2014 billing update

[Ducttape]

ampaphb, What are we going to do?
I will:
1. Cut staff cost, and help the 16% under-employment rate
2. Order less supplies, consolidate my operations. Spend less.
3. Accept less desirable patients.
4. Opt out of crappy commercial contracts tied to medicare
5. charge ridiculously high fees to insurances, and write off 1/2 of out-of-network deductibles. which will still be cheaper for patients than their 10K current deductibles.
5. Move all crappy medicare cases to ACS, and buy more shares to offset losses. this can generate another 80K from lost CESI/LESI fees.
6. move away from governmental insurances.

What are you going to do? wait for ASIPP to write more letters? The majority of the forum members are clueless and clearly don't own businesses. If you actually ran a business, you realize there are many things that can be done, but in the end it hurts patients, and the country. TO date only fox news supports our cause. Show me a democrat that gives a **** about physicians.

the sad part is that, as a profession, pain is already being seen as overpaid and not working as hard as other professions, and i specifically am apparently lazier than most of you.

i am not paid the MGMA median that ampa quotes, and the area pain docs do not make that much. yet i have heard, from at least 4 distinct ortho colleagues and several other doctors that pain is overpaid. this perception doesnt help the profession - at least not in my area.



to get back on track on this thread, why dont you open a separate self-pay anti-aging clinic?

how about hire a PA/NP to improve flow and volumes?

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[bedrock]

the sad part is that, as a profession, pain is already being seen as overpaid and not working as hard as other professions, and i specifically am apparently lazier than most of you.

i am not paid the MGMA median that ampa quotes, and the area pain docs do not make that much. yet i have heard, from at least 4 distinct ortho colleagues and several other doctors that pain is overpaid. this perception doesnt help the profession - at least not in my area.



to get back on track on this thread, why dont you open a separate self-pay anti-aging clinic?

how about hire a PA/NP to improve flow and volumes?

Agree that surgeons think we are overpaid. I overheard one orthopod spine guy saying he was going to do spine injections when he retired from surgery (because he thought it was so easy to make money doing that).

I've thought about a PA many times, but so much of what we do is something that takes time to learn to do well. Most surgical PAs see post-ops, follow protocols on taking out suture, etc. Also see new patients without imaging or PT before they get to the doctor.

I don't trust a PA to manage anyone on opioids or decide who is ready for procedures. I don't accept patients who haven't already done PT and an MRI. So little for PA to do.

When you say anti-aging clinic are you referring to Botox? What else?

 

[Ducttape]

Use the PA for the following:

Post procedure checks
Teaching for SCS/injections
The initial eval - write note, collect data, get outside records, do teaching on b med/ purposes of PT, get PMP data, check felony records, document exam /ROS.
Non opioid patient follow up.
See new inpatient evals before you do.


You could cut your initial eval time to 15 min -and not have to dictate/ write the whole note.

Many routine follow ups that takes 20 min off your schedule can be replaced by a procedure.


Anti aging - I was thinking more of hormonal replacemrnt, like testosterone etc

 

[emd123]

So EMD, go right ahead, and rant like the ***** you sound like you are.

Glad to hear you resorted to name calling. That makes it pretty clear who has run out of rational ideas and valid arguments.

The MGMA average pain doc makes ~$450k, so yes, is is bull to say you will be closing your doors..

For those of us just starting our practices, or those about to finish fellowship, this statistic means nothing, and we haven't seen those numbers. Also, everyone of us has a primary specialty we can go back to. When ASIPP predicts that "40% of Pain physicians may close their practices" there may be more truth to it than you think. Closing ones doors may mean going back to Anesthesia, PMR or whatever their primary specialty is. That absolutely does impact patient access to quality pain care. It may also mean closing their doors and going to work for a hospital system where the same care provided will cost 5-6 times as much. That's money that could have been spent to pay for someone else's healthcare; again, access harmed. So it's not BS, it's a very real possibility.

Are you NOT going to do the right thing, because they cut your fee by $100?

Of course I'm going to do the right thing, and that's the rub. But many won't, and those are precisely the people that gamed the system all along, led us to this in the first place, and will continue to do so, screwing it up for those of us who do the right thing. So, I'll continue to do the right thing and get a 58% pay cut on CESIs while others will hire some non-doctor to do 58% more unnecessary CESIs and then some, to make up the difference. Then next year CMS cuts us even more, while they run off with their millions.

...so, given that you are still taking Medicare, you will earn a bit less. BFD.

It is a big deal because I'm still trying to build my practice and pay back start up costs. Any extra collections goes to that, not to my bank account. So yes, it is a big deal to me, anyone starting out in practice, the leadership at ASIPP, and pretty much everyone here on this forum except you.

 

[painroddin]

What the heck is this release from American Academy of Pain medicine I got. Half way down on their important points is this stuff about reimbursement and with no mention of L code being gone. After reading this, one would think that stim trial rates increased which is only telling half the story??? The source , Emily Hill, has huge experience in this area and curious to why she didn't paint more of a dire picture.

