Spine Surgeon Salaries: Highest paid Docs

SDN Members don't see this ad. (About Ads)

Hi folks,

I was reading some surveys online, and I am absolutely amazed by how much spine surgeons make. The consensus is the same everywhere: spine surgeons are the highest paid docs in America. The average salary is way above $500k.

So I was wondering, why do they make so much money?
And, can anyone tell me what is the future for orthopaedic spine surgeons (will they be making the same amount of cash in future, or will there be a downdrop)?

References:

http://www.cejkasearch.com/compensat...ion_survey.htm

http://www.allied-physicians.com/sal...n-salaries.htm

There are scores of reasons, some of which include:

• Among the longest, if not the longest, total training time of any subspecialty: 5-7 years of Neurosurgery or Orthopedic Surgery Residency + 1-2 years of Spine Fellowship.
• Among the highest malpractice coverage rates.
• Some of the most technically challenging and high-risk procedures.
• Some of the longest operative times.

Also on the flip side:

1) SOME OF THE MOST PAINFUL PATIENTS THAT YOU WILL EVER MEET OR TAKE CARE OF

2) NO MATTER WHAT YOU DO, ALOT OF THEM STILL HAVE PAIN

3) THE PROCEDURES CAN BE LONG AND THERE ARE MORE RISKS, PTS CAN DIE POST OP...

4) THE FELLOWSHIP IS NOT COMPETITIVE, ABOUT 50% DO NOT FILL AFTER ORTHOPEDIC RESIDENCY, AND THERE IS A REASON FOR THAT, SEE ABOVE

(SPORTS MEDICINE FELLOWSHIP IS THE MOST COMPETITIVE ORTHO FELLOWSHIP OUT THERE)

THE REASON THEY GET PAID SO MUCH IS THAT ALL THE LEVELS THAT YOU FUSE ARE BILLED SEPERATELY AND NOT BUNDLED, WHICH MEANS THAT THEY CAN GET PAID A LOT. TWO LEVEL ACDF IS LIKE DOING 6 TOTAL JOINTS IN TERM OF THE RVUs. THIS WILL LIKELY CHANGE IN THE FUTURE SO THEY MAY NOT GET PAID THAT MUCH.

THE MONEY IS ACTUALLY IN SPINE INJECTIONS, THOSE WHO DO INJECTIONS CAN MAKE MUCH MORE.

That's actually pretty incredible that half the fellowships for a chance to make 1 mil/year (supposedly) don't fill. Must be a lot more to it.

Originally Posted by GeraldMonroe

That's actually pretty incredible that half the fellowships for a chance to make 1 mil/year (supposedly) don't fill. Must be a lot more to it.

Spine patients are really that terrible.

One way to look at it is: Would you still be happy with your career choice when/if (most likely when) they fix the billing of multiple levels in such a way that you make as much as the rest of the orthopods?

There is a lot more to life than money, and you will find this out quickly in your 3rd year. You couldn't pay me enough to do internal medicine, family medicine, or psych. Orthopods make really good money in general so most end up choosing what specialty they like the best.

Originally Posted by DHT

when/if (most likely when) they fix the billing of multiple levels in such a way that you make as much as the rest of the orthopods?

This reminds me of how things work in a video game such as an MMORPG. You can spend hours of time 'leveling up' a character designed to exploit a weakness in the game. However, sooner or later, the game masters will change the rules, 'nerfing' your character and making them fall more in line with the other character classes.

This sounds exactly like that. A perpetual shifting cycle.

Originally Posted by GeraldMonroe

This reminds me of how things work in a video game such as an MMORPG. You can spend hours of time 'leveling up' a character designed to exploit a weakness in the game. However, sooner or later, the game masters will change the rules, 'nerfing' your character and making them fall more in line with the other character classes.

This sounds exactly like that. A perpetual shifting cycle.

That's exactly the nature of medicine, thats why I cannot stress enough that picking something you actually like is far more important than what that profession is making right now. Unfortunately the salaries in medicine are up to the whims of the politicians (except cosmetics and LASIK). This is why I suggest giving money to the appropriate lobbying group to make your specialty less likely to get "nerfed."

Currently I don't think spine fellowships are not filling up. That used to be true in the past but recently spine has become a "hot' field that is pretty competitive, especially for top fellowships like Lenke's and Vicarro's fellowship. While they are no where near as competitive as a sports fellowship, they are not easy to obtain either.

I agree with the above post. The top fellowships in spine are very competitive (Thomas Jefferson, UCSD, Emory, U of Wash, Wash U, etc) just like everything else. But overall, it is less competitve than sports med fellowship. The 50% unfilled rate was from two years ago, not sure what it is now or this past year. There are some very complex and technically demanding cases in spine.... procedures can be challenging and interesting, but the post op course and clinics can be very painful.
The orthopods that don't go into sports med, think scoping all day long is boring, so there is always two sides to everything.

I really appreciate all the discussion you guys are putting in this.

