2019 ASIPP guideline on interventional pain sedation

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SommeRiver said:
I have ASC shares and don't use sedation in ASC cases other than stim. There are 5 ppl in my group doing interventions and 3 of us have ASC shares. No one offers sedation. I have multiple clinic sites and do both ASC and office procedures.

I use PO Ativan once or twice a month, and for stellates (I do one every 4 months) I have used IV Ativan once, but usually PO. I have not had a problem.

I just can't understand the rationale for letting a pt demand IV fentanyl and/or Versed just bc they're anxious about a procedure. Pts RARELY even broach that subject with me and I swear I believe your bedside manner plays a role in the anxiety.

Either that or people in Georgia are just tough.

I wonder if there is a correlation between clinic volume and pt anxiety. You spend 3 to 5 min in a room with a pt and walk out and I bet that patient has anxiety about it bc they don't know you. You're all about business and gone...

No other field other than Peds or Psych is bedside manner therapeutic, and I believe that as a fact.
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I am not in Georgia. I am in Colorado. Thank you for the ad hominem attack on my bedside manner and the amount of time I spend with patients with zero information regarding either.
 
nvrsumr said:
Giving sedation is only an outlier on this forum. I think more office based docs(who use less sedation) on this forum than in the real world(i am office based). Very common practice.

Docs own shares of ASCs to get paid. Sedation pays. Partners will ask why the CRNA is in the break room instead of making everyone $
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Sedation certainly does not pay me anything of significance, if at all. In fact, it probably costs me more due to increase turnover and recovery time, and intra-operative time giving nurses orders for sedation meds. I dont even bill for sedation and not sure if it is even possible.
 
SommeRiver said:
I have ASC shares and don't use sedation in ASC cases other than stim. There are 5 ppl in my group doing interventions and 3 of us have ASC shares. No one offers sedation. I have multiple clinic sites and do both ASC and office procedures.

I use PO Ativan once or twice a month, and for stellates (I do one every 4 months) I have used IV Ativan once, but usually PO. I have not had a problem.

I just can't understand the rationale for letting a pt demand IV fentanyl and/or Versed just bc they're anxious about a procedure. Pts RARELY even broach that subject with me and I swear I believe your bedside manner plays a role in the anxiety.

Either that or people in Georgia are just tough.

I wonder if there is a correlation between clinic volume and pt anxiety. You spend 3 to 5 min in a room with a pt and walk out and I bet that patient has anxiety about it bc they don't know you. You're all about business and gone...

No other field other than Peds or Psych is bedside manner therapeutic, and I believe that as a fact.
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I dont let patient demand sedation. It is offered to them as a choice.

Do you offer them any choice?

I have zero midlevels, spend 15-30 mins on FUs, and 45min to 1hr on consults.

Again, if I was a layperson getting a 4 inch needle stuck in my back, I'd opt for sedation personally.

I support you if you feel IV sedation is not appropriate. I am at least letting them have a choice in the matter.
 
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Maybe my information is out of date on sedation reimbursement in ASC and someone else could chime in. In the past I had been told that sedation pays more than the actual procedures performed in ASC
 
nvrsumr said:
I am not in Georgia. I am in Colorado. Thank you for the ad hominem attack on my bedside manner and the amount of time I spend with patients with zero information regarding either.
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I didn't attack your bedside manner.
 
Ligament said:
I dont let patient demand sedation. It is offered to them as a choice.

Do you offer them any choice?

I have zero midlevels, spend 15-30 mins on FUs, and 45min to 1hr on consults.

Again, if I was a layperson getting a 4 inch needle stuck in my back, I'd opt for sedation personally.
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If a pt comes in with cancer pain do you automatically offer them fentanyl, or do you just start out with Norco?

Why do you automatically assume a spinal needle is going to hurt?
 
SommeRiver said:
If a pt comes in with cancer pain do you automatically offer them fentanyl, or do you just start out with Norco?

Why do you automatically assume a spinal needle is going to hurt?
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1. Depends on how theyve been treated in the past. Norco may be great for them.
2. It does hurt, 100% of the time. I've stuck needles in myself to demonstrate to patients it is tolerable but it does indeed hurt a little. Now add anxiety on top of that and some very reasonable, non-opioid dependent, non-PTSD patients are going to have a lot of fear around the procedure. Why should they carry that burden if we can alleviate it in a safe fashion?
 