CMS Releases 2014 Medicare Physician Fee Schedule
Source: Emily Hill, PA
Date: December 6, 2013
0 stars(0 Comments)
The Centers for Medicare and Medicaid Services (CMS) finalized the updates to payment policies and rates under the Medicare Physician Fee Schedule for 2014 on November 27. The release was delayed due to the government shutdown earlier this fall.

The payment rate is based on the sustainable growth rate (SGR) formula and reflects a 20.1 percent reduction in payment for physician services. This is actually less than predicted in the Proposed Rule released this summer. Unless Congress intervenes to override the reduction, the resulting conversion factor on January 1, 2014 will be $27.2006. Congress has acted every year since 2003 to avert cuts in Medicare payments to physicians. The President’s budget calls for averting these cuts and finding a permanent solution to this problem.

Also included in the Final Rule are adjustments to relative value units (RVUs) made as part of the CMS initiative to identify potentially misvalued services. Changes were made to approximately 200 CPT codes as part of this process on an interim basis for 2014. Although many of these changes impacted hip and knee replacements, mental health services, and GI endoscopy services, some services provided by Pain Medicine physicians were also affected. Most notably are the codes for epidural steroid injections (62310, 62311, 62318, 62319) for which the work RVUs were decreased. In contrast, changes to the practice expense component for code 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) resulted in a significant increase in reimbursement for this procedure when performed in the office. The following table compares the 2013 to 2014 reimbursement for these services:

CPT code2013 Total RVU (Office)2014 Total RVU (Office)
623107.443.09
623116.273.04
623187.193.11
623195.173.21
6365012.8537.67

The Final Rule will be officially released on December 10, 2013 and will become effective January 1, 2014.

 

[spinedoctor]

I wonder if we have been overpaid all these years for doing stim trials in the office. I do them in the ASC so I have never derived the financial boom that other physicians have received all these years. I wonder if this is along the lines of doing UDS in the office. It was a cash cow and they are on to us.
I do some of my procedures in the ASC. There is some financial benefit from doing them there, but you will never be as efficient as in your own office. Obviously, the ASC is better than the hospital setting.
I am not sure what CMS is doing by making these cuts and forcing us to do these interventions in the hospital/ASC setting. Do they not see that it will actually increase the cost of medicine? Anyway, I am not sure they care about thinking this through.
I am concerned that I will now be forced to go back to the ASC to do these interventions.
I am not holding my breath that CMS will make any serious changes. As a physiatrist, we got slashed last year with EMG/NCS. The respective societies met with CMS in the summer of 2013 protesting the cuts. Did CMS change their decisions? Nope. They kept the 50-60% cuts that they forced on us starting January 2013. I am not optimistic that these cuts will be reversed.

 

[Ducttape]

Off topic - I heard that reimbursements for Emgs were going up? Any truth?

 

[spinedoctor]

This is the first major shot fired in the war to rid our country of the private practice physician (which at one point was a stated goal of POTUS). The first step in the process is to get rid of the specialists. Remember, these cuts are affecting all specialties. PCPs are somewhat immune because they are not billing codes that are affected by the MEI (which is where most of the cuts are coming from). This will wipe out a lot of solo docs especially the ones who are not well run or unfortunately just starting. So far the plan is working. Make the docs create the language (ie meaningful use, etc.) that will ultimately be used against them. What will happen next?


Either

1) They will succeed. Private practice will go extinct. Docs will be hospital employed and the government will then be able to wield more influence over hospitals and the doctors.
-or-
2) There will be a massive "revolution" where a lot of docs stop seeing medicare and go to private pay models (hard for pain management).
-or-
3) Practices with lots of ancillaries will rule and will be highly sought after by both new docs and established docs (already happening).
-or-
4) Docs will head for the exit signs and retire.


No matter what the war has begun. Please position yourselves to avoid the kill shot. Now is not the time to be an ostrich. We need to wake up and all come up with a battleplan. Otherwise medicine as we know it will be disappear in 3-5 years.

I hate conspiracy theories, but I wonder the same thing. I think the goal is to kill private practice and force us to be employees. That is the beginning of the end for physicians.

 

[spinedoctor]

No but they care if senior citizens, which is a huge voting block, get panicked over lost access to care, which this will cause. That should be the focus for persuasion.

Also, you

MUST

MUST

MUST

send your letter to as many news outlets as possible. Unless it blows up in the Press, it will go nowhere.

Focus on THE PATIENT and their lost access to care, as a result of these massive cuts.

That argument will get much, much, more traction than any of our collections or billing worries.

I have been to DC with ASIPP and our talking points was stating that patients would have access to care issues. We were supposed to say that instead of crying about pay cuts. But we cannot ignore the 800 lb gorilla in the room. We are worried about pay cuts.
In addition, CMS knows that physicians do the right thing and do not stop seeing these patients. There was a recent article stating that physicians over the last year have been seeing more Medicare patients. I am dumbfounded also.