Can anyone tell me what is the future for orthopaedic spine surgeons?

Originally Posted by khash08

I really appreciate all the discussion you guys are putting in this.

Can anyone tell me what is the future for orthopaedic spine surgeons?

Future is good. Salaries will probably drop some to be a little closer to the rest of ortho, but they will always be paid well. As the population ages, there will be plenty of spine cases to go around.

No one can predict the future, so no, no one can tell you the future of spine surgery. If you're only interested in it because of the insane amount of money that can be made.. I think you'll be in for a surprise when you find out how little half a million a year really is for the work you're doing.

There are increasing amounts of statistical data, and research showing that many orthopaedic surgeries are not providing the results wanted. For example, studies have shown that surgeries for back problems, and arthroscopic surgery don't offer the same value for pain remittance that physical therapy can.

I know i know, I'm not a doctor...but the studies are done and out there for you to see.

This being said, Spine surgeons make the most money because they perform mostly elective surgery. The same goes for neurosurgeons. Many neurosurgeons perform spine in addition to tumor/other surgeries as their bread and butter. Without spine based surgery or the high pay they get for it I guarantee you that the salary for either an orthopod spine or neurosurgeon would fall.

That is why I think the outlook is in big question. Especially with Obama's insistence on devloping a cost analysis for procedures and practices they may decide that reimbursement for above procedures shouldnt be at the levels they are today.

Just be careful about what specialty you want to go into....it takes nearly 10 years before you get established and by then things could change.

for example, in the 70s and 80s rads were one of the lowest paid...10 years later they were one of the highest. natch.

Originally Posted by surag

There are increasing amounts of statistical data, and research showing that many orthopaedic surgeries are not providing the results wanted. For example, studies have shown that surgeries for back problems, and arthroscopic surgery don't offer the same value for pain remittance that physical therapy can.

You have to be careful when you cite these studies and what they showed. I assume that for spine you are referring to the SPORT multi-center trial. To fully understand these studies you have to pick them apart, not just read the headlines of the news article or the abstract.

This trial looked at Physical Therapy vs Surgery for degenerative spondylolisthesis associated with spinal stenosis.

This trial was a great lesson in epidemiology and clinical trial design. The patients were randomized and the data was analyzed by the intent to treat principle, meaning whichever group you were put in you were analyzed as, even if you crossed over into the other arm of the study. For example, if you were randomized for PT but decided you needed surgery and crossed over the data was still analyzed as if you had PT only.

In this trial, there was approximately a large crossover. In the randomized cohort, 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. Essentially meaning that all of the severe patients that were randomized into PT got surgery anyways and the patients without severe disease that were randomized to surgery decided not to have surgery. But, they were still analyzed as if they got the treatment that they were randomized to, so the trial was essentially compromised by patient non-adherance to randomization.

When the data was reanalyzed as an observational cohort, there was substantially greater pain relief and improvement of function with surgery compared to non-operative care (PT).

Here is an interesting article explaining this trial:
Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304.Click here to read
PMID: 19487505

So moral of the story, read the articles carefully don't just believe what the conclusion of the trial or the nightly news says...

(Steps down off of soap box)

Originally Posted by JDWflash44

You have to be careful when you cite these studies and what they showed. I assume that for spine you are referring to the SPORT multi-center trial. To fully understand these studies you have to pick them apart, not just read the headlines of the news article or the abstract.

This trial looked at Physical Therapy vs Surgery for degenerative spondylolisthesis associated with spinal stenosis.

This trial was a great lesson in epidemiology and clinical trial design. The patients were randomized and the data was analyzed by the intent to treat principle, meaning whichever group you were put in you were analyzed as, even if you crossed over into the other arm of the study. For example, if you were randomized for PT but decided you needed surgery and crossed over the data was still analyzed as if you had PT only.

In this trial, there was approximately a large crossover. In the randomized cohort, 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. Essentially meaning that all of the severe patients that were randomized into PT got surgery anyways and the patients without severe disease that were randomized to surgery decided not to have surgery. But, they were still analyzed as if they got the treatment that they were randomized to, so the trial was essentially compromised by patient non-adherance to randomization.

When the data was reanalyzed as an observational cohort, there was substantially greater pain relief and improvement of function with surgery compared to non-operative care (PT).

Here is an interesting article explaining this trial:
Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304.Click here to read
PMID: 19487505

So moral of the story, read the articles carefully don't just believe what the conclusion of the trial or the nightly news says...

(Steps down off of soap box)

oh wow....i see...ok

The one I read mentioned sham surgeries...were these part of what you're talking about as well? I just assumed that the sham surgery was the end of it....and it didn't make much sense to me. I didn't have full access to the journal article but only the abstract.

Originally Posted by JDWflash44

You have to be careful when you cite these studies and what they showed. I assume that for spine you are referring to the SPORT multi-center trial. To fully understand these studies you have to pick them apart, not just read the headlines of the news article or the abstract.

