1st year in Practice

[DRacula]

I forget what a good resource this website can be and forget to log-on for many months at a time... I hope there are some Attendings out there that can offer some advice.

So far within my first year of practice, it seems I am not making what my bosses have expected of me. I am still building my patient-base, which I think should be expected since I started my practice approximately 8 months ago, but I am the first non-interventionalist they have hired, so I think it is possible they are used to higher revenues, generally, from their physicians. My practice is MSK but I see mostly back and neck pain. I perform Osteopathic Manipulation and I do NCS/EMG studies.
Anyhow, in an effort to increase referrals, they have asked me to become a physician who declares Maximum Medical Improvement. I have been researching this on the CMS website and it seems like it is a quick training (3-day course) and apparently reimbursement is profitable. I have always been told I am very "nice" and "empathetic," which are attributes I pride myself on. Does crossing over into the medico-legal sector of medicine require a more "ruthless" personality? Does become this type of physician preclude being subpoenaed or court-time in general?

Secondly, I see many patients with tendinosis and although I received training for steroid injections during my training (for tendinitis, joint injections, and trigger point injections), I never once saw the application of PRP or sclerotherapy in my training. I have been curious on how to add this to my practice and in researching the literature, it seems PRP really only has strong evidence for Epidcondylitis (which I do see often) while Sclerotherapy could be used for the remainder of the tendonopathies [please correct me if I am wrong]. It seems for PRP, I'd need some sort of centrifuge, and then know how to use it and how to separate the leucocyte-dense PRP... my question is, Where does one learn how to do this? (not just physically how to do the injection, which, relatively, is the least of my concern, but how to prepare it correctly and safely, where to buy the machine (is it just any centrifuge machine?) and how to bill correctly).

Sclerotherapy seems to be a general term as well. I haven't found a concise description on where to inject exactly (myotendinous junction, attachment, tendon itself, where ever it hurts?) There are also multiple concentrations available as well as combination of products that get injected. How does one choose? One other physiatrist that I work with says he use what they always used in training (A glucose/saline solution), but he is very short with me and says I should use what I am comfortable using. (He's not the 'teaching'-type).

I think I just need one or two more months of returning to residency to get a targeted rotation on things I wish I knew.
... and maybe a whole other month on billing and inurance!

Sorry for the parenthesis within the parenthesis, questions within questions, and probably run-on sentences... I'm typing this quickly between patients due to a cancellation this AM.

Thanks to anyone out there willing to help!

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[kumar28]

if you dont mind me asking how much are you making your first year out?

 

[Paddington]

... and maybe a whole other month on billing and inurance!

I always tell people that billing and insurance is something you need to be a master of before you graduate from residency. If you pay attention to what your attendings are doing, it's easy enough to pickup (and supplement with online resources, billing/coding apps, etc.) The world has changed, and not in the past few decades, but just in the past 2-3 years. They will not bring you on with a generous guaranteed salary for 2-3 years. You'll get a salary for 1 year maybe, and right from the first few months they'll be taking a close look at your collections. By mid-year, that will dictate whether you stay on and what kind of deal you get.

To answer your question, MMI is a work comp concept. Often the patients are seen for a separate office visit to declare them MMI, and that note has a certain billing code, though in states that I'm familiar with I have not heard of that being particularly lucrative. Usually, the treating physician declares them MMI. However, in many cases the patient is declared MMI by an IME physician. IME's can be quite lucrative if you're "working for" (i.e. getting the referrals from) the insurance companies.

 

[RUOkie]

You do not have to be ruthless to be a good IME doc. You need to be HONEST. Even when that is not beneficial to the patient. The hardest thing to do when dealing with the work comp system is telling a patient what they don't want to hear, and have them leave smiling.

I do a lot of medico-legal work. I highly recommend the courses given by Dr. Ranavaya and Dr. Mueller. Rondinelli knows his stuff better than anyone (he was the Editor in Chief of the 6th Ed.of the AMA guides), but he is not the best lecturer. Ranavaya is a hoot. He has 4-5 courses on Impairment ratings a year all throughout the country.