 

[spinedoctor]

the sad part is that, as a profession, pain is already being seen as overpaid and not working as hard as other professions, and i specifically am apparently lazier than most of you.

i am not paid the MGMA median that ampa quotes, and the area pain docs do not make that much. yet i have heard, from at least 4 distinct ortho colleagues and several other doctors that pain is overpaid. this perception doesnt help the profession - at least not in my area.



to get back on track on this thread, why dont you open a separate self-pay anti-aging clinic?

how about hire a PA/NP to improve flow and volumes?

Ducttape is correct. We are perceived as being overpaid for what we do. I am not saying that is correct but that is the perception.
Better have a good exit plan within the next few years.

 

[spinedoctor]

Off topic - I heard that reimbursements for Emgs were going up? Any truth?

Two codes were going to be increased "more". The sad thing is that most physiatrists don't even do those procedures on routine electrodiagnostic testing.

 

[spondy14]

So does anyone have a $ estimate for ultrasound guidance?

We ran our numbers today for a worst case scenario and it's about a 30% hit for us (whole practice). We ran our numbers for HOPD and get basically 3x office numbers. Very strong incentive to sell our and merge.

I received word that the RVU for ultrasound guidance is 2.07. Which will equate to about 70$ as stated earlier.

 

[buddy 2004]

I received word that the RVU for ultrasound guidance is 2.07. Which will equate to about 70$ as stated earlier.

Here is a copy of the entire list of cpt codes:
http://www.acr.org/News-Publication...-Medicare-Physician-Fee-Schedule-Payment-Cuts

 

[lobelsteve]

I received word that the RVU for ultrasound guidance is 2.07. Which will equate to about 70$ as stated earlier.

0.61

 

[specepic]

I am looking forward to the breaking news NYT article about the 'unanticipated' loss of access to care across the board as scores of PCPs and specialists retire early or leave medicine on the next few years. This article will come out in about 2016 or so and state there is no way this could have been predicted and what should be done about it.

I am already seeing other specialists in my area calling it a day one by one.

 

[emd123]

I've started my letter writing campaign with my patients. I have to say, every single one so far has been supportive and nearly all are outraged. They don't want these drastic cuts to affect their access to care or doctors providing their treatments. I'm sending out 5 copies that I have them sign in the office, and also am handing out 5 copies for them to copy and give to friends/family in pain, or who are on Medicare. Most were unaware these cuts were this drastic and all are outraged that they are combined with increases to already more expensive payment to hospitals for the same exact procedures. They all know ultimately this will not be good for them.

Print out the ASIPP Capwiz letter, have the patient sign it, and send out one to each on the top of the letter. 5 per patient could be 100-200 per day. i think this is more effective than an email, because this takes all of the work out of it for the patient. If there is any time that Medicare or Congress might listen it's going into an election year when healthcare is a hot button issue. Remember, this is bad for patients and bad for the country if they increase spending on already more expensive hospital based procedures, when we can do it cheaper and more efficiently. Do this, and you'll be surprised at how supportive your patients are.

It may not help, but it might, and certainly doing nothing will not help.

Word format of Capwiz letter for patients:

http://www.asipp.org/documents/Congressionalletterforpatients.doc

 

[Maverikk]

Wow, as someone who was thinking about going into pain from my perspective this is even worse for the quality of future trainees, I can't imagine pain will be competitive at all when the salary is pretty similar to doing OR anesthesia. I'm wondering what next years application cycle will be like

 

[Taus]

It's already pretty similar to OR anesthesia. My co-fellows have been somewhat surprised, however readily admit that the predictable schedule, lack of call, weekends and holidays are worth a lot more than extra $$

 

[ssmallz]

It's already pretty similar to OR anesthesia. My co-fellows have been somewhat surprised, however readily admit that the predictable schedule, lack of call, weekends and holidays are worth a lot more than extra $$

+1,000,000

 

[Maverikk]

Yeah, I guess I meant pay per hour. From what I gather here pain will always be a good lifestyle, it just won't be a good paycheck, when I did pain I covered the weekly overnight pager and got called in once, the attending said it was the first time in many years he had to come in. Now it's going to be paid like that, when I was med school a resident told me all specialties choose 2 out of 3: pay, lifestyle, respect. Now pain only has lifestyle, I'd rather take more call when the pay dips below OR anesthesia

 

[michaelrack]

when I was med school a resident told me all specialties choose 2 out of 3: pay, lifestyle, respect. Now pain only has lifestyle

It was good when doctors had that choice, but that time is over. Now it's 1.5 out of 3 at best

 

[Jkc423]

"Stop the Medicare cuts to senior citizens and the disabled in pain"

http://www.kevinmd.com/blog/2013/12/stop-medicare-cuts-senior-citizens-disabled-pain.html

Here's an article on our issue on KevinMD.com which gets 1 million monthly page views and is regularly cited by the Wall Street Journal, New York Times, USA Today, and CNN. Over 100,000 subscribe to this site through various social media.