This trial looked at Physical Therapy vs Surgery for degenerative spondylolisthesis associated with spinal stenosis.

This trial was a great lesson in epidemiology and clinical trial design. The patients were randomized and the data was analyzed by the intent to treat principle, meaning whichever group you were put in you were analyzed as, even if you crossed over into the other arm of the study. For example, if you were randomized for PT but decided you needed surgery and crossed over the data was still analyzed as if you had PT only.

In this trial, there was approximately a large crossover. In the randomized cohort, 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. Essentially meaning that all of the severe patients that were randomized into PT got surgery anyways and the patients without severe disease that were randomized to surgery decided not to have surgery. But, they were still analyzed as if they got the treatment that they were randomized to, so the trial was essentially compromised by patient non-adherance to randomization.

When the data was reanalyzed as an observational cohort, there was substantially greater pain relief and improvement of function with surgery compared to non-operative care (PT).

Here is an interesting article explaining this trial:
Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304.Click here to read
PMID: 19487505

So moral of the story, read the articles carefully don't just believe what the conclusion of the trial or the nightly news says...

(Steps down off of soap box)

also, why was this done? Couldnt they evaluate the sham surgery patients first and then perform full surgery?

any1

salaries are already dropping, altho not as fast as other ortho docs. 10 years ago, it was a virtual lock to make $1M in the midwest. now it's *only* high six figures. a spine surgeon in san diego will be lucky to cross $0.5M.

the real scary part is that increasingly surgeons are having to make up for the drop in reimbursement with ancillary income (e.g. owning part of the surgery center, dividend from the hospital, some BS directorship, self-referral to a rehab center that one owns, self-referral to one's own MRI, etc etc). This doesn't just apply to spine docs of course, but it's a sign of the times. from my understanding, north carolina doesn't allow docs to own a surgery center anymore.

Originally Posted by surag

also, why was this done? Couldnt they evaluate the sham surgery patients first and then perform full surgery?

I am not as familiar with the literature as I should be, however it was my understanding that the sham surgeries were to evaluate arthroscopy for osteoarthritis of the knee.

Showing that sham surgery = arthroscopic surgery for knee arthritis.

Speaking with my adult reconstruction (joint replacement) bosses, they tell everyone that arthroscopy does not work for arthritis. And that if we were doing it for knee arthritis we would be operating 24/7.

This is not the case for acute meniscal tears, ACLs, OCDs, etc where arthroscopy is the standard of care.

Also I believe SPORT trial showed that for herniated disks causing radiculopathy -- radiating pain, patients did better with surgery for 2 yrs afterwards; but outcomes were the same further out.

Spine surgery just like all other branches of surgery -- patient selection is the most important factor in successful outcomes. There are a lot of patients that you could operate on, but only a percentage of those should get surgery.

Originally Posted by Dimoak

There are scores of reasons, some of which include:

• Among the longest, if not the longest, total training time of any subspecialty: 5-7 years of Neurosurgery or Orthopedic Surgery Residency + 1-2 years of Spine Fellowship.
• Among the highest malpractice coverage rates.
• Some of the most technically challenging and high-risk procedures.
• Some of the longest operative times.

i think PLDD is the new advanced for spine surgeon

• • Among the longest, if not the longest, total training time of any subspecialty: 5-7 years of Neurosurgery or Orthopedic Surgery Residency + 1-2 years of Spine Fellowship.
  • Among the highest malpractice coverage rates.
  • Some of the most technically challenging and high-risk procedures.
  • Some of the longest operative times.

Spine seems to exist mostly on two extremes and seldom in the middle:

Extreme 1: really high highs- when the procedure is routine, immediate results and great outcome

Extreme 2: some really low lows- arguably highest risk region, even if no major catastrophes occur, outcome may be suboptimal and pain remains a life-long issue. Case in point, the highest prevalence of opioid medication abuse is among spine patients...chronic pain, whether real or imagined among patients is really a pain for spine docs too

Middle: Occasional midway, run-of-the-mill patients who can't decide if they should have had surgery but are glad for some relief.

The built-in bipolar nature of this specialty and the liability involved contribute to its handsome reimbursement rates vs other specialties.

I still believe, that although (thankfully) reimbursement rates at least attempt to mirror the amount of training/liability that are inherent to this specialty, rates still fall woefully short of what they should be compared to levels of training/liability inherent to...oh I dunno say being a frigging BlueCrossBlueShield CEO...?

Operative time-wise,
after you come off your Pedi Surgery rotation, I'll let you make that decision.
I remember the first time my attending on Spine said to me- "Girlie, this is the big one! tank up, get ready, this one's 5 hours"
all I could think of were the consecutive 20-hour neuroblastoma resections and Kasais.
"Sir, are you kidding? 5 hours is long?" (I had balls back then)

While I didn't actually say that, I certainly felt operative times, while being the longest of the ortho procedures, were dwarfed by those of pedi surg in particular.

