Billing info.!!

[ether]

I'm not sure if everybody has heard this so if u have ignore it and if u haven't listen up!!

It seems that one of the reasons our procedure reimbursements always are decreasing is that CMS (medicare) has many interventional pain physicians labeled with the code for anesthesiologists, which of course, is not true. The problem, from what I here, is then they are likely to continue cutting reimbursement since they realize anesthesiologists have very little overhead unlike us interventional pain docs.

Our speciality code with CMS as interventional pain physician SHOULD be
"09". Make sure with ur people that u are signed up with CMS with
"09" and not the anesthesiologists code!!

If you need to make a change there is a link on the far right hand column down on the front page on the asipp website.
"
Personally, I think if u haven't u should join asipp as well. I feel they at least try to lobby!!

Thanks for listening and pass on this IMPORTANT info. to ur other collegues so we can at least get the proper recognition in the billing world!!

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[Tenesma]

it has little to do with whether you are listed as 09...

the main reason these codes are seeing high percentage drops is because of the volume of the codes.

You CANNOT believe how many internists, family practitioners, naturopaths, neurosurgeons, homeless people, etc are billing medicare for lumbar facet injections when they are in fact just sticking a needle blindly into the subcutaneous tissues near the spine...

so medicare tracks the volumes of codes and then figures the best way to solve the problem is to drop the reimbursements so as to de-incentivize the scammers --- but that unfortunately is the wrong solution

the GI guys had a far better solution to this when all of a sudden everybody was doing anoscopies or sigmoidoscopies and billing as colonoscopies... they went to their state Medicare carriers and had the codes changed for colonoscopies with a whole set of new modifiers without letting word out to the "ninkompoops"

sometimes i wonder why we can't do the same? what should really happen is that only board-certified pain docs do these procedures.... the problem of telling medicare to only reimburse codes charged by 09 designated interventionalists is that anybody can register with medicare as 09... I know a few naturopaths who consider themselves "interventional pain physicians" and who do blindly guided procedures without fluoro and they are making each over 500k/year. (their procedures are: ESIs except it really ain't epidural, facet joints except it they ain't really facet, facet denervations with botox (they charge the patients cash for the botox) and bill the denervation to medicare) - pretty much they are doing everything legally but it is quite unethical

the question is how do you regulate that?

 

[Mister Mxyzptlk]

Everybody complains about these people but nobody ever picks up the phone to report them. There's a bad boy in my area who now has 4 state and federal agencies looking at him for exactly what you're talking about.

1. Report them to the medical board for practicing medicine without a license. Naturopaths are not licensed to do spine injections - or any injections.

2. Report them to your state's Medicare administrator or directly to the OIG. Medicare takes a very dim view of this sort of thing.

 

[Tenesma]

i believe in some states that the medical board has no jurisdiction over naturopaths (i am thinking of a few of the southwestern states)

medicare has no recourse - they document that they injected based on landmarks - as long as they have a medicare number and/or credentialed with other insurers then nothing can really stop them from getting paid - and technically it isn't fraud... except we all know it is fraud...

then again many of us have done blind epidural steroid injections in the past before fluoro became the thing to do - and how many of those were "truly" epidural...

 

[Mister Mxyzptlk]

All states have authority over people who practice medicine without a license no matter what the circumstances.

Medicare does, indeed, take a hard look at these practices. Although an ESI can arguably be done w/o fluoro, facets and paravertebrals cannot. All they need is a knowledgeable person to explain to them what's happening. Chances are they are not documenting the procedure properly either.

I can tell you from experience this can work. Medicare investigators can be educated as to what's going on. I had a Medicaid investigator come into my office last month asking me if it was reasonable that a rheumatologist billed Medicaid for 2,300 intercostal nerve blocks in the office in the past 10 years. I walked him through some EOBs (facets, paravertebrals, etc) and showed him where the skeletons are buried. That bad boy is being looked at by 4 state and federal agencies.

 

[Tenesma]

these naturopaths are licensed

there is no link between having a medical license and doing crazy stuff... i mean how many MDs are in California right now opening Botox/dermatology clinics and they only did 2 or 3 months of internship at best???

facets are done routinely without fluoro - much to my chagrin

did i mention a neurosurgeon who treats all of his failed backs with this formula: 1) escalating narcotic management 2) monthly visits 3) at each monthly visit he does bilateral blindly guided facet blocks... he is rolling in it...
and of all people he probably has a far better understanding of spine anatomy then most naturopaths, family practitioners... etc..

it's disgustin...

 

[Mister Mxyzptlk]

You can whine about it or you can do something about it. I chose to do something about it and it worked. Twice. And I plan to do some more. These people get away with what they do because others won't step up and speak out against them.

 

[ether]

Tenesma the few posts I have read from you made me feel u were a very bright guy in not only the theory of medicine but the practice and business side as well.