Most importantly, if you agree, read it on a device that allows you to click the share the link on Facebook, Twitter, Linkedin, and G+1, and comment after the article to make your voice heard.

 

[100YardDash]

"Stop the Medicare cuts to senior citizens and the disabled in pain"

http://www.kevinmd.com/blog/2013/12/stop-medicare-cuts-senior-citizens-disabled-pain.html

Here's an article on our issue on KevinMD.com which gets 1 million monthly page views and is regularly cited by the Wall Street Journal, New York Times, USA Today, and CNN. Over 100,000 subscribe to this site through various social media.

Why is it that medicare plans to increase reimbursement for pain procedures done in hospitals and decrease those done in the outpt setting? To drown out the private practice docs? whats the reasoning here? Thanks for the reply

 

[Ducttape]

Why is it that medicare plans to increase reimbursement for pain procedures done in hospitals and decrease those done in the outpt setting? To drown out the private practice docs? whats the reasoning here? Thanks for the reply

Maybe there is the perception ( rightly or not ) that there is greater ability to monitor procedures done in a hospital? Or maybe there might be the thought that a hospital is more likely to check a proceduralists qualifications?

Just shooting from the hip. Go ahead and declare somehow that that rhetorical response shows how I am a liberal, you-know-who....

 

[Pain Applicant1]

Maybe there is the perception ( rightly or not ) that there is greater ability to monitor procedures done in a hospital? Or maybe there might be the thought that a hospital is more likely to check a proceduralists qualifications?

Just shooting from the hip. Go ahead and declare somehow that that rhetorical response shows how I am a liberal, you-know-who....

Those are the reasons, mainly because it's thought that in order to have hospital privileges one must be better credentialed and if one is better credentialed than less overuse will occur. More overuse is likely occurring in the outpt setting so it threw up red flags.

I used to socialize heavily with all of these policy making people, including the meaningful use folks (another topic).

 

[emd123]

Maybe there is the perception ( rightly or not ) that there is greater ability to monitor procedures done in a hospital? Or maybe there might be the thought that a hospital is more likely to check a proceduralists qualifications?

Just shooting from the hip. Go ahead and declare somehow that that rhetorical response shows how I am a liberal, you-know-who....

I disagree. If they wanted "oversight" and "qualifications" all they had to do was put a national coverage determination on all these procedures requiring ABMS Pain Boards and/or ACGME Pain fellowship training to do these procedures. Problem solved with one stroke of the pen.

Instead, they've allowed and said it's okay, for not only non-board certified MDs to do these procedures, but even non-doctors such as NPs, PAs and CRNAs to do them.

Also, to imply that "hospital based" somehow equals "less overuse" is outrageous. Some of the worst offenders in overuse, unnecessary care, unnecessary surgeries, heart caths, fusions, CT scans, MRIs and other diagnostics are in hospitals.

It's political. It's about power. It's about the government's master plan. Crush individual doctors who as independents are difficult to control, and suffocate anyone not in the hospitals which are under their puppet strings, and line their pockets. Their only hope for a nationalized system is to have all of us under their control and to do so, they've got to get us under one roof. Crush private practice, fund hospitals, even if it costs 5 times as much. You're paying for it with your tax dollars after all, not them.

 

[clubdeac]

I disagree. If they wanted "oversight" and "qualifications" all they had to do was put a national coverage determination on all these procedures requiring ABMS Pain Boards and/or ACGME Pain fellowship training to do these procedures. Problem solved with one stroke of the pen.

Instead, they've allowed and said it's okay, for not only non-board certified MDs to do these procedures, but even non-doctors such as NPs, PAs and CRNAs to do them.

Also, to imply that "hospital based" somehow equals "less overuse" is outrageous. Some of the worst offenders in overuse, unnecessary care, unnecessary surgeries, heart caths, fusions, CT scans, MRIs and other diagnostics are in hospitals.

It's political. It's about power. It's about the government's master plan. Crush individual doctors who as independents are difficult to control, and suffocate anyone not in the hospitals which are under their puppet strings, and line their pockets. Their only hope for a nationalized system is to have all of us under their control and to do so, they've got to get us under one roof. Crush private practice, fund hospitals, even if it costs 5 times as much. You're paying for it with your tax dollars after all, not them.

emd is absolutely right. If there goal was better policing then yes, just require ABMS board certification. Moving into the hospital polices nobody and only adds to expenditures. A doc I know who makes > 1 million/year works in a hospital. I used to fee base out IT pumps to him when I worked at the VA. Instead of the pump he would first do a series of 3 ESIs, then facets, repeat RF and on and on …. before finally considering my request. I put a stop to this crap pretty quickly. Point is, he was an abuser of the system and worked solely within a hospital. Would see ~50 pts/day

 

[Pain Applicant1]

Setting up a system like yours is not as simple as you're making it out and would open up Pandora's box. All physicians are licensed in medicine and surgery and to start cherry picking CPT codes and assigning them to specific specialties is a very complicated, if not impossible, process. There's no conspiracy or big secret on why government is choosing to do what it's deciding to do. You can can always call the offices of the policy makers and find out the reasons why they make their decisions. You may not be able to speak directly with the policy maker but you can speak with one of their staffers, who more often than not actually have a big influence over which decision is made.