I like it when pre-meds speak with authority about things they know nothing more about than what can be found on this site. you should be studying for your orgo test! or not, making my life easier

forget spine surgery ---

shoulder surgery is the new ortho gold mine

Originally Posted by Tenesma

forget spine surgery ---

shoulder surgery is the new ortho gold mine

Not sure about gold mine, but reoperation rate is pretty darn high if you are an aggressive shoulder surgeon.

Originally Posted by Wahoos

Also on the flip side:

THE MONEY IS ACTUALLY IN SPINE INJECTIONS, THOSE WHO DO INJECTIONS CAN MAKE MUCH MORE.

No. Not true. Not even close.

Originally Posted by scottie7397

No. Not true. Not even close.

I am sorry but you are incorrect. If a private practice performs ESI in office, they can make up to $1200 per injection with Medicare reimbursement at $400 plus and Workers Compensation upwards of $900. If 10 can be done per day in addition to new patients and a few post ops, that is much more lucrative than performing a two level fusion which will pay around $3000 under Medicare and take just as much time if not more.

Actually I believe cardic surgeons are number one and have been for a while.

Originally Posted by khash08

Hi folks,

I was reading some surveys online, and I am absolutely amazed by how much spine surgeons make. The consensus is the same everywhere: spine surgeons are the highest paid docs in America. The average salary is way above $500k.

So I was wondering, why do they make so much money?
And, can anyone tell me what is the future for orthopaedic spine surgeons (will they be making the same amount of cash in future, or will there be a downdrop)?

References:

http://www.cejkasearch.com/compensat...ion_survey.htm

http://www.allied-physicians.com/sal...n-salaries.htm

I am sorry but you are incorrect. If a private practice performs ESI in office, they can make up to $1200 per injection with Medicare reimbursement at $400 plus and Workers Compensation upwards of $900.

Sorry but you're both wrong and those compensation numbers are also inaccurate.

As of 2011, a single in-office lumbar ESI only reimburses at a medicare rate of $200 (+/-$20-$40 for regional medicare variations). Workers comp is considered to be very good if it pays you 150% of medicare but that still only nets you $300 per ESI, and about 40%-50% of most pain/spine practices are medicare patients, workers comp maybe 10-20% if you actively seek out work comp patients.

MGMA compensation numbers are considered to be the most accurate and used by most practices and law firms when calculating physician contracts.
I don't have the 2010 numbers but here are the 2009 MGMA numbers. I listed both the mean incomes and the 90% percentile

General surgery $350,290 $545,171
Pain medicine $460,243 $710,642
Cardiac surgery $522,819 $724,618
Ortho (general) $505,640 $837,834
Ortho (Spine) $669,073 $1,086,528
Neurosurgery $660,664 $1,050,293



General surgeons get paid poorly compared to other surgeons and make less than pain docs who work far better hours.
The ortho spine and neurosurg numbers are similar as most PP neurosurgeons do mainly spine. CT surgeons still do well but certainly bring home less than spine surgeons.

Spine surgeons make the most (for now) but plenty of general ortho incomes (particularly shoulder and sports ortho) come close to the levels of spine surgeons while having easier patients to deal with.
Unwise to let money steer you towards a spine fellowship unless you truly have a passion for the field because spine reimbursements are a major target for insurance companies. In a few years spine incomes will be even closer to other ortho specialities.

Actually I believe cardic surgeons are number one and have been for a while.

Cardiac surgeons haven't been number one since the 80s.

Originally Posted by bedrock

Sorry but you're both wrong and those compensation numbers are also inaccurate.

As of 2011, a single in-office lumbar ESI only reimburses at a medicare rate of $200 (+/-$20-$40 for regional medicare variations). Workers comp is considered to be very good if it pays you 150% of medicare but that still only nets you $300 per ESI, and about 40%-50% of most pain/spine practices are medicare patients, workers comp maybe 10-20% if you actively seek out work comp patients.

MGMA compensation numbers are considered to be the most accurate and used by most practices and law firms when calculating physician contracts.
I don't have the 2010 numbers but here are the 2009 MGMA numbers. I listed both the mean incomes and the 90% percentile

General surgery $350,290 $545,171
Pain medicine $460,243 $710,642
Cardiac surgery $522,819 $724,618
Ortho (general) $505,640 $837,834
Ortho (Spine) $669,073 $1,086,528
Neurosurgery $660,664 $1,050,293



General surgeons get paid poorly compared to other surgeons and make less than pain docs who work far better hours.
The ortho spine and neurosurg numbers are similar as most PP neurosurgeons do mainly spine. CT surgeons still do well but certainly bring home less than spine surgeons.

Spine surgeons make the most (for now) but plenty of general ortho incomes (particularly shoulder and sports ortho) come close to the levels of spine surgeons while having easier patients to deal with.
Unwise to let money steer you towards a spine fellowship unless you truly have a passion for the field because spine reimbursements are a major target for insurance companies. In a few years spine incomes will be even closer to other ortho specialities.