So I am quite surprised that you would spend the time stating over and over again that these people (especially non physicians) are doing a lot of these blocks AND not doing anything proactive about it. Why don't you just call the State medical board and Medicare about non physicians doing and billing for these services. I would suggest dropping an email to Manchikanti at ASIPP as well of these guys masquerading as pain MD's.

IF after doing this and nothing happens then you can just throw ur hands in the air. Until then u are letting the problem propegate itself (like any of us who doesn't at least TRY to speak up and let the right people know). I may be naive, but I think if u reported these people they would at least look into it. Either way what do u have to lose.

P.s. I have a friend who actually reported a Non MD doing these exact things and he is now under investigation!!

 

[joshmir]

A re-read of Tenesma's post (and a potential reason why an intervention may not be high yield) yields this statement:


medicare has no recourse - they document that they injected based on landmarks - as long as they have a medicare number and/or credentialed with other insurers then nothing can really stop them from getting paid - and technically it isn't fraud... except we all know it is fraud...


Gorback, witht he rheumatologist you have (correctly) brought attention to, what did you say?

Does anyone here have an example of appropriate phrases Tenesma can use, in light of the fact that what the naturopaths and neurosurgeons are doing is legal?

 

[joshmir]

I just sent an email to Dr Manchikanti, with the link to this thread, and invited him to respond, or to email me a response to post.

 

[ampaphb]

You can whine about it or you can do something about it. I chose to do something about it and it worked. Twice. And I plan to do some more. These people get away with what they do because others won't step up and speak out against them.

Although, you better be pretty damn sure YOUR practices can withstand the scrutiny of the OIG before you do so. Gorback's might be - make sure yours are too - people in glass houses ...

 

[ampaphb]

Does anyone here have an example of appropriate phrases Tenesma can use, in light of the fact that what the naturopaths and neurosurgeons are doing is legal?

Naturopaths doing spinal injections are practicing medicine without a licence (to practice medicine). Your state medical board most certainly DOES have the power to deine what constitutes the practice of medicine, and once they do so, any who is not an MD or a DO (ie. a CRNA, an naturopath, etc) who does so is violating state law, and can be brought up on criminal charges.

Anyone can do blind facet injections. Billing for them (CPT codes 64470 and 64475) without using fluroscopy is fraud. The CMS LCD states:

Since procedures 64470-64476 are performed under radiological guidance, they should be reported in conjunction with the appropriate radiology service rendered (e.g., fluoroscopy 76005). CPT code 76005 is intended to be reported per spinal region (e.g., cervical lumbar) and not per level. CPT code 76005 has been deleted as of 12/31/2006. For dates of service on or after 01/01/2007, use CPT code 77003.​

The neurosurgeon performing blind facet injections is fraudulently billing. the naturopath is practicing medicine without a license.

 

[ampaphb]

09 is a good idea, but not for the reasons stated earlier

Part of what you will be looked at for, both by Medicare and third-party payers, is over-ultilization. If you are being compared to general PM&R or anesthesiologists, you will do far more injections than the mean, and be an outlier, worthy of closer inspection.

If the group you are being compared to is other injectionists, however, you will be far less likely to fall outside the norm

 

[ether]

Look this forum is terrific for people in the same field to get together and discuss stuff, but this is not the place to complain about other practitioners (physician or other) if u realistically think someone is commiting fraud.

IF u believe someone is commiting fraud to the government, state medical board, or insurance do ur duty as a physician and relay it to the appropriate people. It makes practicing medicine safer for the public (isn't that want we want??) It is a single phone call!!

IF after that nothing happens then throw up ur hands, until then, if others are doing unethical and/ or illegal activities you are only contributing!!

DO UR PART and report it!!

p.s. just my thoughts.

 

[Mister Mxyzptlk]

p.s. just my thoughts.

Ah. For a minute there I thought they might be someone else's thoughts. Glad we got that cleared up.

Based on my limited experience, don't be surprised if people don't drop everything and jump on the case you present them. Like everyone else, regulators are busy people. My initial attempts at reporting this guy went nowhere. Be tenacious.

 

[C Fiber]

Ditto

 

[Ligament]

09 is a good idea, but not for the reasons stated earlier...
If the group you are being compared to is other injectionists, however, you will be far less likely to fall outside the norm

This is an excellent point. This "falling outside the norm" happened to a doctor I know with BCBS. They said he was "over utilizing and subject to losing his contract"! Since BCBS patients were over one-third of his practice, this was very scary. He was actually being compared to part time anesthesiologists, rather than other full time interventionalists.
He had to meet in person with the Medical Director at BCBS to explain this to him. Fortunately, the guy was very reasonable, followed the argument and called off the dogs. And it turned out the Director asked him for advice on how to review utilization on other pain docs!

Also- make sure Medicare has you listed at provider enrollment as Board Certified. I don't know what will happen with the new NPI database (probably will involve a headache), but the old UPIN database designated whether or not you were boarded when other offices were looking you up.