It doesn't matter which individual doc you know who's milking the system. Everyone on here can give examples in all settings. Policy makers tend to look at trends and the overall picture.

 

[Ducttape]

I disagree. If they wanted "oversight" and "qualifications" all they had to do was put a national coverage determination on all these procedures requiring ABMS Pain Boards and/or ACGME Pain fellowship training to do these procedures. Problem solved with one stroke of the pen.

Instead, they've allowed and said it's okay, for not only non-board certified MDs to do these procedures, but even non-doctors such as NPs, PAs and CRNAs to do them.

Also, to imply that "hospital based" somehow equals "less overuse" is outrageous. Some of the worst offenders in overuse, unnecessary care, unnecessary surgeries, heart caths, fusions, CT scans, MRIs and other diagnostics are in hospitals.

It's political. It's about power. It's about the government's master plan. Crush individual doctors who as independents are difficult to control, and suffocate anyone not in the hospitals which are under their puppet strings, and line their pockets. Their only hope for a nationalized system is to have all of us under their control and to do so, they've got to get us under one roof. Crush private practice, fund hospitals, even if it costs 5 times as much. You're paying for it with your tax dollars after all, not them.

theres a lot of truth to your last paragraph. combine the two.....

however, from a politician's viewpoint, he thinks he sees one big institution, making daily master schedules, sometimes weeks in advance, monitoring by nursing and admin who is more than happy to tell a doctor to stop doing something... vs. an office where the proceduralist pretty much can do what he wants. no monitoring, no oversight, no mechanism of control.

he knows there are administrators in the hospital that he can scare, threaten, sic JCAHO on. independent doctors, not so much.


finally, just like you think that CMS can solve a "problem with one stroke of the pen" (one which i agree on), it could also pretty much crush all office based proceduralists by just stating "all procedures must be done in a JCAHO certified facility for patient safety".

It doesn't matter which individual doc you know who's milking the system. Everyone on here can give examples in all settings. Policy makers tend to look at trends and the overall picture.

i agree thoroughly.

(ps CMS did not actually decide that it was okay for noctors to do procedures. they specifically decided that it was not their decision to make, and local ie State bylaws and regulations take precedence.)

 

[nvrsumr]

Setting up a system like yours is not as simple as you're making it out and would open up Pandora's box. All physicians are licensed in medicine and surgery and to start cherry picking CPT codes and assigning them to specific specialties is a very complicated, if not impossible, process. There's no conspiracy or big secret on why government is choosing to do what it's deciding to do. You can can always call the offices of the policy makers and find out the reasons why they make their decisions. You may not be able to speak directly with the policy maker but you can speak with one of their staffers, who more often than not actually have a big influence over which decision is made.

It doesn't matter which individual doc you know who's milking the system. Everyone on here can give examples in all settings. Policy makers tend to look at trends and the overall picture.

I have to provide my Emg board certification and serial number of my Emg machine for each Emg I bill and submit to Medicare. Doesn't seem that hard for them

 

[Taus]

I have to provide my Emg board certification and serial number of my Emg machine for each Emg I bill and submit to Medicare. Doesn't seem that hard for them

Providing emg boards??? Wow. Never heard if that coming from an insurer. What area of the country are you located? I had zero intentions of taking the emg boards,...

 

[Pain Applicant1]

I have to provide my Emg board certification and serial number of my Emg machine for each Emg I bill and submit to Medicare. Doesn't seem that hard for them

You're speaking of one set of CPT codes that only 2 specialties are involved in (mainly). The vast majority of CPT codes don't fall into that category. The serial number has nothing to do with anything. It's purpose is most likely to prove that the EMG machine is FDA approved.

Who's your Medicare FI? I'd be curious to read their LCD on EMGs.

 

[lobelsteve]

http://www.forbes.com/sites/scottgo...-will-have-to-take-a-pay-cut-under-obamacare/

 

[hyperalgesia]

You're speaking of one set of CPT codes that only 2 specialties are involved in (mainly). The vast majority of CPT codes don't fall into that category. The serial number has nothing to do with anything. It's purpose is most likely to prove that the EMG machine is FDA approved.

Who's your Medicare FI? I'd be curious to read their LCD on EMGs.

Good observation that the prevalent argument comparing US to euro pay doesn't include any reference frame. It's like when they compare 'outcomes' but forget to mention obesity and diabetes. Liberals have a real problem distinguishing correlation from causality.

 

[Jcm800]

http://www.forbes.com/sites/scottgo...-will-have-to-take-a-pay-cut-under-obamacare/

i support this. its asinine to say we should pay a large dinosaur more for the same service because they have 'higher overhead". Im not gonna buy a sony TV and pay more at store A because it has higher overhead, then to buy the same TV down the street for less... its silly. We want to save money, ELIMINATE paying for procedures in a site of service that is more expensive, or, like this article implies, PAY THEM THE SAME THEY PAY IN AN OFFICE. Then lets see how greedy hospitals are buy up practices...