Cardiac surgeons haven't been number one since the 80s.

I am wondering what your qualificiations are to quote these numbers.

A normal in office Lumbar ESI consists of codes

62311, 94760,72275,77002,76000,99070 (epi tray reimbused by ins contract), med code.

Apparently, you are giving numbers for code 62311 only. I honestly don't know any specialist who is performing ESI blind without fluoro and the other services that go with it.

As far as the MGMA numbers, you do realize that these numbers are a survey for those who choose to participate. However, even according to their data, cardiologists remain the highest paid. http://healthcareers.about.com/od/co...PayDoctors.htm

Originally Posted by Quillandink

As far as the MGMA numbers, you do realize that these numbers are a survey for those who choose to participate. However, even according to their data, cardiologists remain the highest paid. http://healthcareers.about.com/od/co...PayDoctors.htm

Cardiologists: Depending on the type of cardiology one practices, cardiologists earn anywhere from $418,000 to over $537,000 annually. Cardiologists diagnose and treat diseases and disorders of the heart and circulatory system.

Orthopedic Surgeons earn anywhere from $450,000 for pediatric orthopedic surgery, to a high of over $600,000 for spine surgeons. Orthopedic surgeons specialize on surgeries of the bones and joints, including sports-related injuries, trauma, and arthritic deterioration.

...

QUILLANDINK....

I am wondering what your qualifications are - because you should definitely not be a coder for a pain clinic

first of all, it isn't 77002 but 77003 that is used for 6231X codes
second of all, you cannot unbundle pulse oximetry
third of all, you cannot bill for an epidurogram at the same time that you do a 6231X code
fourth of all, you cannot bill for fluoroscopy 76000 since the appropriate code is 77003
fifth of all, NO payor (not even work comp in my state) pays for trays of anything
sixth of all, a lot of payors bundle your med code into the procedure - and those that don't barely pay above market price for the med code (so no money to be made off the steroid).

so a fluoro-guided epidural steroid injection in an office in my state is:
62311 $208 77003 $52 = $260.... if you do the procedure in an outpatient hospital or ASC, your professional fee is 62311 $88 77003 $28 = $116

Next thing: Cardiac Surgeons are NOT number ONE and have not been for a while now, ever since medicare drastically (and most CABG/Valve patients are medicare) cut their reimbursements.... in fact, there are more cardiac surgeons graduating then there are open positions, so there is an over-supply and not much demand for them. so most cardiac surgeons are doing more and more thoracic cases.

where do you get your data from (besides your about.com link - which was completely useless).

Originally Posted by Quillandink

I am wondering what your qualificiations are to quote these numbers.

A normal in office Lumbar ESI consists of codes

62311, 94760,72275,77002,76000,99070 (epi tray reimbused by ins contract), med code.

Apparently, you are giving numbers for code 62311 only. I honestly don't know any specialist who is performing ESI blind without fluoro and the other services that go with it.

As far as the MGMA numbers, you do realize that these numbers are a survey for those who choose to participate. However, even according to their data, cardiologists remain the highest paid. http://healthcareers.about.com/od/co...PayDoctors.htm

You do understand that cardiologists and cardiac surgeons are two different animals, right?

Originally Posted by bedrock

...MGMA compensation numbers are considered to be the most accurate and used by most practices and law firms when calculating physician contracts...

Actually, MGMA is used as their numbers are generally significantly lower then any of the other surveys. Hospitals/employers love them cause it enables them to point to a low number and then proclaim "fair market value... here's the data". IMHO, it's not about a belief in accuracy so much as a belief in a lower bottom line expenditure if they use MGMA over the others. I can't speak to spine per se. However, in numerous fields, I have seen MGMA having medians upwards of 15+% lower then AMGA (i.e. Cejka numbers).

These numbers enable the employers to convince you they are "stretching" and "giving" you something if they start to increase even a little. However, under Stark laws and such, employers can utilize AMGA median numbers. Hospitals know this and rely on it. While crying how "risky" it is to increase beyond MGMA median, they know already that they have significantly greater upward range without any fears of criminal violation. It is interesting to see this becoming glaringly apparent when a hospital wants a specific talent and pulls out all stops. Suddenly MGMA gets thrown out the window and something like AMGA gets used... with a sometimes dramatic midstream flip-flop.

Another thing to notice is how MGMA will often not collect "data" on additional subspecialty fellowship trained physicians; rather lumps many into a base specialty i.e. general surgery = breast surgery fellowship trained or = MIS surgery trained or others..... Again, I can't speak to the spine field on this.

JackADeli,
I appreciate your input on MGMA/AMGA numbers, I'll keep that in mind when negotiating my next contract.

QUILLANDINK....

