how are you all handling medicare SIJ with the new rules?

[bedrock]

How are you are handling medicare SIJ with the new ridiculous rules that went into place this year?

1- Are you doing a diagnostic injection with bup first or doing both bup and steroid, but documenting the bup results?
2- are you doing therapeutic SIJ injections after that?
3- are you documenting that they are psychologically stable?
4- are some of you just throwing in the towel and making SIJ injections cash only
5- Is there a limit to how many medicare SIJ they will let you do in a given year? Because of needing to do extra BS diagnostic injections, I don't want to run out of total SIJ injections per year

I'm usually one for bending the rules as most of you know, but I would hate for medicare to claw this back and I'm debating how to handle them as I'm in a Noridian area which has gone to this LCD.

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[RoloTomassi]

I know this isn't helpful to your question, but I stopped taking new Medicare this year. Existing patients are grandfathered in, but I will start referring those out to my local colleagues at some point. This BS along with declining reimbursements has pushed me over the edge. The ROI for navigating this stuff has become too low. Honestly it feels liberating. Like when I switched to non-opioid practice. Miss my LoLs but definitely better QoL.

 

[stsa84]

I haven't changed anything yet. But I think I'll start documenting "diagnostic" blocks and just adding steroid. For one, it's the right thing to do from a patient care standpoint. Secondly, the prospect of trying to explain to patients the purpose of 2 diagnostic blocks before the therapeutic injection, for an freaking joint injection, is exhausting.

"So, you'll need have a needle in my SI joint?"
"Yes"
"But you're only going to inject a medicine that lasts a few hours?"
"Yes"
"And you're going to do this twice?"
"Yes"
"And then I'll finally be able to get the real medicine?"
"Yes"
"Can't you just put in the medicine that will last a longer time while you're in there the first time?'
"Well, you'd think..."

 

[drusso]

I'm offering it as a cash-pay service and telling patients they must sign an ABN.

 

[PikminOC]

I'm offering it as a cash-pay service and telling patients they must sign an ABN.

What's abn?

 

[SageCraft]

What is a Medicare waiver/Advance Beneficiary Notice (ABN)?​

An ABN is a written notice from Medicare (standard government form CMS-R-131), given to you before receiving certain items or services, notifying you:

• Medicare may deny payment for that specific procedure or treatment
• You will be personally responsible for full payment if Medicare denies payment

An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. It also offers you the right to appeal Medicare's decision.

 

[drrosenrosen]

I'm offering it as a cash-pay service and telling patients they must sign an ABN.

Are you billing medicare and reimbursing pt if medicare pays? Or just saying that it's cash pay only? I thought you could do an ABN for a non-covered service, but not because you didn't want to follow Medicare rules. For example, the way I'd understood it was that you can't skip diagnostic MBB and do an RFA with an ABN.

 

[Dr. Ice]

Do Medicare patients REALLY have sij pain anyway? Unless their spines were fused?

 

[MitchLevi]

Do Medicare patients REALLY have sij pain anyway? Unless their spines were fused?

Occasionally in my experience, but your point is valid IMO.

Skinny and anxious post-menopausal white woman with penia/porosis who smokes? Mmmhmmm.

 

[SpineandWine]

I haven’t done it yet, but I’m leaning towards learning more about fusion

 

[bedrock]

I'm offering it as a cash-pay service and telling patients they must sign an ABN.

Are you billing medicare and reimbursing pt if medicare pays? Or just saying that it's cash pay only? I thought you could do an ABN for a non-covered service, but not because you didn't want to follow Medicare rules. For example, the way I'd understood it was that you can't skip diagnostic MBB and do an RFA with an ABN.

I have the same question. Can you legally make a Medicare SIJ a cash injection just because you don’t want to follow their diagnostic injection rules ?

I’m not criticizing drusso here. I’m debating the same thing myself due to the hassle.

Also, are we seeing any other insurances follow these new guidelines for Medicare?

I’m wondering if blue cross will pick this up next?

