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Series: Audits of Medicare Payments for Spinal Pain Management Services

Announced on  | Last Modified on  | Series Number: SRS-A-25-006
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Medicare Part B covers various spinal pain management services including facet joint injections, facet joint denervation sessions, lumbar epidural injections, and trigger point injections. Medicare Part B also covers sedation administered during these pain management services. We will audit whether Medicare payments for spinal pain management services billed by physicians complied with Federal requirements.

There are 7 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (1)

Project OAS-25-09-021 • Announced on Nov 7, 2024

COMPLETED PROJECTS IN THIS SERIES (6)

Medicare Program Oversight

Project A-09-23-03013 • Completed on July 29, 2025

Medicare Program Oversight

Project A-09-22-03006 • Completed on March 22, 2023

Medicare Program Oversight

Project A-07-21-00618 • Completed on March 10, 2023

Medicare Program Oversight

Project A-09-21-03002 • Completed on December 3, 2021

Audit of Medicare Part B Payments by Noridian Healthcare Solutions, LLC, to Physicians for Facet Joint Injections in MAC Jurisdiction E

Project A-09-20-03010 • Completed on February 19, 2021

Review of Medicare Part B Payments to Physicians for More Than Five Facet Joint Injection Sessions for Beneficiaries During a Rolling 12-Month Period

Project A-09-20-03003 • Completed on October 9, 2020

TIMELINE

  • September 5, 2019
    Series Number SRS-A-25-006 Assigned
  • September 5, 2019
    Projects Announced

    Review of Medicare Part B Payments to Physicians for More Than Five Facet Joint Injection Sessions for Beneficiaries During a Rolling 12-Month Period - A-09-20-03003

  • Audit of Medicare Part B Payments by Noridian Healthcare Solutions, LLC, to Physicians for Facet Joint Injections in MAC Jurisdiction E - A-09-20-03010

  • October 9, 2020
    Project Complete - A-09-20-03003

    Review of Medicare Part B Payments to Physicians for More Than Five Facet Joint Injection Sessions for Beneficiaries During a Rolling 12-Month Period has been marked as complete. This audit resulted in 5 recommendations.

  • November 23, 2020
    Project Announced

    Medicare Program Oversight - A-09-21-03002

  • February 19, 2021
    Project Complete - A-09-20-03010

    Audit of Medicare Part B Payments by Noridian Healthcare Solutions, LLC, to Physicians for Facet Joint Injections in MAC Jurisdiction E has been marked as complete. This audit resulted in 3 recommendations.

  • June 25, 2021
    Project Announced

    Medicare Program Oversight - A-07-21-00618

  • December 3, 2021
    Project Complete - A-09-21-03002

    Medicare Program Oversight has been marked as complete. This audit resulted in 6 recommendations.

  • February 8, 2022
    Project Announced

    Medicare Program Oversight - A-09-22-03006

  • March 10, 2023
    Project Complete - A-07-21-00618

    Medicare Program Oversight has been marked as complete. This audit resulted in 4 recommendations.

  • March 22, 2023
    Project Complete - A-09-22-03006

    Medicare Program Oversight has been marked as complete. This audit resulted in 3 recommendations.

  • September 12, 2023
    Project Announced

    Medicare Program Oversight - A-09-23-03013

  • November 7, 2024
    Project Announced

    Project OAS-25-09-021

  • July 29, 2025
    Project Complete - A-09-23-03013

    Medicare Program Oversight has been marked as complete. This audit resulted in 4 recommendations.

  • Today
    1 Audit In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

6 REPORT PUBLISHED

Medicare Improperly Paid Physicians for Epidural Steroid Injection Sessions (A-07-21-00618)

23-A-07-053.01 to CMS - Open Unimplemented
Update expected on 09/07/2025
We recommend that the Centers for Medicare and Medicaid Services direct the MACs to recover the $3,585,422 in improper payments made to physicians for epidural steroid injection sessions.

23-A-07-053.02 to CMS - Closed Implemented
Closed on 07/01/2024
We recommend that the Centers for Medicare and Medicaid Services instruct the MACs to, based on the results of this audit, notify appropriate physicians (i.e. those for whom CMS determines this audit constitutes credible information of potential overpauments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

23-A-07-053.03 to CMS - Closed Implemented
Closed on 09/07/2023
We recommend that the Centers for Medicare and Medicaid Services assess the effectiveness of oversight mechanisms, put in place after our audit period, that are specific to preventing or detecting improper payments to physicians for more than 4 epidural steroid injection sessions in a 12-month period and modify the oversight mechanisms, if necessary, based on that assessment.