I am wondering what your qualifications are - because you should definitely not be a coder for a pain clinic

first of all, it isn't 77002 but 77003 that is used for 6231X codes
second of all, you cannot unbundle pulse oximetry
third of all, you cannot bill for an epidurogram at the same time that you do a 6231X code
fourth of all, you cannot bill for fluoroscopy 76000 since the appropriate code is 77003
fifth of all, NO payor (not even work comp in my state) pays for trays of anything
sixth of all, a lot of payors bundle your med code into the procedure - and those that don't barely pay above market price for the med code (so no money to be made off the steroid).

so a fluoro-guided epidural steroid injection in an office in my state is:
62311 $208 77003 $52 = $260.... if you do the procedure in an outpatient hospital or ASC, your professional fee is 62311 $88 77003 $28 = $116

Next thing: Cardiac Surgeons are NOT number ONE and have not been for a while now, ever since medicare drastically (and most CABG/Valve patients are medicare) cut their reimbursements.... in fact, there are more cardiac surgeons graduating then there are open positions, so there is an over-supply and not much demand for them. so most cardiac surgeons are doing more and more thoracic cases.

where do you get your data from (besides your about.com link - which was completely useless).

Nothing I can add to Tenesmas comments as he summed up both points up perfectly.

Originally Posted by bedrock

Sorry but you're both wrong and those compensation numbers are also inaccurate.

As of 2011, a single in-office lumbar ESI only reimburses at a medicare rate of $200 (+/-$20-$40 for regional medicare variations). Workers comp is considered to be very good if it pays you 150% of medicare but that still only nets you $300 per ESI, and about 40%-50% of most pain/spine practices are medicare patients, workers comp maybe 10-20% if you actively seek out work comp patients.

MGMA compensation numbers are considered to be the most accurate and used by most practices and law firms when calculating physician contracts.
I don't have the 2010 numbers but here are the 2009 MGMA numbers. I listed both the mean incomes and the 90% percentile

General surgery $350,290 $545,171
Pain medicine $460,243 $710,642
Cardiac surgery $522,819 $724,618
Ortho (general) $505,640 $837,834
Ortho (Spine) $669,073 $1,086,528
Neurosurgery $660,664 $1,050,293



General surgeons get paid poorly compared to other surgeons and make less than pain docs who work far better hours.
The ortho spine and neurosurg numbers are similar as most PP neurosurgeons do mainly spine. CT surgeons still do well but certainly bring home less than spine surgeons.

Spine surgeons make the most (for now) but plenty of general ortho incomes (particularly shoulder and sports ortho) come close to the levels of spine surgeons while having easier patients to deal with.
Unwise to let money steer you towards a spine fellowship unless you truly have a passion for the field because spine reimbursements are a major target for insurance companies. In a few years spine incomes will be even closer to other ortho specialities.



Cardiac surgeons haven't been number one since the 80s.

Based upon my 15 years in private practice you are accurate in your asessment. I would point out that as of Jan. 1st the epidurogram is now bundled with the injection code. The injection code pays more than in 2010 but still less than the combined coding. Note to all you future pain docs...you are about to be "bent over" by the Government big time.
The numbers are a good relative indication of what each specialty is currently making compared to another but as pointed out by other posters there is a significant regional variation. A pain doc in the Southeast may make more than a spine surgeon in the Pacific Northwest. Ask me how I know.

Originally Posted by Quillandink

I am sorry but you are incorrect. If a private practice performs ESI in office, they can make up to $1200 per injection with Medicare reimbursement at $400 plus and Workers Compensation upwards of $900. If 10 can be done per day in addition to new patients and a few post ops, that is much more lucrative than performing a two level fusion which will pay around $3000 under Medicare and take just as much time if not more.

Medicare reimbursement is about $150 for the average injection and if performed in office is about $200 total. Now don't forget that the cost of injectants and procedure tray. Yes and staff aren't free and neither is that fluoro machine..how about rent? I do my own injections and can perform up to four injections per hour. Depending upon the type of fusion you may hit 3k on reimbursement but generally not. That said eight Medicare injections...$1600 minus overhead of about 50% is $800. One Medicare spine fusion/lami or lami averages two hours and no overhead so about 2k. Class over.

Please don't get angry but I am really curious. Do you guys think that in the future with the rise of ACOs (accountable care organizations) that PMR guys will be doing most of the spine/back pain management? and that instead of a couple of ortho guys employing PMRs, the patient will go to the PMR first and then get referred to ortho?

Originally Posted by citizenbang

Please don't get angry but I am really curious. Do you guys think that in the future with the rise of ACOs (accountable care organizations) that PMR guys will be doing most of the spine/back pain management? and that instead of a couple of ortho guys employing PMRs, the patient will go to the PMR first and then get referred to ortho?