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Ligament said:
1. Depends on how theyve been treated in the past. Norco may be great for them.
2. It does hurt, 100% of the time. I've stuck needles in myself to demonstrate to patients it is tolerable but it does indeed hurt...
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1. Haha. Touche...Agreed.
2. It does not hurt 100% of the time, and you've been on this forum long enough that I would surmise you've done a ton of these procedures so I can't see how you'd make that claim. I really don't see how you can say it hurts 100% of the time, especially if you're using 25g spinal needles. It is not uncommon that I have pts say, "We're done? Really?" Surely my interventional skills are no better than anyone else on here so I am left thinking that apparently people living in rural Georgia are harder than yalls pts and I must have an amazing bedside manner and sexy voice bc I am obviously doing something different.

Edit - Maybe a pain pt is extremely sensitive to body language, changes in weather patterns, daylight savings, full moons, etc...BC many are wound up like a clock, and when you make a big deal about the procedure by fasting them and doing all this other medical BS it changes their perception so when they feel general movement of a needle in their back they reflexively assume it is supposed to hurt so they flinch and jump and holler...Pain is by definition an emotional experience.
 
SommeRiver said:
1. Haha. Touche...Agreed.
2. It does not hurt 100% of the time, and you've been on this forum long enough that I would surmise you've done a ton of these procedures so I can't see how you'd make that claim. I really don't see how you can say it hurts 100% of the time, especially if you're using 25g spinal needles. It is not uncommon that I have pts say, "We're done? Really?" Surely my interventional skills are no better than anyone else on here so I am left thinking that apparently people living in rural Georgia are harder than yalls pts and I must have an amazing bedside manner and sexy voice bc I am obviously doing something different.
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RE: 2. It hurts ME 100% of the time I stick a needle in myself to demonstrate to the patient it is not too bad. Its not bad, but it does hurt. Take a 25ga needle and stick it in your arm today. Does it not hurt at least a little? If not, you are fortunate.

Heres the situation
patient: "Im scared of the needle. Sounds terrible"
me: "Its really not too bad. *sticks 25 ga needle in arm*"
Patient: "you are crazy but you did not pass out in pain so ok not so bad"
 
Ligament said:
RE: 2. It hurts ME 100% of the time I stick a needle in myself to demonstrate to the patient it is not too bad. Its not bad, but it does hurt. Take a 25ga needle and stick it in your arm today. Does it not hurt at least a little? If not, you are fortunate.

Heres the situation
patient: "Im scared of the needle. Sounds terrible"
me: "Its really not too bad. *sticks 25 ga needle in arm*"
Patient: "you are crazy but you did not pass out in pain so ok not so bad"
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...well I guess I'm trying to think about the last time I did an arm injection. The lower back or cervical spine isn't the arm so why mention that?

By that rationale I would say EMG hurts 100% of the time bc the APB needle hurts, even though most other sites don't hurt.

Also I would encourage you not to ever stick yourself to prove something to a pt...That's completely insane dude.

Stick an acupuncture needle in your eye and that would hurt too.
 
SommeRiver said:
...well I guess I'm trying to think about the last time I did an arm injection. The lower back or cervical spine isn't the arm so why mention that?

By that rationale I would say EMG hurts 100% of the time bc the APB needle hurts, even though most other sites don't hurt.

Also I would encourage you not to ever stick yourself to prove something to a pt...That's completely insane dude.
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I know we are both trying to do the right thing for the patient. 🙂
 
drusso said:
The facility fee certainly does!
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Ligament said:
Sedation certainly does not pay me anything of significance, if at all. In fact, it probably costs me more due to increase turnover and recovery time, and intra-operative time giving nurses orders for sedation meds. I dont even bill for sedation and not sure if it is even possible.
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usually anesthesia services are billed by a separate corporate entity. This may be a local anesthesia group providing sedation at your ASC. This may be a superpartner in the ASC who set up the ASC and anesthesia group corporate entities who hires the CRNA and keeps the profits over CRNA salary. This may be separate anesthesia services entity that all partners in the ASC get a piece of the pie.