23-A-07-053.04 to CMS - Closed Implemented
Closed on 10/01/2024
We recommended that Centers for Medicare and Medicaid Services direct the MACs (or other CMS-designated entities) to review a sample of claims for epidural steroid injection sessions administered during the period beginning on January 1, 2021, and ending on the date that the revised coverage limitations (i.e., up to four sessions per 12-month period) became effective in the relevant MAC's jurisdiction (I.e. December 5, 2021, and June 19, 2022), to identify instances in which Medicare paid physicians for injection sessions that exceeded the number of allowable sessions (in accordance with the applicable LCDs) and recover any improper payments identified.

View in Recommendation Tracker

Medicare Improperly Paid Physicians for More Than Five Spinal Facet-Joint Injection Sessions During a Rolling 12-Month Period (A-09-20-03003)

21-A-09-005.01 to CMS - Closed Unimplemented
Closed on 06/11/2021
For the 11 MAC jurisdictions with a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services direct the MACs that oversee the 11 jurisdictions to recover $748,555 in improper payments made to physicians.

21-A-09-005.02 to CMS - Closed Unimplemented
Closed on 06/11/2021
For the 11 MAC jurisdictions with a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services, instruct the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

21-A-09-005.03 to CMS - Closed Implemented
Closed on 02/04/2021
For the 11 MAC jurisdictions with a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services develop oversight mechanisms for the MACs to implement to prevent or detect payments to physicians for more than 5 facet-joint injection sessions received by beneficiaries during a rolling 12-month period in the lumbar spine or cervical/thoracic spine.

21-A-09-005.04 to CMS - Closed Implemented
Closed on 10/26/2023
For the 11 MAC jurisdictions with a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services direct the MACs that oversee the 11 jurisdictions to review claims for facet-joint injections after our audit period to identify instances in which Medicare paid physicians for more than 5 injection sessions received by beneficiaries during a rolling 12-month period and recover any improper payments identified.

21-A-09-005.05 to CMS - Closed Implemented
Closed on 03/04/2022
For the remaining MAC jurisdiction, which did not have a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services consider working with First Coast to determine whether it should re-implement this coverage limitation, which could have saved $513,328 during our audit period.

View in Recommendation Tracker

Noridian Healthcare Solutions, LLC, Made Improper Medicare Payments of $4 Million to Physicians in Jurisdiction E for Spinal Facet-Joint Injections (A-09-20-03010)

21-A-09-062.01 to CMS - Closed Unimplemented
Closed on 06/11/2021
We recommend that Noridian Healthcare Solutions, LLC recover $12,546 in improper payments made to physicians.

21-A-09-062.02 to CMS - Closed Unimplemented
Closed on 06/11/2021
We recommend that Noridian Healthcare Solutions, LLC based upon the results of this audit, notify appropriate physicians (i.e., those for whom Noridian determines this audit constitutes credible information of potential overpayments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

21-A-09-062.03 to CMS - Closed Implemented
Closed on 06/11/2021
We recommend that Noridian Healthcare Solutions, LLC provide annual training to physicians and their billing staff in Jurisdiction E specific to Medicare requirements for billing of facet-joint injections, which could have saved an estimated $4,155,889 for our audit period.

View in Recommendation Tracker

Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions (A-09-21-03002)

22-A-09-019.01 to CMS - Closed Implemented
Closed on 11/28/2022
We recommend that the Centers for Medicare & Medicaid Services direct the MACs to recover $9,528,296 in improper payments made to physicians for selected facet-joint denervation sessions.

22-A-09-019.02 to CMS - Closed Implemented
Closed on 11/28/2022
We recommend that the Centers for Medicare & Medicaid Services instruct the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

22-A-09-019.03 to CMS - Closed Implemented
Closed on 07/08/2022
We recommend that the Centers for Medicare & Medicaid Services assess the effectiveness of oversight mechanisms specific to preventing or detecting improper payments to physicians for more than two facet-joint denervation sessions related to the lumbar spine or cervical/thoracic spine per beneficiary during a rolling year and modify the oversight mechanisms based on that assessment.

22-A-09-019.04 to CMS - Closed Implemented
Closed on 02/24/2023
We recommend that the Centers for Medicare & Medicaid Services assess the effectiveness of oversight mechanisms specific to preventing or detecting improper payments to physicians for more than the allowed number of facet joints per denervation session to determine why the MACs allowed more than the MUE values that were applicable during our audit period, and modify the oversight mechanisms based on that assessment.