It'll depend on marketing to both the general public and primary referral sources. I definitely don't see spine surgeons maintaining their volume in the future. The question is who will be doing the non-surgical management of these patients.

why would we get angry?

but i think you misunderstand ACOs --- in order for them to succeed they have to provide cost-savings...

therefore, an RN will triage patients based on algorithms. Most of them will end up with an NP who will keep on sending them to PT (over and over again). The rest of them will end up with a PCP who is financially incentivized to minimize the costs of this patient - and will send them to a pain doctor who will rx generic narcotics, muscle relaxants. That pain doctor will then close the cycle and send them back to the original NP who will re-schedule more PT.... Very few if any of those patients will end up with procedures - and even fewer will end up with surgeons unless they have a true neurologic deficit.

I'm in PM&R. From many programs, a majority of grads are going into interventional spine fellowships (or if they can, Anesthesia pain fellowships). The end goal is the same, which is to learn those fluoroscope spine injections. Most people who then graduate don't want to bother with any more than lumbar epidurals, rhizotomies, and a few other things, as many of the other things they learn are high risk.

Anyway, if I was an insurer or Medicare administrator, what incentive would I have to pay much of anything for these procedures going into the future? I cannot stress enough what a glut of people there are doing these now, and how many more there will be as each year goes by.

That said, I don't have a very high opinion of laminectomy or fusion surgeries. But I don't have a very high opinion of any other treatment modality for these back pain patients either. The different treatment types work some of the time. That's the reality. Disregarding the obvious acute surgical cases, you can get better at predicting who will respond to medications alone vs. PT vs. Prednisone vs. Epidural vs. laminectomy vs. other treatment modalities, but you can never predict with anything approaching excellent accuracy.

The doctors who I've worked with who are extremely "pro" have superior physical exam skills, reread all the imaging, come up with more precise diagnoses than lumbago or radiculitis, and are more methodical in their approach to treating patients. They hit the target more often. But even these guys miss a lot of the time.

Originally Posted by Paddington

I'm in PM&R. From many programs, a majority of grads are going into interventional spine fellowships (or if they can, Anesthesia pain fellowships). The end goal is the same, which is to learn those fluoroscope spine injections. Most people who then graduate don't want to bother with any more than lumbar epidurals, rhizotomies, and a few other things, as many of the other things they learn are high risk.

Anyway, if I was an insurer or Medicare administrator, what incentive would I have to pay much of anything for these procedures going into the future? I cannot stress enough what a glut of people there are doing these now, and how many more there will be as each year goes by.

That said, I don't have a very high opinion of laminectomy or fusion surgeries. But I don't have a very high opinion of any other treatment modality for these back pain patients either. The different treatment types work some of the time. That's the reality. Disregarding the obvious acute surgical cases, you can get better at predicting who will respond to medications alone vs. PT vs. Prednisone vs. Epidural vs. laminectomy vs. other treatment modalities, but you can never predict with anything approaching excellent accuracy.

The doctors who I've worked with who are extremely "pro" have superior physical exam skills, reread all the imaging, come up with more precise diagnoses than lumbago or radiculitis, and are more methodical in their approach to treating patients. They hit the target more often. But even these guys miss a lot of the time.

So, the question is, who do you think are in the best position to maintain their market share, as surgical volume goes down?

Originally Posted by bronx43

So, the question is, who do you think are in the best position to maintain their market share, as surgical volume goes down?

This is kind of a silly discussion. Yes, if you believe that all Spine does is lami w/fusion, the rates will continue to decline. But there are constant advances in surgical techniques and implants, and I seriously doubt that Spine will collapse any time soon (pun intended).

Think about the PM&R guy's statement above: the Interventionalists are growing exponentially due to the multiple pathways into the practice. Spine, on the other hand, is relatively stable. So as more interventionalists start working, and more patients see them, where will the 50%+ go who don't get the results they want? Straight to the surgeon...

I agree that the literature is a mess when it comes to back surgery, but I don't see the numbers of people seeking surgical options dropping off, ever.

I have not had a PMR rotation yet, can someone tell me what PMR interventions are available for back pain vs what spine surgery interventions are available (and how they compare)?

Originally Posted by Paddington

That said, I don't have a very high opinion of laminectomy or fusion surgeries. But I don't have a very high opinion of any other treatment modality for these back pain patients either. The different treatment types work some of the time...
The doctors who I've worked with who are extremely "pro" have superior physical exam skills, reread all the imaging, come up with more precise diagnoses than lumbago or radiculitis, and are more methodical in their approach to treating patients. They hit the target more often. But even these guys miss a lot of the time.

Lumbar fusion is indicated in unstable spondylolisthesis or if the decompression would lead to an unstable spine. Lumbar fusion is NOT indicated for low back pain and is unpredictable in relieving low back pain, but does reliably relieve true radiculopathy with appropriate decompression. People who perform fusions strictly for back pain are performing an inappropriate operation. People with chronic back pain are often unable to appreciate the fact that their radiculopathy is better but quickly become consumed again by their ever present back pain.