I am sure that there are some docs on this forum who can speak to the average reimbursement for anesthesia services in the ASC for common pain procedures. Outside of my wheelhouse.
 
nvrsumr said:
usually anesthesia services are billed by a separate corporate entity. This may be a local anesthesia group providing sedation at your ASC. This may be a superpartner in the ASC who set up the ASC and anesthesia group corporate entities who hires the CRNA and keeps the profits over CRNA salary. This may be separate anesthesia services entity that all partners in the ASC get a piece of the pie.

I am sure that there are some docs on this forum who can speak to the average reimbursement for anesthesia services in the ASC for common pain procedures. Outside of my wheelhouse.
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Thanks. I dont use a CRNA or MDA/DOA...just me and the nurse.
 
For those of you offering sedation, are you explaining/consenting the patient that closed claims analysis indicates that there is 2x likelihood of bad things happening during cervical procedures? I don't remember the data for lumbar. When I tell my patients this data, the only patients who still want sedation are the ones who are incredibly anxious with lots of psychiatric overtones, and they never get better no matter what medication/therapy/injection is thrown at them. I think it is an enormous red flag if a patient is demanding sedation. And there's obviously data that people with depression/anxiety do not respond well to any sort of interventional procedure we do, so maybe these patients should not be getting an injection at all. "Require" sedation. If someone REQUIRES sedation, I have to wonder whether the injection is going to help at all/if it should be offered at all.
 
MD87 said:
For those of you offering sedation, are you explaining/consenting the patient that closed claims analysis indicates that there is 2x likelihood of bad things happening during cervical procedures? I don't remember the data for lumbar. When I tell my patients this data, the only patients who still want sedation are the ones who are incredibly anxious with lots of psychiatric overtones, and they never get better no matter what medication/therapy/injection is thrown at them. I think it is an enormous red flag if a patient is demanding sedation. And there's obviously data that people with depression/anxiety do not respond well to any sort of interventional procedure we do, so maybe these patients should not be getting an injection at all. "Require" sedation. If someone REQUIRES sedation, I have to wonder whether the injection is going to help at all/if it should be offered at all.
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Arent most of if not all the closed claims data revolving around deep/MAC sedation with non responsive patients?

Again, patients are given a choice. They do not bust through the door demanding anything at all.

I've had a few patients treated at other clinics who expect MAC sedation with propofol, I always tell them no.
 
You guys are conflating anesthesia with propofol and moderate sedation with versed/fentanyl in regards to facility profit. There is no profit margin for moderate sedation services. There is no indication for pain procedures under anesthesia.
 
BobBarker said:
You guys are conflating anesthesia with propofol and moderate sedation with versed/fentanyl in regards to facility profit. There is no profit margin for moderate sedation services. There is no indication for pain procedures under anesthesia.
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Yes. What would be a ball park estimate for MAC in an ASC for a standard pain procedure like an LESI?
 
My argument is more for medical necessity than for reimbursement, but the people running propofol are definitely doing it for reimbursement bc that's the only thing that would possibly make sense in that scenario. I don't think fentanyl and Versed would make you any money.
 
Ligament said:
I dont let patient demand sedation. It is offered to them as a choice.

Do you offer them any choice?

I have zero midlevels, spend 15-30 mins on FUs, and 45min to 1hr on consults.

Again, if I was a layperson getting a 4 inch needle stuck in my back, I'd opt for sedation personally.

I support you if you feel IV sedation is not appropriate. I am at least letting them have a choice in the matter.
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What if u tell them the truth? That the risks of sedation out weigh the benefits? That’s easy for a layperson to understand
 
The doc and the asc are in network with the patients insurance. The anesthesia services are billed separately and not in network so the patients may be stuck with a large surprise bill and/or the insurance will pay a negotiated percentage of charges for the anesthesia services

Even if super conservative and use the Medicare numbers for MAC could theoretically gross 100+k/month
 
I don't use a lot of sedation, but when I do I would say it does on average pay about 1/4 to 1/3 of the actual procedure ......So one who does it all the time could certainly make a nice chunk of change
 
