Lumbar RFA after fusion

[oneforfighting]

Patient has L3-L5 posterior fusion and R SI fusion. Complains of persistent low back/buttock pain worse to the right side. No extremity pain, just some intermittent n/t to lateral feet. Back pain worse with standing, no pain while seated. On exam, +facet loading in low back but nothing above fusion site. Tenderness over right SI. Would you do an L5 DR block by itself? Would insurance pay for this??

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[mdo1738]

Would try a R SIJ first.

 

[oneforfighting]

Would try a R SIJ first.

You'd inject at the fusion?

 

[MitchLevi]

Patient has L3-L5 posterior fusion and R SI fusion. Complains of persistent low back/buttock pain worse to the right side. No extremity pain, just some intermittent n/t to lateral feet. Back pain worse with standing, no pain while seated. On exam, +facet loading in low back but nothing above fusion site. Tenderness over right SI. Would you do an L5 DR block by itself? Would insurance pay for this??

R L5-S1 MBB/RFA or R L5-S1 TFESI.

Personally, I'd do L5-S1 MBB/RFA and simultaneously get S1 LB and not bill it.

We also know it can't possibly be the SIJ that hurts bc SIJ fusions are the most effective procedures in modern healthcare.

 

[Ferrismonk]

I'd try the L5DR MBB and an SIJ inj. You can still put stuff in the SIJ even if there's a fusion there.

That being said, if all else doesn't help, this guy does technically qualify for an SCS trial.

 

[RoloTomassi]

Right L5-S1 MBB will be approved. Try your best with the L4 MB.

 

[oneforfighting]

I'd try the L5DR MBB and an SIJ inj. You can still put stuff in the SIJ even if there's a fusion there.

That being said, if all else doesn't help, this guy does technically qualify for an SCS trial.

Would you worry about seeding hardware? And would insurance approve?
Agree with SCS but no extremity pain...

 

[oneforfighting]

R L5-S1 MBB/RFA or R L5-S1 TFESI.

Personally, I'd do L5-S1 MBB/RFA and simultaneously get S1 LB and not bill it.

We also know it can't possibly be the SIJ that hurts bc SIJ fusions are the most effective procedures in modern healthcare.

I don't personally do SI Fusions so can't comment but one of the areas of pain is definitely over SI

 

[MitchLevi]

L5-S1 MBB/RFA. If you want to be nice, give 'em a free needle at the S1 lateral branch.

Like Rolo said, try your best at the L4 MB.

Yes, insurance will cover this.

No seeding of hardware will happen.

The buttock and sacroiliac area are common painful spots for L5-S1 facet pain, as well as L5 and S1 radic.

Very common my L5 or S1 radic pts ONLY hurt at the buttock.

 

[oneforfighting]

L5-S1 MBB/RFA. If you want to be nice, give 'em a free needle at the S1 lateral branch.

Like Rolo said, try your best at the L4 MB.

Yes, insurance will cover this.

No seeding of hardware will happen.

The buttock and sacroiliac area are common painful spots for L5-S1 facet pain, as well as L5 and S1 radic.

Very common my L5 or S1 radic pts ONLY hurt at the buttock.

Not worried about seeding at the L5 level screw. Moreso from a SIJ injection next to the SI fusion hardware.

 

[MitchLevi]

Not worried about seeding at the L5 level screw. Moreso from a SIJ injection next to the SI fusion hardware.

You shouldn't be near any hardware. You're right up on the sacral foramina.

Admittedly, not too up on sacral fusions so I'm not sure about how that hardware is placed. Can't imagine it's anywhere near the exiting sacral nerves.

 

[mdo1738]

You'd inject at the fusion?

Lol damn sorry I absolutely did not see that was fused

 

[Ferrismonk]

Don't inject the hardware, inject the joint. The SI fusion is just 3 screws/bolts that come in laterally. You won't seed it if you're sterile.

 

[DrMDAware]

Don't inject the hardware, inject the joint. The SI fusion is just 3 screws/bolts that come in laterally. You won't seed it if you're sterile.

I’m sure you already know there are different types of SIJ fusions. Not all are lateral nor three screws/bolts.

Now, where are my pointy shoes?

 

[oneforfighting]

Don't inject the hardware, inject the joint. The SI fusion is just 3 screws/bolts that come in laterally. You won't seed it if you're sterile.

Yeah it's the 3 screw variety

 

[clubdeac]

I don't injection TKA or THA's so I wouldn't injection an SIJ fusion either.

 

[RaceCanyon]

I don't injection TKA or THA's so I wouldn't injection an SIJ fusion either.

I don't think that is a fair comparison. With TKA and THA the joint space is removed entirely. With SIJ fusion, the native joint remains in place as the fusion essentially just stabilizes it. This stabilization may have failed or may have never effective for the patient to begin with.

 

[lobelsteve]

I don't think that is a fair comparison. With TKA and THA the joint space is removed entirely. With SIJ fusion, the native joint remains in place as the fusion essentially just stabilizes it. This stabilization may have failed or may have never effective for the patient to begin with.

Not all fusions are the same.

 

[oneforfighting]

Not all fusions are the same.

So you would inject an SI fusion?

 

[lobelsteve]

So you would inject an SI fusion?

Sure. For joints with no real mobility before the fusion, the existing problem remains.