Doing "new patient impairment ratings" (99456) pays pretty well in most states. Check the fee schedule first. IMEs are very lucrative in the right situation. Again, you need to be honest,and not only give opinions in the favor of either plaintiff or defense.

I had a conversation with an attorney today about a case he wishes to send to me. I did NOT tell him that I would tell him what he wanted to hear. I told him I'd review the records, see the woman, and give an HONEST opinion. Good attorneys like that.

 

[Doctodd]

Technically there are no codes for PRP cuz nobody reimburses it. There are codes, but it's a waste of time to use them.

 

[SSdoc33]

dont do prolo.

ive said this before, but any medical technique where you have to go to Honduras to become proficient doesnt exactly scream "legitimate". its on the fringe of quackery. not quite there, but almost. and the true indications are rare: SIJ instability, maybe pubic symphysis pain.

PRP is a different story, but you will have to get patients to pay out of pocket, and it takes a lot of leg work to set up. that is something you'd have to arrange with your practice. not exactly a huge money-maker if that is their aim.

do the medico-legal stuff. disability evals and IMEs are fine, and you are trained to be an expert in it via your PMR training. continue with EMGs. joint injections and soft tissue isjections with u/s as long as it pays. most importantly, see more patients faster. admin is not gonna complain as long as you bring home the bacon, and if you do the above, you SHOULD do fine.

best of luck

 

[Disciple]

You do not have to be ruthless to be a good IME doc. You need to be HONEST. Again, you need to be honest,and not only give opinions in the favor of either plaintiff or defense.

I had a conversation with an attorney today about a case he wishes to send to me. I did NOT tell him that I would tell him what he wanted to hear. I told him I'd review the records, see the woman, and give an HONEST opinion. Good attorneys like that.

Agree with this.

If you get a reputation as being one sided, your medical opinion will not carry weight in your med-legal community, and you will not be valuable to your referral sources.

They will stop seeking out your services.

 

[DRacula]

I am so grateful for these responses; this advice is very helpful. Especially about the courses available!

I have found a little more on what they have in mind. Apparently, they have a good lawyer who will be sending referrals if I decide to go that route. I asked to meet the lawyer, but I think I feel equipped to follow this through and see how it goes.
I really do just want to be a good doc... honest I can do. I've gotten faster since I started, but of course, I aim to be even faster than that. I think my progress notes are "too perfect," and I can probably cut corners there. And yes, in hindsight, I should have been much more aggressive in residency learning about billing/coding. I have told all of my juniors as much in the hopes that they don't repeat the same mistake I did in assuming it is to be learned later.

Thanks again!

 

[Gauss]

I do not envision this as reimbursable soon. More trouble than it's worth. Let someone else in the practice have the privilege.

It hasn't been reimbursable since the T code was added several years ago. That's why you charge cash up front. It's a bundled, all inclusive code. What are you talking about?

 

[Gauss]

"Cash up front," is what I'm talking about. What are you talking about? If you bill Medicare share with us how that plays out over a few years. You know, the audits, repayment and penalties. Lots of fun, huh? Seriously if you have a cash only practice that's terrific, but it's not feasible throughout the country.

you cannot submit a T code for reimbursement so you can't bill medicare, that's why I said you charge cash. You don't have to be a cash only practice to do PRP, it's a portion of a balanced a sports and MSK practice. Working only within the confines of what insurance pays will drive you insane and harm your patients.

 

[RUOkie]

"Cash up front," is what I'm talking about. What are you talking about? If you bill Medicare share with us how that plays out over a few years. You know, the audits, repayment and penalties. Lots of fun, huh? Seriously if you have a cash only practice that's terrific, but it's not feasible throughout the country.

T-codes are tracking codes. You are allowed to charge cash for it, but still have to submit to Medicare with the T-codes knowing you will get zilch from Medicare. I have elected not to purchase the PRP equipment for financial reasons as well, and just refer the rare patient to a doc who I know does it.

