (CT) guidance Vivex Biologics VIA Disc? NPstates these are the appropriate code assignments for this service.

Diagnosis Codes- The Vivex reimbursement guide attached states that based on the 2023 ICD-10-CM Official Guidelines for Coding and Reporting, there are four ?possible codes?that might meet medical necessity requirements However, no Medicare NCDs or LCDs provide additional coverage requirements or diagnoses for these procedures.

Prior Aut horizat ions ?Beginning July 1, 2023, Medicare added some Facet Joint Interventions (64xxx HCPCScodes) procedures to outpatient procedures requiring prior authorization Our 2023 Outpatient Procedures Requiring a Medicare Prior Authorization paper provides the full list. However, the Medicare Prior Authorization process does not apply to CAHs.

ABN Guidance- When a healthcare provider expects a denial for a service Medicare generally covers, they must issue an ABN to the beneficiary. This requirement includes any time the diagnosis may not support the medical necessity for the service or treatment

See the Advance Beneficiary Notice of Non-coverage Tutorial? Requirements tab for additional information on when an ABN must be issued

Non-Medicare Payers- Each commercial plan varies in reimbursement policies, so each plan should be reviewed, and prior authorization should be obtained when possible. We found that UHCCommercial Plans consider procedures reported as 0627T-0630T ?unproven and not medically necessary?per Discogenic Pain Treatment

Medicaid in some states. such as Indiana, does not cover these procedures.