 

[SSdoc33]

Im not injecting a fused sij either

 

[bedrock]

Im not injecting a fused sij either

Agree. SIJ RFA for cash, or nothing

 

[MitchLevi]

Agree. SIJ RFA for cash, or nothing

How much you charge?

 

[MitchLevi]

Before I send off this email:

Correct me if I'm wrong...A PA in our practice did an injection in clinic in which he billed a major joint injection for what he described as an SIJ injection. It's basically a TPI of course. He documented "SIJ injection" and gave Dex 10mg and 40mg triamcinolone. I'm super annoyed by this of course.

You can't do an SIJ injection and bill it as a major joint injection and do it blind correct?

Billed 20610.

SIJ requires imaging, contrast and provocative maneuvers.

Look at this s%%t:

 

[nynydoc]

Before I send off this email:

Correct me if I'm wrong...A PA in our practice did an injection in clinic in which he billed a major joint injection for what he described as an SIJ injection. It's basically a TPI of course. He documented "SIJ injection" and gave Dex 10mg and 40mg triamcinolone. I'm super annoyed by this of course.

You can't do an SIJ injection and bill it as a major joint injection and do it blind correct?

Billed 20610.

SIJ requires imaging, contrast and provocative maneuvers.

Look at this s%%t:

View attachment 375450

Dex and kenalog.. lol

I think it should’ve been billed trigger point injection if no imaging was used. 20610 is not acceptable for blind injection of si joint.

 

[Baron Samedi]

Dex and kenalog.. lol

I think it should’ve been billed trigger point injection if no imaging was used. 20610 is not acceptable for blind injection of si joint.

It's a shame that even if you use ultrasound guidance it's billed as a trigger point injection.

 

[pmrmd]

Dex and kenalog.. lol

I think it should’ve been billed trigger point injection if no imaging was used. 20610 is not acceptable for blind injection of si joint.

Without question a TPI.

But dex and triamcinolone is a great combo. I use it every day. Why lol?

 

[MitchLevi]

My email to him addressed it. TPI obviously, also WTF with Dex 10 and Kenalog 40.

Give me a reason why dex and Kenalog together have any sort of extra benefit.

I DO believe dex behaves differently by the way.

 

[buddababa]

My email to him addressed it. TPI obviously, also WTF with Dex 10 and Kenalog 40.

Give me a reason why dex and Kenalog together have any sort of extra benefit.

I DO believe dex behaves differently by the way.

i agree with you. i dont see a medical reasoning to combine dex and kenalog

 

[SSdoc33]

could reasonably bill a tendon/ligament injection as well. not SIJ nor large joint

 

[bedrock]

How much you charge?

$1000 for unilateral SIJ RFA, $1500 for bilateral.

That’s without IV sedation. Many of them choose IV sedation, which is another $200.

 

[MitchLevi]

$1000 for unilateral SIJ RFA, $1500 for bilateral.

That’s without IV sedation. Many of them choose IV sedation, which is another $200.

I can't charge that.

 

[bedrock]

I can't charge that.

You can charge whatever you’re comfortable with.

Do you do most of your procedure in the ASC? I could see charging less 1/3 less to do SIJ RFA in an office procedure setting but ASC time is expensive and they rightly get a portion of any cash procedure I do.

Think of it this way, most dentists will charge $1000 for a root canal/crown. Why should we, who spent triple the clinical hours in training, charge less than a dentist?

A good SIJ RFA takes time. I charge $400 cash for LESI to help out non insured people out in dire need , but that takes 10 min. SIJ RFA takes much more time including setup.

 

[MitchLevi]

You can charge whatever you’re comfortable with.

Do you do most of your procedure in the ASC? I could see charging less to do SIJ RFA in an office procedure setting but ASC time is expensive and they rightly get a portion of any cash procedure I do.

Think of it this way, most dentists will charge $1000 for a root canal/crown. Why should we, who spent triple the clinical hours in training, charge less than a dentist?

A good SIJ RFA takes time. I charge $400 cash for LESI to help out non insured people out in dire need , but that takes 10 min. SIJ RFA takes much more time including setup.

I'm 2/3 clinic and 1/3 ASC.

Also, I'm extremely weird about money. I hate talking about it. I'm cheap. Drive a 2019 Honda Accord.

I'm sure an SIJ RFA is worth $1k, but I'm stuck on $0.75 gas and $3 movie tickets.

 

[callmeanesthesia]

$760 unilateral, 1.5x that bilateral. We just looked at our allowed amounts across insurers and set the charge a tiny bit above the highest.

 

[Ducttape]

Drive a 2019 Honda Accord.

I'm sure an SIJ RFA is worth $1k, but I'm stuck on $0.75 gas and $3 movie tickets.

how can you afford such a new and expensive car?


but im with you. i wouldnt make it in PP partly because of guilt if i charged someone and the procedure didnt work... (maybe not $800, but definitely if over two grand)

 

[MitchLevi]

how can you afford such a new and expensive car?


but im with you. i wouldnt make it in PP partly because of guilt if i charged someone and the procedure didnt work... (maybe not $800, but definitely if over two grand)

I walk into a room 6w after a cash procedure (PRP usually) and if they tell me it didn't work I feel guilty no matter the amount.