22-A-09-019.05 to CMS - Closed Implemented
Closed on 09/15/2022
We recommend that the Centers for Medicare & Medicaid Services direct the MACs to review claims for facet-joint denervation sessions after our audit period to identify instances in which Medicare paid physicians for denervation sessions that exceeded the number of allowable sessions in a 12-month period (in accordance with the applicable LCDs) and recover any improper payments identified.

22-A-09-019.06 to CMS - Closed Implemented
Closed on 09/15/2022
We recommend that the Centers for Medicare & Medicaid Services direct the MACs to review claims for facet-joint denervation sessions after our audit period to identify instances in which Medicare paid physicians for facet joints that exceeded the number of allowable facet joints per session (in accordance with the applicable LCDs) and recover any improper payments identified.

View in Recommendation Tracker

Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions (A-09-22-03006)

23-A-09-059.01 to CMS - Closed Implemented
Closed on 08/21/2023
We recommend that the Centers for Medicare & Medicaid Services direct the MACs to recover $18,084 in improper payments made to physicians for the 66 sampled sessions for facet-joint interventions.

23-A-09-059.02 to CMS - Closed Unimplemented
Closed on 08/21/2023
We recommend that the Centers for Medicare & Medicaid Services instruct the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

23-A-09-059.03 to CMS - Closed Implemented
Closed on 07/26/2023
We recommend that the Centers for Medicare & Medicaid Services encourage the MACs to: (1) develop collaborative training programs to be used for all of the MAC jurisdictions and that are specific to Medicare requirements for facet-joint interventions, which could have saved an estimated $29,566,172 for our audit period; and (2) develop solutions to prevent the incorrect billing of diagnostic facet-joint injections as therapeutic facet-joint injections, such as developing additional education specific to billing injections with modifier KX or updating guidance on how each type of injection should be billed.

View in Recommendation Tracker

Medicare Could Have Saved an Estimated $17.7 Million if CMS’s Oversight Had Prevented At-Risk Payments for Anesthesia Administered During Spinal Pain Management Procedures (A-09-23-03013)

Medicare Part B paid physicians $45.7 million for anesthesia administered during selected SPM procedures that were at risk for noncompliance with Medicare requirements. Specifically, Medicare paid for anesthesia that may not have been administered in only rare circumstances.

  • Anesthesia was administered during approximately 18 percent of 3.9 million sessions associated with selected SPM procedures, and CMS and the MACs denied payment for anesthesia less than 1 percent of the time that it was billed for these procedures.
  • For 20 of 28 sessions in our nonstatistical sample, the enrollees’ medical records did not document a rare circumstance in which administering anesthesia was reasonable or necessary for the specific SPM procedure.

Medicare made at-risk payments for anesthesia administered during selected SPM procedures because CMS and MAC oversight was not adequate. If oversight had been adequate, Medicare could have saved an estimated $17.7 million from May 2, 2021, through August 31, 2023. (We calculated this amount using the MACs’ expectations of how often anesthesia would be reimbursed for selected SPM procedures, i.e., only in rare circumstances.)

25-A-09-087.01 to CMS - Closed Acceptable Alternative
Closed on 09/17/2025
We recommend that the Centers for Medicare & Medicaid Services direct the MACs or other CMS contractors to review potentially improper claims for anesthesia administered during selected SPM procedures that had dates of service during our audit period to determine whether payments for administration of anesthesia complied with Medicare requirements.

25-A-09-087.02 to CMS - Open Unimplemented
Update expected on 01/28/2026
We recommend that the Centers for Medicare & Medicaid Services collaborate with the MACs to develop or update system edits that would lower the risk of improper Medicare payments for anesthesia administered during selected SPM procedures, which could have saved an estimated $17,688,110 during our audit period.

25-A-09-087.03 to CMS - Open Unimplemented
Update expected on 06/04/2026
We recommend that the Centers for Medicare & Medicaid Services collaborate with the MACs to develop additional physician education specific to anesthesia administered during selected SPM procedures, and consider the suggestions provided by the physicians for the 28 sessions in our nonstatistical sample.

25-A-09-087.04 to CMS - Open Unimplemented
Update expected on 01/28/2026
We recommend that the Centers for Medicare & Medicaid Services share the results of this audit with all of the MACs to show that: (1) for the SPM procedures for which LCDs are in place, MACs paid physicians for anesthesia administered during selected SPM procedures that were at risk for noncompliance with Medicare requirements and (2) for sacroiliac joint injections for which two MACs do not have LCDs in place, these two MACs paid for almost half of the sessions nationwide in which anesthesia was administered during these procedures.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Medical Supplies and Equipment Physician and Healthcare Practitioners
Target Groups
Elderly
Financial Groups
Medicare B