 

[Yo GabbaPentin]

i support this. its asinine to say we should pay a large dinosaur more for the same service because they have 'higher overhead". Im not gonna buy a sony TV and pay more at store A because it has higher overhead, then to buy the same TV down the street for less... its silly. We want to save money, ELIMINATE paying for procedures in a site of service that is more expensive, or, like this article implies, PAY THEM THE SAME THEY PAY IN AN OFFICE. Then lets see how greedy hospitals are buy up practices...

Note that this article is from 6 months ago. They claim that there will be equalization between hospitals and PP. THEN they drop the hammer on PP while giving hospitals a raise! I guess they forgot to mention the step about killing PP BEFORE cutting these rates on hospitals.

 

[nvrsumr]

You're speaking of one set of CPT codes that only 2 specialties are involved in (mainly). The vast majority of CPT codes don't fall into that category. The serial number has nothing to do with anything. It's purpose is most likely to prove that the EMG machine is FDA approved.

Who's your Medicare FI? I'd be curious to read their LCD on EMGs.

Actually, IM became the number the number 2 specialty as far as total billed to Medicare for EMGs in 2012 after Neuro.... Lots of fraudulent billing with little hand held nerve conduction devices. Very similar situation to Pain as far as unaccredited docs ruining the field. I am uncertain as to why the serial number but my guess is the hand held devices weren't approved anymore.

My guess is lots of "pain docs" only bill 10 codes(ESI, facet, SI) 90+% of the time. Similar to EMG.

I wouldn't sit for EMG boards again though I do market I'm board certified rather than the untrained neurologist doing 4 limb emgs on everything and calling everything a chronic radic.

 

[hyperalgesia]

Actually, IM became the number the number 2 specialty as far as total billed to Medicare for EMGs in 2012 after Neuro.... Lots of fraudulent billing with little hand held nerve conduction devices. Very similar situation to Pain as far as unaccredited docs ruining the field. I am uncertain as to why the serial number but my guess is the hand held devices weren't approved anymore.

My guess is lots of "pain docs" only bill 10 codes(ESI, facet, SI) 90+% of the time. Similar to EMG.

I wouldn't sit for EMG boards again though I do market I'm board certified rather than the untrained neurologist doing 4 limb emgs on everything and calling everything a chronic radic.

There's a PCP near me that does four limb EMGs + f-waves on everything that enters the office. The impression is completely standardized and worthless, as if EMG is a form of therapy. Do all the cuts in Medicare hurt this 'doctor' at all. Nope. Depressing.

In the case above, you can say their is some risk to a pt getting an emg and certainly discomfort. And almost certainly fraudulent billing. But what do you guys think about using a US machine for the sake of higher billing? I'm talking about knee joint injections here. How hard is it to get into the knee joint? I don't see anything other than a financial benefit in these cases. But at the same time, I don't think doing so is all that unethical. It's not like an US is harmful to a pt... Plus it makes the pt more satisfied (outcome measure). What is our obligation to protect tax payer dollars?

 

[Yo GabbaPentin]

My previous less than ethical practice was doing "neural scans." Had an MA doing them alone, generating reports and then billing for emgs.

 

[Pain Applicant1]

Actually, IM became the number the number 2 specialty as far as total billed to Medicare for EMGs in 2012 after Neuro.... Lots of fraudulent billing with little hand held nerve conduction devices. Very similar situation to Pain as far as unaccredited docs ruining the field. I am uncertain as to why the serial number but my guess is the hand held devices weren't approved anymore.

My guess is lots of "pain docs" only bill 10 codes(ESI, facet, SI) 90+% of the time. Similar to EMG.

I wouldn't sit for EMG boards again though I do market I'm board certified rather than the untrained neurologist doing 4 limb emgs on everything and calling everything a chronic radic.

I never heard of this. Just out of curiosity, who's your Medicare FI? I'm interested in reading up on their LCD.

 

[axm397]

"Stop the Medicare cuts to senior citizens and the disabled in pain"

http://www.kevinmd.com/blog/2013/12/stop-medicare-cuts-senior-citizens-disabled-pain.html

Here's an article on our issue on KevinMD.com which gets 1 million monthly page views and is regularly cited by the Wall Street Journal, New York Times, USA Today, and CNN. Over 100,000 subscribe to this site through various social media.

Most importantly, if you agree, read it on a device that allows you to click the share the link on Facebook, Twitter, Linkedin, and G+1, and comment after the article to make your voice heard.

Reading the comments below his article makes me very frustrated though...

 

[nvrsumr]

I never heard of this. Just out of curiosity, who's your Medicare FI? I'm interested in reading up on their LCD.

Have to check with my billing folks. Everyone on vacation. Had every EMG denied until I started submitting with each hcfa

 

[Jkc423]

Reading the comments below his article makes me very frustrated though...

Did you comment?