 

[Dr. Ice]

I haven’t done it yet, but I’m leaning towards learning more about fusion

Boo..why would you fuse it. Show me that there’s instability there outside of relaxin hormonal preggo stuff

 

[RoloTomassi]

Boo..why would you fuse it. Show me that there’s instability there outside of relaxin hormonal preggo stuff

I haven't delved too deeply into the literature but it does seem like lateral approach can be effective, more so than the posterior approach most pain docs do. I think it's more a matter of appropriate patient selection than flat out not working. Haven't done any myself and probably never will given complications like superior gluteal artery injury that I wouldn't be comfortable managing intraoperatively.

 

[SpineandWine]

Boo..why would you fuse it. Show me that there’s instability there outside of relaxin hormonal preggo stuff

Ligament laxity is most likely cause- will help with adjacent segmental disease as well if someone is fused from L5-S1, which is what I see frequently. Like I said, haven’t done it yet but seems like it’s delivering some promising results for other people

 

[SSdoc33]

Ligament laxity is most likely cause- will help with adjacent segmental disease as well if someone is fused from L5-S1, which is what I see frequently. Like I said, haven’t done it yet but seems like it’s delivering some promising results for other people

From the questions you have asked on this board in the last month...... you should not be anywhere near this procedure.

 

[Dr. Ice]

Ligament laxity is most likely cause- will help with adjacent segmental disease as well if someone is fused from L5-S1, which is what I see frequently. Like I said, haven’t done it yet but seems like it’s delivering some promising results for other people

How would it help with adjacent segment disease? The procedure makes no sense based on the sole reason for fusion. Does it make sense to fuse something solely based on postulated ligament laxity? I

 

[SpineandWine]

From the questions you have asked on this board in the last month...... you should not be anywhere near this procedure.

Why so judgemental- I ask questions to improve myself constantly- I don’t see it as a sign of weakness. I don’t see this forum as a means to brag/but a resource to continually up my game

Rather it’s people who claim to be experts or pretend to think they know best. My patients do well and they get good relief from my blocks. These questions of joint injections or shoulder injections may seem basic to you, but people do things differently and I am never content with techniques I solely learn in fellowship.

Kind of a presumptuous statement to think you are “superior” to anyone on this thread or you are entitled to do procedures that others are not capable of doing/shouldn’t be doing.

 

[MitchLevi]

From the questions you have asked on this board in the last month...... you should not be anywhere near this procedure.

D-head comment

 

[clubdeac]

ssdoc is a d-head but he's like that to everyone so don't worry about it

 

[Dr. Ice]

Yes let’s all placate the Millennials, cause that’s gonna be good during real life terminator as the bots try to eradicate us. Softies go first. I’m pretty sure my wife wouldn’t stand one day in that scenario

 

[Dr. Ice]

Ssdoc can be crude and I mostly don’t agree with the Uber liberal views, but I can tell he’s of gen x or above..and likely very hard working and wouldn’t cry if someone said something not PC

 

[SpineandWine]

Prolly undertrained heavily procedural- with fears that skill sets can be replaced by CRNAs or NPs and over sense of doom and gloom

Millennials are ****ed due to decisions of prior generations to sell to PE, over utilization of medicine and lack of ethics

 

[Dr. Ice]

Prolly undertrained heavily procedural- with fears that skill sets can be replaced by CRNAs or NPs and over sense of doom and gloom

Millennials are ****ed due to decisions of prior generations to sell to PE, over utilization of medicine and lack of ethics

Dude, the selling to PE **** has only become really “cool” within the last 6-7 years or so. Yes it was happening before under the radar, but no one talked about it at nauseum as they do now.

Sometimes I wonder if I should go back to Rothman.. ho hum. Maybe they won’t take me back although I’m pretty sure I can run circles around all of their jersey docs.

Millenials are ****ed because they are overly sensitive to the very slightest criticism. And the men are probably worse. I almost wanna stop seeing millenial males altogether like people don’t want to take Medicare. That entire generation of people should follow “the silent generation” which for many of you
are your grandparents dead or alive. Read about their lives and you will be really humbled..