Originally Posted by skiz knot

Lumbar fusion is indicated in unstable spondylolisthesis or if the decompression would lead to an unstable spine. Lumbar fusion is NOT indicated for low back pain and is unpredictable in relieving low back pain, but does reliably relieve true radiculopathy with appropriate decompression. People who perform fusions strictly for back pain are performing an inappropriate operation. People with chronic back pain are often unable to appreciate the fact that their radiculopathy is better but quickly become consumed again by their ever present back pain.

Even worse, the chronic low back pain patients who struggle for years with assorted interventional procedures, then one day find a surgeon to fuse them for no good reason. Post-op they go on narcs, and of course end up with "prolonged post-op pain" that necessitate further prescriptions, which they then "can't" get off of...

Spine surgery is a ball. If you are not out to fuse everyone who walks through the door, you won't make a million dollars, but you will have a very nice lifestyle, high job satisfaction and hundreds of appreciative patients over a few years. The tough part is choosing the right mentors- and you need more than one. A lot of people make it trough residency and fellowship training in programs that over - fuse, and then go into practice fusing every patient that comes their way. Some of these surgeons who end up in small hospitals end up with complications they don't want to deal with- csf leaks, revisions, lawsuits and worse.

Microsurgical technique, less invasive procedures are the way to go. The microscope and high speed burr are the best instruments in the room. Learn to use them. In my experience- 8 years now in private practice- most folks with stenosis are served well by a unilateral laminectomy. Blood loss is less than 100ml, they're out of the hospital the next day, and they go home and tell all their friends how well their doing. Although the decompression without fusion pays 1/3 what a big fusion pays- I can do two and sometimes three in a day, while fusions take a lot of time. Suddenly your practice becomes very busy. Sure, you still need to know how to place a pedicle screw, but your life is a lot better if you're only fusing a dozen or two backs a year. I've only had to go back and fuse 2 patients out of hundreds. . . and those, in hindsight had a bit of a dynamic slip.

Start off slow. After 2 years of private practice, you'll look back and realize you weren't as good as you thought at the time you graduated. Read this paragraph a few times and remember it!

Once, I performed a unilateral laminectomy on an 88 year old whose stenosis was so bad he was in a wheelchair for 2 years. I suggested that he wouldn't walk again, and although he did stay on the rehab unit for 3 weeks, he walked out of the hospital, and he cried tears of joy at his follow-up. That's why I'm a spine surgeon, not the money. Never forget why you're a doctor!

If you feel the need to do complex adult scoliosis, trauma, front-back. . . God love you, stick to practice in a university setting.

Originally Posted by scottie7397

Based upon my 15 years in private practice you are accurate in your asessment. I would point out that as of Jan. 1st the epidurogram is now bundled with the injection code. The injection code pays more than in 2010 but still less than the combined coding. Note to all you future pain docs...you are about to be "bent over" by the Government big time.
The numbers are a good relative indication of what each specialty is currently making compared to another but as pointed out by other posters there is a significant regional variation. A pain doc in the Southeast may make more than a spine surgeon in the Pacific Northwest. Ask me how I know.

How do you know?

.

Originally Posted by MacBones

Spine surgery is a ball. If you are not out to fuse everyone who walks through the door, you won't make a million dollars, but you will have a very nice lifestyle, high job satisfaction and hundreds of appreciative patients over a few years. The tough part is choosing the right mentors- and you need more than one. A lot of people make it trough residency and fellowship training in programs that over - fuse, and then go into practice fusing every patient that comes their way. Some of these surgeons who end up in small hospitals end up with complications they don't want to deal with- csf leaks, revisions, lawsuits and worse.

Microsurgical technique, less invasive procedures are the way to go. The microscope and high speed burr are the best instruments in the room. Learn to use them. In my experience- 8 years now in private practice- most folks with stenosis are served well by a unilateral laminectomy. Blood loss is less than 100ml, they're out of the hospital the next day, and they go home and tell all their friends how well their doing. Although the decompression without fusion pays 1/3 what a big fusion pays- I can do two and sometimes three in a day, while fusions take a lot of time. Suddenly your practice becomes very busy. Sure, you still need to know how to place a pedicle screw, but your life is a lot better if you're only fusing a dozen or two backs a year. I've only had to go back and fuse 2 patients out of hundreds. . . and those, in hindsight had a bit of a dynamic slip.

Start off slow. After 2 years of private practice, you'll look back and realize you weren't as good as you thought at the time you graduated. Read this paragraph a few times and remember it!

Once, I performed a unilateral laminectomy on an 88 year old whose stenosis was so bad he was in a wheelchair for 2 years. I suggested that he wouldn't walk again, and although he did stay on the rehab unit for 3 weeks, he walked out of the hospital, and he cried tears of joy at his follow-up. That's why I'm a spine surgeon, not the money. Never forget why you're a doctor!

If you feel the need to do complex adult scoliosis, trauma, front-back. . . God love you, stick to practice in a university setting.

Thank you for the practical and knowledgeable post.

Originally Posted by Tig2575

How do you know?

Networking with docs throughout the country.