Anesthesia for ESI

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nycitygas

nycitygas

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Has anybody seen the announcement that medicare is no longer reimbursing anesthesia care for pain procedures? Commercial insurances will follow I assume?

In my area, the local pain MDs employ their own CRNAs and every patient gets snowed with propofol. The all receive large out of network anesthesia bill.
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I went to residency with a guy who was making over 7 figures doing ESIs with his own propofol sedation in Texas. This is a cut I can get behind if it actually takes pressure off legitimate anesthesia codes and practices.
 
The chronic pain population are also not the same as a normal person. Often you have psych co-morbidities and other factors that require some light sedation in order to help these people. But yeah generally most private practice folk are just doing it to make more money. Private practice pain is really shady stuff most of the time especially in the area I am in.
 
I had several facet blocks a few years back - all with versed/fent sedation done by sedation nurses in our own pain clinic. All went well. I was surprised when a pain doc in another practice (frequent SDN guy) told me he gives nothing to his patients when he does these blocks.

Recently, I had an SI and facet block done with absolutely zero sedation by one of our pain docs. A couple little sticks with local, a little achy with the steroid injection - and that was it. The whole thing lasted less than five minutes. WTH do I need sedation for? I'm a convert.

I can't imagine giving (and billing) MAC for these kinds of things. Total overkill and obviously $$$ oriented.
 
jwk said:
I had several facet blocks a few years back - all with versed/fent sedation done by sedation nurses in our own pain clinic. All went well. I was surprised when a pain doc in another practice (frequent SDN guy) told me he gives nothing to his patients when he does these blocks.

Recently, I had an SI and facet block done with absolutely zero sedation by one of our pain docs. A couple little sticks with local, a little achy with the steroid injection - and that was it. The whole thing lasted less than five minutes. WTH do I need sedation for? I'm a convert.

I can't imagine giving (and billing) MAC for these kinds of things. Total overkill and obviously $$$ oriented.
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Simple eye and pain procedures are an absolute waste of anesthesia resources for the vast majority of cases. These people need a good preop discussion of what to expect and some hand holding during the procedure. Maybe a wiff of something.

Manage expectations from the start. I don’t know how many times I’ve had to tell a preop nurse not to tell one of these patients they will be “asleep”.

You want to run a prop gtt at 100+ on a patient in the prone while questionably monitored be my guest. I’m not playing that game.
 
DocMcCoy said:
Simple eye and pain procedures are an absolute waste of anesthesia resources for the vast majority of cases. These people need a good preop discussion of what to expect and some hand holding during the procedure. Maybe a wiff of something.

Manage expectations from the start. I don’t know how many times I’ve had to tell a preop nurse not to tell one of these patients they will be “asleep”.

You want to run a prop gtt at 100+ on a patient in the prone while questionably monitored be my guest. I’m not playing that game.
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I won't lie, if/when I ever need cataracts or any other eye procedure done, stick an LMA in. No way I could tolerate it.
 
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DocMcCoy said:
Fair enough. I can tolerate a hell of a lot with 2 of versed. Give me that any day to avoid a GA for a cataract.
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I've never had versed personally, and I'd probably need more than I'd want to get through it (think GI-led sedation levels for scopes).
 
We are currently giving sedation for pain blocks (versed, a bump of propofol). Sounds like some of my afternoons may be getting lighter.
 
Admittedly I am not very familiar with billing, but if they gave propofol wouldn’t they bill for general and not mac?
 
Your eyes will be so dilated you won't be able to see the surgeon and his instruments so close you won't see those either.
 
jwk said:
I had several facet blocks a few years back - all with versed/fent sedation done by sedation nurses in our own pain clinic. All went well. I was surprised when a pain doc in another practice (frequent SDN guy) told me he gives nothing to his patients when he does these blocks.

Recently, I had an SI and facet block done with absolutely zero sedation by one of our pain docs. A couple little sticks with local, a little achy with the steroid injection - and that was it. The whole thing lasted less than five minutes. WTH do I need sedation for? I'm a convert.

I can't imagine giving (and billing) MAC for these kinds of things. Total overkill and obviously $$$ oriented
Click to expand...

Same. All my medial branch blocks w/ zero sedation. Drove myself there and back home.
 
We do all our pain docs' blocks with sedation... Even trigger points. I just give a whiff of propofol and that's enough. Completely unnecessary of course and some insurance companies are blocking reimbursement if there's no appropriate comorbidity to justify patient receiving anesthesia. That's being said, some of these pain pts are ****oo and would not do well without being sedated.
 
Ridiculous. If you need anesthesia for an ESI, you may as well start doing it for flu shots too.

The idea that pain patients are this special breed that can't tolerate an effing trigger point without sedation is bogus. In ten years I've probably used sedation on fewer than 100 non-kypho patients out of more than 15000. A rare RF patient got Valium. But I don't stick needles in bad candidates.

If a pain patient *needs* sedation, central sensitization is the issue. Needle based procedures are almost universally a waste of time. Unless, of course, you're a businessman, not a doctor. Even PT is a waste on these people because exercise "makes it worse". Until you fix the problem between the ears, you'll never fix the problem in their back, butt, foot, elbow, shoulder, neck, external ear, left finger...
 
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