 

[SpineandWine]

As a pain physician, I can’t imagine your population is heavily leaning towards millennial population to begin with. Kind of odd to shun an entire population from a practice

Milenials (which is generation I’m part of) are stuck doing TFESIs now for 100 bucks, unable to do SI RFAs- honestly at times making me think anesthesia (minus call) would be better to practice

Regarding being sensitive, I’ll concede that 80 hour work restrictions, prioritization of mental health and other changes in healthcare does create a “softer” work force- however, that doesn’t mean millennials cannot take well researched and constructive criticism - I wonder if our perceived attitude towards work would change if we were reimbursed as pain physicians were in 2000s

Quick paced procedural skill I’d argue is not even a skill at all- again, can teach my MAs how to put in a stimulator if need be. Some of the worst physicians I have seen provide a high volume placebo practice that take pride in their flourishing practices

 

[Dr. Ice]

Lol..I’ve been in practice for 14 years and at 43 with a 9 month old, I will need to weather multiple storms and have in the past and I will tell you I will rise over and over again. I have heard over and over again that I won’t survive or that I won’t be reimbursed and yada yada. And yet my practice flourishes year over year despite the fact that my actual group may be tank or sell out.

Just because a veteran is quick paced doesn’t mean they aren’t thorough, it just means they’ve been in the biz long enough to know what to do my young padawan..

 

[10KHertz]

Sounds like CMS/Medicare is responding to over utilization of SI fusion technologies by limiting the SI diagnostic and therapeutic blocks. Almost like limiting a scs trial , by adding psych clearances and extra steps… IMO sacroiliitis is rarely a catastrophic condition .

If you look at the scs Medicare lcd’s and possibly the new SI injection lcd you just need psych inventories or screening , not necessarily a psychiatrist or LSW. If people are limited in resources (due to location or access to psych) consider doing your own psych inventories.it’s not that difficult .

Also the pain guys that are running state pain societies, you really need to fight this at a state level and then take it nationally if you want to reverse this crap.

 

[SpineandWine]

Lol..I’ve been in practice for 14 years and at 43 with a 9 month old, I will need to weather multiple storms and have in the past and I will tell you I will rise over and over again. I have heard over and over again that I won’t survive or that I won’t be reimbursed and yada yada. And yet my practice flourishes year over year despite the fact that my actual group may be tank or sell out.

Just because a veteran is quick paced doesn’t mean they aren’t thorough, it just means they’ve been in the biz long enough to know what to do my young padawan..

Not doubting anyone’s skill here. Hence, I ask questions to forum. I made statement that I’m not impressed when someone talks about high volume practice because I don’t think it’s really a skill.

I do 30-35 procedures a day (on my procedure days- so I consider myself high volume relatively- again easy to do as most are streamlined evaluations by ortho colleagues) and plan on making investments in facility fees (which is really how to make money in medicine - investments outside of your 9-5 job is only way- that or real estate according to members in this forum who seem to have had really good success).

Regarding procedures- it’s a vicious cycle that’s existed forever. Medicare cuts prices, new technology comes out and people adopt due to reps/reimbursements, over utilization occurs, Medicare cuts prices again or gets rid of procedures all together (didn’t Intradiscal procedures used to be common?)
Key would be (myself guilty here as well) to stop overutilization. I don’t think anything can be done regarding state representation level if majority of people who step into pain clinics with axial pain gets MBNB and RFA (when reported incidence is 15-20%, or SI injections if RFAs fail and then an ILESI for good measure. Luckily with my new practice, don’t have to worry about creating unnecessary volume myself as I don’t deal with many PCP referrals.

I haven’t stepped into this territory yet but people are doing facet fusions, indirect discectomies, SI fusions, scopes to get rid of medial branches all together (don’t know what this procedure is even called)- (mostly people in Florida)- I don’t think I’ll ever do high volume of these procedures but interested to learn more about them and apply them to appropriate patients.
I wouldn’t ride off SI fusion as complete bogus procedure-i think in select patients it could help (again, can’t spreak volumes as I haven’t done a case yet)

BTW- 33 year old, 2 years in practice (only 1 month at my new job) and a 1 week old at home

 

[painfree23]

Have we answered OPs question?

 

[lobelsteve]

Not doubting anyone’s skill here. Hence, I ask questions to forum. I made statement that I’m not impressed when someone talks about high volume practice because I don’t think it’s really a skill.