 

[Doctodd]

T-codes are tracking codes. You are allowed to charge cash for it, but still have to submit to Medicare with the T-codes knowing you will get zilch from Medicare. I have elected not to purchase the PRP equipment for financial reasons as well, and just refer the rare patient to a doc who I know does it.

As an individual in a group practice setting 20 plus years in practice, you pick and choose. It is unfeasible on many levels to work within those confines. As an owner, employer, and educator I am selective in what I do. I am not comfortable with PRP. Perhaps you have some literature supporting a wider use of this modality? An unusual FVL+ case remains embedded in my mind.

Just send to a doctor who knows what he is doing and has made the significant time and money investment. I do them and am very comfortable with it. I know who will respond and who probably won't.

 

[nvrsumr]

Just send to a doctor who knows what he is doing and has made the significant time and money investment. I do them and am very comfortable with it. I know who will respond and who probably won't.

Any experience with TFCC tear and PRP? Have a patient Im looking at poking. Surgeon already did a "failed" osteotomy on one side and wont touch the other.

 

[Gauss]

difficult to see and you won't be able to confirm your needle is in the tear so hard to know what you're injecting into. chronic case with prior osteotomy may be more OA.
With that being said, if no other options are available and he's had a surgery, I'd do it, even if it spreads into the joint

 

[Doctodd]

Any experience with TFCC tear and PRP? Have a patient Im looking at poking. Surgeon already did a "failed" osteotomy on one side and wont touch the other.

Not specifically....What do you expect the PRP to do alone?

 

[nvrsumr]

Difficult case. Nice lady. No narcs.Independent contractor without insurance who was in auto accident. Subsequent wrist pain and ortho did surgery 7 mos ago with worsening symptoms. Told her X-rays look good nothing else to offer.

MRI from yesterday shows lunate chondromalacia, bone cyst and edema. Will be a ulnar lunate triquetral joint injection on post surgical side. Will do dx block first. Don't know if i believe in magic blood yet but she has limited options so thought worth a try and of interest to me clinically.

As an aside just got Wc denial for prp for pes anserine bursitis. Lit up on MRI and 100% relief times 7 days after us guided injection but internist insurance co hack says "not ready for prime time" based on one positive study for patella tendinitis.

Anyone have any good prp patella tendon papers to stuff in his wallet next to insurance co blood $$ ?

 

[Doctodd]

PRP alone won't significantly grow cartilage and/or resolve chondromalacia and bone marrow edema....especially in older patients. Might give her a few weeks relief. Bursitis is a different animal due to the anatomy. There is an epicondylitis paper with some cred. I dont know it off top of my head.

 

[RUOkie]

As an aside just got Wc denial for prp for pes anserine bursitis. Lit up on MRI and 100% relief times 7 days after us guided injection but internist insurance co hack says "not ready for prime time" based on one positive study for patella tendinitis.

Anyone have any good prp patella tendon papers to stuff in his wallet next to insurance co blood $$ ?

don't think there is any literature supporting the use of PRP for pes anserine bursitis. Not saying it would not help, just no studies.

As another aside, how do you relate pes anserine bursitis to a work incident? What was the injury?

 

[nvrsumr]

Thanks for the responses. the wrist is a tough case

Cant remember the mechanism of injury but I treat the medical issues and let the bean counters work out causality. SInce they denied will go with CRPS dx which will lead to whole person impairement and bigger settlement. Dumb

 

[RUOkie]

Thanks for the responses. the wrist is a tough case

Cant remember the mechanism of injury but I treat the medical issues and let the bean counters work out causality. SInce they denied will go with CRPS dx which will lead to whole person impairement and bigger settlement. Dumb

I'm sorry, but that kind of response really pisses me off (as a doc who does a lot of occ med.) If you choose to see work comp patients, it is your job to address issues like causality, and NOT use made up diagnoses just to get paid. There is a reason that the reimbursement is better for comp. There is more work involved.

How on earth do you go from pes anserine bursitis to CRPS? Do you even read the Colorado Comp Guidelines?

/rant

 

[nvrsumr]

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