Why aren't more of you going to the article and commenting? Support your case. Fight back, for your patients, the American taxpayer, and yourselves. That blog is read by tens of thousands, many influential people, and most importantly many of the only people who can make a difference: VOTERS. Do you feel your patients, the taxpayers and you deserve these cuts when they're paying a hospital 7 times what they pay you for the same service? This will be bad for patients. It will be terrible for the tax payers. It will drive care to more expensive, over utilized hospital settings, bankrupting Medicare further, while giving a huge boost to pill mills catering to the opioid abuse epidemic. It will punish the best doctors particularly those who have been most conservative and utilized interventions judiciously, the most.

Require Pain board certification? Fine.

Require Pain fellowship training? Fine.

But don't drastically cut what is paid for interventions, by a private practice board certified and fellowship trained Pain MD then continue to pay 7 times more to a hospital, for the same procedure, just because it's done in a hospital. Is that not insane?

Where's the outrage?

This is the court of public opinion. Every "vote" counts.

Comment.

http://www.kevinmd.com/blog/2013/12/stop-medicare-cuts-senior-citizens-disabled-pain.html

 

[Ducttape]

Did you comment?

Why aren't more of you going to the article and commenting? Support your case. Fight back, for your patients, the American taxpayer, and yourselves. That blog is read by tens of thousands, many influential people, and most importantly many of the only people who can make a difference: VOTERS. Do you feel your patients, the taxpayers and you deserve these cuts when they're paying a hospital 7 times what they pay you for the same service? This will be bad for patients. It will be terrible for the tax payers. It will drive care to more expensive, over utilized hospital settings, bankrupting Medicare further, while giving a huge boost to pill mills catering to the opioid abuse epidemic. It will punish the best doctors particularly those who have been most conservative and utilized interventions judiciously, the most.

Require Pain board certification? Fine.

Require Pain fellowship training? Fine.

But don't drastically cut what is paid for interventions, by a private practice board certified and fellowship trained Pain MD then continue to pay 7 times more to a hospital, for the same procedure, just because it's done in a hospital. Is that not insane?

Where's the outrage?

This is the court of public opinion. Every "vote" counts.

Comment.

http://www.kevinmd.com/blog/2013/12/stop-medicare-cuts-senior-citizens-disabled-pain.html

To be honest... Where are people getting this "7 times " figure?

Even in the article, The author states that it will be 5-6 times, and that is accurate with the new cuts.

We as a forum don't look good if we exaggerate the figures. Right now, HOPD and SCS get 2.5x more than office based ($250 vs. $565+110).

I am also uncomfortable using the argument that not doing injections is going to make us pain doctors write more opioids. There is an unethical edge to that position, just like how we all rail about those docs that use opioids to lure patients towards getting injections.

Finally, I do not comment on those other forums because it ultimately looks and sounds petty and demeaning

 

[powermd]

To be honest... Where are people getting this "7 times " figure?

They are rounding down a $140 lumbar ESI to $100, then multiplying by 7 to get the approximate HOPD rate.

None of us can honestly believe at this point the draconian cuts won't continue to include facets, RF, and transforaminals at some point. Sooner or later those cuts will come and utterly trash the field for Medicare patients. At that point many pain docs really will go out of business, and patients will be left to their PCPs who will only have a script pad available to treat facet syndrome and radiculopathy. What do you think they're going to prescribe?

At that point I hope to be direct-pay only. I'll make a lot less, but work less too, with an honest value for money relationship with my patients.

 

[lobelsteve]

Setting up a system like yours is not as simple as you're making it out and would open up Pandora's box. All physicians are licensed in medicine and surgery and to start cherry picking CPT codes and assigning them to specific specialties is a very complicated, if not impossible, process. There's no conspiracy or big secret on why government is choosing to do what it's deciding to do. You can can always call the offices of the policy makers and find out the reasons why they make their decisions. You may not be able to speak directly with the policy maker but you can speak with one of their staffers, who more often than not actually have a big influence over which decision is made.

It doesn't matter which individual doc you know who's milking the system. Everyone on here can give examples in all settings. Policy makers tend to look at trends and the overall picture.

Complete nonsense. Could be done in 5 minutes with existing system. If incorrect taxonomy code for provider for specific CPT, then assign payment value $0.00

 

[emd123]

To be honest... Where are people getting this "7 times " figure?

From the CMS fee schedule, it looks pretty spot on to me:

In 2014, CMS will spend $105 to pay for a patient to get a CESI done by a private MD in his office (physician non-facility for 62310).

In 2014, CMS will spend $739 for a patient to get the same CESI in a hospital ($70 facility physician +$669 HOPD). Do the math: $739 / $105 = 7.03

(See CMS 2014 fee schedules, Physician- http://www.asipp.org/documents/Physicians2014F.pdf ; Hospital- http://www.asipp.org/documents/HOPD2014F.pdf )


$739 for a cervical epidural in a hospital costs *7.03 times more* than $105 for a cervical epidural in a doctor's office


I don't see where there's any exaggeration. Is there? Please correct me if wrong, but I think that is absolutely correct, come 2014.