I do 30-35 procedures a day (on my procedure days- so I consider myself high volume relatively- again easy to do as most are streamlined evaluations by ortho colleagues) and plan on making investments in facility fees (which is really how to make money in medicine - investments outside of your 9-5 job is only way- that or real estate according to members in this forum who seem to have had really good success).

Regarding procedures- it’s a vicious cycle that’s existed forever. Medicare cuts prices, new technology comes out and people adopt due to reps/reimbursements, over utilization occurs, Medicare cuts prices again or gets rid of procedures all together (didn’t Intradiscal procedures used to be common?)
Key would be (myself guilty here as well) to stop overutilization. I don’t think anything can be done regarding state representation level if majority of people who step into pain clinics with axial pain gets MBNB and RFA (when reported incidence is 15-20%, or SI injections if RFAs fail and then an ILESI for good measure. Luckily with my new practice, don’t have to worry about creating unnecessary volume myself as I don’t deal with many PCP referrals.

I haven’t stepped into this territory yet but people are doing facet fusions, indirect discectomies, SI fusions, scopes to get rid of medial branches all together (don’t know what this procedure is even called)- (mostly people in Florida)- I don’t think I’ll ever do high volume of these procedures but interested to learn more about them and apply them to appropriate patients.
I wouldn’t ride off SI fusion as complete bogus procedure-i think in select patients it could help (again, can’t spreak volumes as I haven’t done a case yet)

BTW- 33 year old, 2 years in practice (only 1 month at my new job) and a 1 week old at home

You’re a kid. In 5 years you will realize everything you were taught is now wrong. If you see an article or a post on a newer procedure: it is marketing. KOLs lie to get paid.

 

[SpineandWine]

Here is a sheet I made for my NP for SI related issues - feedback welcome
To answer the question:
1) Doing both and proceeding with second injection if they get anticipated 2-3 month duration with steroid
2) I'll avoid doing bupi only injections as much as possible (waste of time for patients). As long as patients get >50% relief for 3 months with steroids, you can do them q3 months (I believe)
3) I document current psych history and meds they're on/we administer PHQ-9 to each patient and refer to psych or PCP for assessment if abnormal.
4) No, don't do cash only practice - i am restricted in this sense as i'm part of large organization
5) I believe it's 2 diagnostic and 4 thearpeutic in a year.

I have also attached ASIPP e-mail in how they prefer you to structure your practice with a checklist. Not sure if this is helpful.

~~

Look, only advanced procedures i've done here are kyphos/stim implants/PNS (for LFCN or GON) - haven't done MILD or interspinous distraction device. I look at all procedures with skeptical eye but I wasn't exposed to any in my last job as they were not allowed in the hospital (there were docs that did open SI fusions and treated grade 1 spondy with surgery) - All i'm saying is i'd like to learn more about them prior to poo-pooing them as my new job allows them if i want to.

 

[bedrock]

Have we answered OPs question?

No , and as the OP, I would appreciate it, if we can get back to my original questions-

 

[Dr. Ice]

Here is a sheet I made for my NP for SI related issues - feedback welcome
To answer the question:
1) Doing both and proceeding with second injection if they get anticipated 2-3 month duration with steroid
2) I'll avoid doing bupi only injections as much as possible (waste of time for patients). As long as patients get >50% relief for 3 months with steroids, you can do them q3 months (I believe)
3) I document current psych history and meds they're on/we administer PHQ-9 to each patient and refer to psych or PCP for assessment if abnormal.
4) No, don't do cash only practice - i am restricted in this sense as i'm part of large organization
5) I believe it's 2 diagnostic and 4 thearpeutic in a year.

I have also attached ASIPP e-mail in how they prefer you to structure your practice with a checklist. Not sure if this is helpful.

~~

Look, only advanced procedures i've done here are kyphos/stim implants/PNS (for LFCN or GON) - haven't done MILD or interspinous distraction device. I look at all procedures with skeptical eye but I wasn't exposed to any in my last job as they were not allowed in the hospital (there were docs that did open SI fusions and treated grade 1 spondy with surgery) - All i'm saying is i'd like to learn more about them prior to poo-pooing them as my new job allows them if i want to.