I am leaving a practice where sedation was commonplace, even for TPI's and joint injections. I refused to operate like that and did not want to become a partner partially because of this amongst other reasons. I am now going to a practice that does not sedate for anything other than implants or for SCS trial/Kypho if patient wants to do it in a surgery center. My question for everybody on here is, if a patient is already on meds and performing a RFA, epidural, etc would be 100% appropriate for their issue and they refuse to do a procedure with anything other than IV sedation, but say they will just keep coming in to get their meds renewed, how many people are telling them to go elsewhere and refusing to see them in follow up? My last practice would not allow patients to come in for a med follow up if they were scheduled for a procedure unless they had a contraindication. Not sure how my next place handles this, but I want an idea of how others approach this situation.
 
Sedation for TPI = I just had a stroke.

The rest of your post I don't comprehend bc this has NEVER happened to me. I've offered procedures to pts and they have said no, but I've never been at an impasse with a pt over sedation. It hasn't ever happened and I don't sedate.

I can't stand it. The ppl offering sedation for TPI should lose their license now, so that I'll still be able to make a living 10 yrs from now bc dudes like this are going to screw all of us. If you're reading this and you sedate for TPI I hate you, and I hope you get a kidney stone.
 
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RM38 said:
I am leaving a practice where sedation was commonplace, even for TPI's and joint injections. I refused to operate like that and did not want to become a partner partially because of this amongst other reasons. I am now going to a practice that does not sedate for anything other than implants or for SCS trial/Kypho if patient wants to do it in a surgery center. My question for everybody on here is, if a patient is already on meds and performing a RFA, epidural, etc would be 100% appropriate for their issue and they refuse to do a procedure with anything other than IV sedation, but say they will just keep coming in to get their meds renewed, how many people are telling them to go elsewhere and refusing to see them in follow up? My last practice would not allow patients to come in for a med follow up if they were scheduled for a procedure unless they had a contraindication. Not sure how my next place handles this, but I want an idea of how others approach this situation.
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Good on you for leaving. I think sedation for RF is reasonable - I’m a firm believer that it can be done under local only for most people as long as you give the local enough time to work, but I’ve had a few patients recently who seem resistant to local anesthetic. I’ve used 2% lidocaine (normally use 1%), with bicarbonate, in higher than normal volumes, allowing 2+ Minutes and while my patients would normally not even notice the ablation these few people were struggling to make it through, clearly feeling the burn. All mentioned a history of dentists having a hard time getting them numb too. And I think for people with bad needle phobia, a little oral sedation is reasonable prior to an epidural. But the people who demand to be totally put out for a caudal are poor candidates for procedures, and I suspect are using medications to manage psychological issues, not just pain.
 
RFA is 1cc of 2% lido with 2 min before lesion. I do not do more than 3 levels in the lower back or 2 in the neck on any one day. That's at most 4 needles in the back and 3 in the neck.

Give your pts credit; they're fine if you inject this way.
 
SommeRiver said:
RFA is 1cc of 2% lido with 2 min before lesion. I do not do more than 3 levels in the lower back or 2 in the neck on any one day. That's at most 4 needles in the back and 3 in the neck.

Give your pts credit; they're fine if you inject this way.
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I do 5 subq, and drop 2 prior, 2 after w/20 depo

17 coolief
 
SommeRiver said:
Sedation for TPI = I just had a stroke.

The rest of your post I don't comprehend bc this has NEVER happened to me. I've offered procedures to pts and they have said no, but I've never been at an impasse with a pt over sedation. It hasn't ever happened and I don't sedate.

I can't stand it. The ppl offering sedation for TPI should lose their license now, so that I'll still be able to make a living 10 yrs from now bc dudes like this are going to screw all of us. If you're reading this and you sedate for TPI I hate you, and I hope you get a kidney stone.
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Yeah I was stunned when I saw this happening after I started working there. Literally every other pain doc I talked to about it advised me to leave. It was with propofol too and also using flouro for everything. It was all about the billing and apparently medicaid was paying for it. They tried to get me to operate this way and I told them no and to fire me if they didn't like it. Tried to make it work due to location, but it just wasn't going to happen. I had a very large medicaid population, many of whom absolutely refused any procedures without being sedated due to anxiety issues or just lack of desire to feel any discomfort what so ever. I even discussed that they need for this was totally non-sensical as I was using was smaller needle than the IV for basic stuff in addition to additional risk from sedation, but they didn't care and kept doing it at the other offices. I did many of my procedures without sedation and patients were fine. Most that had previously done procedures under sedation would be surprised at how easy the procedure was to tolerate and decided to not get sedated for anything anymore because it. I will not sedate with the exception of the occasional PO valium and I will make significantly more at my next place than I do here.
 
