Practice Guidelines For Spinal Diagnostic Amp; Treatment Procedures - 2nd Edition
Amabella Batton
NASS develops clinical practice guidelines regarding the diagnosis and treatment of spinal disorders. Guidelines are intended as educational tools for a multidisciplinary audience to improve patient care by outlining reasonable information-gathering and decision-making processes used in the management of back pain in adults.
The NASS Clinical Practice Guideline Committee is trained in evidence analysis and uses an evidence-based guideline development methodology. Questions? Contact guide...@spine.org.
Interested in proposing a topic for future NASS Clinical Practice Guidelines?
The NASS Clinical Practice Guideline (CPG) Committee accepts future CPG topic proposals from NASS members, nonmembers, societies, and all members of the public.
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NASS encourages widespread circulation and implementation of the evidence-based recommendations made in NASS guidelines. To this end, NASS supports responsible translation of its clinical practice guidelines into other languages. NASS strongly encourages use of appropriately trained translators with an excellent knowledge of the English language, an excellent knowledge of the target language, significant experience in both languages, cultures and medicine, and ideally some content knowledge.
It is also strongly recommended that translators implement a rigorous procedure for verifying the accuracy of translations via a multiple forward translation process or a back-translation process with careful comparisons between documents. Individuals interested in translating guidelines are granted permission to do so, provided the resulting publication follows these requirements:
Reprinted and translated with the permission of NASS. NASS does not verify, certify and is not responsible for the accuracy of any translations, and has advised any parties translating the NASS clinical practice guidelines to carefully verify the accuracy of their translations prior to publication and dissemination.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.
The treatment guidelines are written from a clinical perspective, to guide clinical care. Providers should consult the Medical Aid Rules and Fee Schedule (MARFS) for documentation and coding requirements.
The Treatment Guidelines (also called Medical Treatment Guidelines, Medical Practice Guidelines or Review Criteria) are evidence based and were developed by the Office of the Medical Director in collaboration with practicing physicians and advisors.
Some guidelines are intended to be educational tools for medical providers. Some guidelines and the review criteria are used by L&I in the Utilization Review program and claim management process to promote best practices and improve the health of injured workers. They are published by L&I, which is solely responsible for coverage decisions that may result from their use.
The Washington Legislature passed a new law in 2009 (ESHB 2105/ Chapter 258, Laws of 2009) that directed the State to convene an Advanced Imaging Management Work Group. The Work Group was directed to identify evidence-based best practice guidelines for advanced imaging; State agencies were directed to implement the Work Group recommendations. Work Group recommendations include:
L&I offers self-directed online learning, in-person seminars, and occasional conferences. Topics range from billing for staff to evidence based clinical topics for providers. Some allow you to meet our program requirements, some describe our processes, and some offer FREE education certificates.
These conservative care resources target specific occupational conditions/regions and were developed by the Industrial Insurance Chiropractic Advisory Committee in conjunction with L&I. The best evidence has been collected and organized to provide you with easy strategies to manage these conditions. Recommendations for provocation tests, diagnostic strategies, outcomes assessments and treatment interventions are included.
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This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for facet joint interventions for pain management. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for facet joint interventions for pain management and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
The spine is the most common source of chronic pain. Chronic axial spinal pain is one of the major causes of disability and accounts for a substantial U.S. health burden. Chronic spine pain poses a peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features, and nonspecific radiological findings.
There are various methods that may be used in performing facet joint denervation. Percutaneous radiofrequency ablation (RFA) is a minimally invasive procedure done with imaging guidance (fluoroscopy or CT per code descriptor) and involves using energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. Conventional radiofrequency ablation (non-pulsed or continuous) applies thermal energy of typically 80 to 85 degrees Celsius. The terms RFA and radiofrequency neurotomy are used interchangeably. Both terms refer to a procedure that destroys the functionality of the nerve using radiofrequency energy. Non-thermal methods of denervation include chemical (chemodenervation), low-grade thermal energy (less than 80 degrees Celsius), pulsed RFA, laser neurolysis, and cryoablation.1
Throughout this document, societal recommendations with the grading of evidence are referenced. There are multiple systems to grade or rank the quality of medical evidence and develop evidence-based recommendations. Not all grading systems are equivalent, so while there are typically similarities in the grades or recommendations from various grading systems, they must be considered independent of the other. The references in this document refer to the following grading systems.
Notice: Services performed for any given diagnosis must meet all the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Patient safety and quality of care mandate that healthcare professionals who perform facet injections/procedures are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure, and utilization of the required associated imaging modalities.
In addition to the above requirements, non-physician providers, such as certified nurse anesthetist, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; FR Vol. 65, No. 68 page18543, April 7, 2000). Each practitioner must provide only those services within the scope of practice for each state.
Cervical Facet Pain: Pain located in the cervical spine, which may be characterized by chronic headaches, restricted motion, and axial neck pain, which may radiate sub-occipitally to the shoulders or mid-back.
Facet Joint Intraarticular Injections, Therapeutic: The placement of local anesthetic and possibly a corticosteroid into the facet joint to produce the beneficial effect of pain reduction.
Facet Joint: A diarthrodial joint in the spinal column (also called the zygapophysial joint or z-joint), producing the articulation of the posterior elements of one vertebra with its neighboring vertebra. There are bilateral superior and inferior articular surfaces at each spinal level. The terminology or nomenclature of the facet joint is classified by the specific vertebrae level that forms it (e.g., C4-5 or L2-3). There are two (2) facet joints, right and left, at each spinal level.
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