I can appreciate you wanting to learn new procedures and there’s nothing wrong with having tools as long as you recognize that sometimes the tools should just stay in the tool box and never come out. Sij fusion is total crap. It makes no sense in any real structural or scientific way and if you really pin down the reps, they have no ability to answer the basic question as to why it should even work.

You cannot take a patients experience as being solid because there are a myriad of reasons why what they tell you is not actually true.

I honestly wonder how many docs that use Dex for epidurals exclusively also foster SIJ fusions. Cause that would be completely ironical in my view

 

[Agast]

Re: psychologically stable

All my assessment and plan templates include a portion for Psychology (no maladaptive behaviors, UDS appropriate, anxiety treated by PCP/psychiatrist, major life events like husband recently passed) and Rehabilitation (using cane/walker, fall risk, completed formal PT, currently in PT or on a home exercise plan, received handout for exercises)

Putting that in every visit helps reduce the Peer to Peer calls. At least until recently, where I suspect the push has increased to deny everything everywhere all at once

 

[SpineandWine]

I can appreciate you wanting to learn new procedures and there’s nothing wrong with having tools as long as you recognize that sometimes the tools should just stay in the tool box and never come out. Sij fusion is total crap. It makes no sense in any real structural or scientific way and if you really pin down the reps, they have no ability to answer the basic question as to why it should even work.

You cannot take a patients experience as being solid because there are a myriad of reasons why what they tell you is not actually true.

I honestly wonder how many docs that use Dex for epidurals exclusively also foster SIJ fusions. Cause that would be completely ironical in my view

What’s wrong with trying posterior approach SIJ fusion still covered in 2023 under 27279 (Si Fix) in person who was getting significant relief with steroids (long duration in manner of several months) with diminishing time frame of benefit?

10-15 minute procedure, minimal recovery and reported good benefit (apparently according to my friend in Florida- as mentioned, never used by me).

Better question is what do you offer them next? Patient getting >75% relief for six months now having had 7 injections and with last two less than one month relief
-expectation management/turmeric/meds/yoga
-SI fusion
-cash based SI RFA as it’s no longer covered
-search other pain generators-

 

[specepic]

We are doing both DX and TX inj with steroid and local. Pain log for injx 1 and 2

 

[knoxdoc]

Same as specepic. I am doing nothing different, other than documenting positive provocative maneuvers, then calling it diagnositic and giving a pain log for injections 1 and 2. Now whether that actually gets me paid remains to be seen.

 

[Dr. Ice]

What’s wrong with trying posterior approach SIJ fusion still covered in 2023 under 27279 (Si Fix) in person who was getting significant relief with steroids (long duration in manner of several months) with diminishing time frame of benefit?

10-15 minute procedure, minimal recovery and reported good benefit (apparently according to my friend in Florida- as mentioned, never used by me).

Better question is what do you offer them next? Patient getting >75% relief for six months now having had 7 injections and with last two less than one month relief
-expectation management/turmeric/meds/yoga
-SI fusion
-cash based SI RFA as it’s no longer covered
-search other pain generators-

You can’t help everyone. Doesn’t mean you should fuse them. I can tell you that I have seen a bunch of patients post sij fusion with either continued pain or worsening pain. Interestingly their illustrious pain docs don’t want to see them anymore.

It’s a difficult conversation to have. I’m not sure if you are a male or female, but men have an incredible need or want to “fix” everything when sometimes things can’t be fixed. Trust me I have learned this the very hard way in all avenues of my life

By the way you also don’t seem to be able to answer the question of why it should actually work. Ligament laxity (as a sole reason) doesn’t really make sense as a reason to fuse bone

 

[bedrock]

Still want to focus on my original questions

However, for the second discussion going on…for hypermobile SIJ you do PRP injection including the ligaments.

If PRP fails then you proceed to SIJ RFA.

No neither of these two procedures are covered by insurance.

However there is huge reason to choose them over SIJ fusion. Because SIJ PRP and SIJ RFA are REVERSIBLE!!

A fusion is a terrible answer to any medical issue. Should only be the last resort. Which it isn’t, 99% of the time.