RM38 said:
Yeah I was stunned when I saw this happening after I started working there. Literally every other pain doc I talked to about it advised me to leave. It was with propofol too and also using flouro for everything. It was all about the billing and apparently medicaid was paying for it. They tried to get me to operate this way and I told them no and to fire me if they didn't like it. Tried to make it work due to location, but it just wasn't going to happen. I had a very large medicaid population, many of whom absolutely refused any procedures without being sedated due to anxiety issues or just lack of desire to feel any discomfort what so ever. I even discussed that they need for this was totally non-sensical as I was using was smaller needle than the IV for basic stuff in addition to additional risk from sedation, but they didn't care and kept doing it at the other offices. I did many of my procedures without sedation and patients were fine. Most that had previously done procedures under sedation would be surprised at how easy the procedure was to tolerate and decided to not get sedated for anything anymore because it. I will not sedate with the exception of the occasional PO valium and I will make significantly more at my next place than I do here.
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You're doing the right thing, and you're also pointing out a simple fact about Medicaid - Not only does it not pay you what you're worth, those pts are the most entitled individuals of all time.

Fluoro + propofol for TPI = Jail + Fines.
 
SommeRiver said:
You're doing the right thing, and you're also pointing out a simple fact about Medicaid - Not only does it not pay you what you're worth, those pts are the most entitled individuals of all time.

Fluoro + propofol for TPI = Jail + Fines.
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Socialism pays for TPI's with propofol and fluoro and punishes direct access pain physicians who charge 1/10 the amount in cash without sedation or bogus imaging localization.
 
drusso said:
Socialism pays for TPI's with propofol and fluoro and punishes direct access pain physicians who charge 1/10 the amount in cash without sedation or bogus imaging localization.
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socialism is the reason my sandwich tastes like sh$t today.

also, my car wouldnt start because of the SOS differential.

my cat got sick because of hospital lobbying efforts
 
drusso said:
Socialism pays for TPI's with propofol and fluoro and punishes direct access pain physicians who charge 1/10 the amount in cash without sedation or bogus imaging localization.
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that has less to do with socialism and more to do with greed from hospitals (and possibly complicit physicians)
 
drusso said:
Socialism pays for TPI's with propofol and fluoro and punishes direct access pain physicians who charge 1/10 the amount in cash without sedation or bogus imaging localization.
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I have never heard of Private practice Docs doing unscrupulous thing before
 
Ligament said:
I dont let patient demand sedation. It is offered to them as a choice.

Do you offer them any choice?

I have zero midlevels, spend 15-30 mins on FUs, and 45min to 1hr on consults.

Again, if I was a layperson getting a 4 inch needle stuck in my back, I'd opt for sedation personally.

I support you if you feel IV sedation is not appropriate. I am at least letting them have a choice in the matter.
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I forget, are you salaried?
 
I have two other pain clinics on my street. About 10 other clinics within a 10 mile radius. I offer (moderate/conscious) sedation for the same reason dentists offer sedation: patient satisfaction. Not routine, but if its a service that patients request and I can give it safely, what's the matter?

For what it's worth, I do my procedures in the office and contract out the sedation. No financial gain for me.

It sometimes seems that we work ourselves into a tizzy on this board. No opiates, No NSAIDs, No muscle relaxers, send out to PT, send out to psych, No sedation for procedures, max 3 steroid injections per year, PRP/BMAC is snake oil, etc, etc.

I say stay within guidelines and don't milk the patients, but do what you can to help them. Everything is a risk/benefit discussion
 
the problems with "routine" sedation:
1. increased cost to healthcare
2. increased risk to patient both from sedation and from procedure
3. increased utilization of healthcare resources above and beyond 1 and 2.
4.
 
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