By the way, your figure of CMS paying "only 2.5 times more" for the same service was from 2013 fee schedules and will not apply from 1/1/14 moving forward, as if it ever made sense to pay "only" 2 1/2 times more for a CESI based on site of service. Yet now, they are increasing those already nonsensically higher fees to hospitals even more; see link above. Now that's only one procedure, but if you go from procedure to procedure doing the same calculation, the trend is that CMS is paying not 5 or 10% more for the same procedure just because they are done in the hospital, but hundreds of percents greater for the same procedures done in the hospital. Whether it's 7 times more, 4-5 times more, or 2.5 times more is irrelevant. Paying 200-600% more for the same procedure is wasteful, makes no sense, is punitive to doctors and is money that could be spent on someone else's care. Isn't that what the ACA is about,

"Affordable" care?

What's so "affordable," sensible, economical, fair, or right, about spending 2, 4 or 7 times more for a service based on site of service? All the while, this encourages these services to be performed at the radically more expensive sites while punitively cutting them in the much more efficient sites of service, ie, physician office? It is a recipe for disaster and insolvency.

Whether you offered your support in the past or not, CMS and the ACA should have a profound lack of credibility with everyone, based on these recent decisions alone.

I am also uncomfortable using the argument that not doing injections is going to make us pain doctors write more opioids. There is an unethical edge to that position..

It's not to say you, I or anyone single physician will make that decision, or change their practice. It is to say that at a minimum, if you de-fund treatments that are alternatives to opioids, or at worst put doctors that try to emphasize alternatives to opiates out of business, necessarily the patients will be forced to go to those doctors and treatments that remain, which by default will be practices that focus more on opioids. There's nothing unethical about that argument. It's just common sense that if you force practices that de-emphasize opiates out of business, those that focus more on opiates will be given a boost, will flourish more and ultimately prescribe more opioids. Some of those practices may be operating well within the guidelines, other may not be. I suppose it all comes down to whether or not you feel opioids are currently underprescribed. If so, then you would conclude this is a good thing. If however, you feel opiates currently are overprescribed then you would conclude it is not good policy, or healthy for this country, to defund treatments that are alternatives.

 

[Pain Applicant1]

Complete nonsense. Could be done in 5 minutes with existing system. If incorrect taxonomy code for provider for specific CPT, then assign payment value $0.00

I'm not talking about actually setting up a physical system. Obviously that wouldn't be that difficult. I'm talking about the political issues involved with it. Who would decide who gets to do what, etc. - doctors, payers, gov't, etc.? This has been discussed at previous ASIPP meetings.

 

[drusso]

What's so "affordable," sensible, economical, fair, or right, about spending 2, 4 or 7 times more for a service based on site of service? All the while, this encourages these services to be performed at the radically more expensive sites while punitively cutting them in the much more efficient sites of service, ie, physician office? It is a recipe for disaster and insolvency.

In order to control something, you must own it. This reimbursement incentivizes what "the system" wants...hospital employed docs.

 

[Ducttape]

Do you feel your patients, the taxpayers and you deserve these cuts when they're paying a hospital 7 times what they pay you for the same service?

$739 for a cervical epidural in a hospital costs *7.03 times more* than $105 for a cervical epidural in a doctor's office


I don't see where there's any exaggeration. Is there? Please correct me if wrong, but I think that is absolutely correct, come 2014.

im sorry, i didnt realize it was 2014 already. i thought it was December 28th, 2013. are people are already paying 7 times more already, even though the rules dont go into effect for another week? (ps the posts i am commenting on state that).

What's so "affordable," sensible, economical, fair, or right

its not about you, the doctor. the idea is to make healthcare affordable for the average american. id guess the average pain PP does not take medicaid, definitely does not take "FINA". the ACA's current iteration sucks, of course, but access to healthcare is for this demographic - 16-20% of the US population.

It's not to say you, I or anyone single physician will make that decision, or change their practice. It is to say that at a minimum, if you de-fund treatments that are alternatives to opioids, or at worst put doctors that try to emphasize alternatives to opiates out of business, necessarily the patients will be forced to go to those doctors and treatments that remain, which by default will be practices that focus more on opioids. There's nothing unethical about that argument. It's just common sense that if you force practices that de-emphasize opiates out of business, those that focus more on opiates will be given a boost, will flourish more and ultimately prescribe more opioids.

essentially, this argument is petty. just because PP pain docs wont take the little money they will be given by an insurance that they dont take, then "we'll show you" and the PP clinics that stay in business will be the opioids ones. "Waa waa if you dont give me what i want, i wont love you any more!!"

this is not the argument an established and intellectually competent specialty wants to present.

the implicit assumption is also that pain as a profession can be "bought". if you pay us less, then the profession will do what it needs to stay afloat, and that is to prescribe more opioids.

after reading your post, i now feel it is unethical to threaten CMS, congress, the american public with this suggestion.