When your SIJ fusion fails then what? Now you have zero options to treat the patient, and you have personally doomed them to a lifetime of pain.

 

[Dr. Ice]

Still want to focus on my original questions

However, for the second discussion going on…for hypermobile SIJ you do PRP injection including the ligaments.

If PRP fails then you proceed to SIJ RFA.

No neither of these two procedures are covered by insurance.

However there is huge reason to choose them over SIJ fusion. Because SIJ PRP and SIJ RFA are REVERSIBLE!!

A fusion is a terrible answer to any medical issue. Should only be the last resort. Which it isn’t, 99% of the time.

When your SIJ fusion fails then what? Now you have zero options to treat the patient, and you have personally doomed them to a lifetime of pain.

Is there a double like option 👍🏼👍🏼

 

[Dr. Ice]

Male
Admittedly, can’t answer as I haven’t gotten exposed myself to procedure. Mechanistically and outcomes are two different things.
Would need more training/info - there are others in forum who claim they’ve done it with some success in prior thread

Furthermore, haven’t practiced at this new job long enough to find a patient who id consider it in as of yet

Do you use Dex or depo for transforaminal injections? It’s seemingly unrelated but there is a point

 

[SpineandWine]

Do you use Dex or depo for transforaminal injections? It’s seemingly unrelated but there is a point

Dex

 

[Dr. Ice]

Dex

Why?

 

[SpineandWine]

Why?

Guidelines, non particulate to avoid any accidental arterial injection-lowest risk arterial clot formation

actually want to know where you’re going with this

 

[Dr. Ice]

Guidelines, non particulate

You’re concerned about safety yes? Even though the literature shows a .01 chance of particulate causing catastrophic injury.

But you are considering putting hardware into a joint that doesn’t move enough to cause instability.

You can’t argue numbers theory. The math doesn’t really work. If your argument is that you would do way more transforaminal injections over SIJ fusion, percentage wise, you are still better off using a particulate. The mechanism of the fusion just doesn’t make any sense. Whoever came up with it put the cart before the horse. Using steroid for epidurals makes sense and the argument over particulate vs non is valid, but the logic should be consistent

 

[Taus]

Still want to focus on my original questions

However, for the second discussion going on…for hypermobile SIJ you do PRP injection including the ligaments.

If PRP fails then you proceed to SIJ RFA.

No neither of these two procedures are covered by insurance.

However there is huge reason to choose them over SIJ fusion. Because SIJ PRP and SIJ RFA are REVERSIBLE!!

A fusion is a terrible answer to any medical issue. Should only be the last resort. Which it isn’t, 99% of the time.

When your SIJ fusion fails then what? Now you have zero options to treat the patient, and you have personally doomed them to a lifetime of pain.

You have clearly missed the point. They now qualify as fbss and can get approved for a stim.

 

[SpineandWine]

Okay, done arguing so we can focus on original question. Last message on this thread

Level of evidence must be high for SI PRP for people here to offer it for cash payments.

Now I’m going to focus on my “reversible” procedure cash practice of intradiscal PRP, joint injections charging >1K per joint for PRP- so safe, no harm

 

[Dr. Ice]

Okay, done arguing so we can focus on original question. Last message on this thread

Level of evidence must be high for SI PRP for people here to offer it for cash payments.

Now I’m going to focus on my “reversible” procedure cash practice of intradiscal PRP, joint injections charging >1K per joint for PRP- so safe, no harm

Thank you for being open to perspectives

 

[bedrock]

Okay, done arguing so we can focus on original question. Last message on this thread

Level of evidence must be high for SI PRP for people here to offer it for cash payments.

Now I’m going to focus on my “reversible” procedure cash practice of intradiscal PRP, joint injections charging >1K per joint for PRP- so safe, no harm

No one has to charge >1k for PRP.

Many docs (outside of LA/NYC) will charge $750 if using a kit or $500 if not using a kit.

Both are less than a root canal/crown.

 

[Dr. Ice]

Agree I charge $850

 

[RoloTomassi]

Agree I charge $850

For 1 joint I assume? How much for intradiscal?