Anesthesia trained in Ortho Group

[agolden1]

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Exploring an alternative gig with a large-ish orthopedic group.

Presently, the interventional pain doctors with the group are physiatry trained. My background training is in anesthesia.

Typically, as some of the new physiatry trained docs have come in, they have done EMGs for the practice as they build their interventional practice. As I don't do EMGs, the current physicians with the group have been asking me if there is anything else I can do to bring value to the group as I build my practice. I can do some anesthesia locums, but this would likely only benefit me and not the orthopedic group. While I offer some different interventions some of the other docs there don't at the present, I can't really think of anything that different that I could offer to the practice off the top of my head.

Has anyone anesthesia trained encountered this issue? What did you end up offering?

 

[Ferrismonk]

EMGs don't pay very well I believe. That's not a huge revenue generator. Sell them on your willingness to market aggressively and offer new procedures. You could also get the other PMR pain guys to refer you cases they don't do.

 

[RoloTomassi]

Ketamine infusion for all their CRPS patients?

 

[Ducttape]

you could do the anesthesia for their cases at ASC.

 

[Agast]

If they really need you to do anything other than interventional pain, they aren’t ready to bring on another pain doctor.

Or you could run a Preop evaluation clinic. We had to rotate through that during anesthesiology residency, basically did the H&P, coordinated labs and cardiology clearances.

 

[callmeanesthesia]

Our ASCs and hospitals are desperate for anesthesia coverage. Our surgeons aren’t able to be fully productive because they don’t have block time for their cases, due to anesthesia availability. One of the ASCs is so desperate they offered me $425 an hour for anesthesia locums. So if your schedule isn’t full, you can absolutely benefit the surgeons with locums coverage.

 

[SpineandWine]

- See if they'll let you 1099 for their group with 50% collection as your practice is building. Then you can 1099 elsewhere while your practice grows.
- Can see if they'll salary you for management of catheters in post-op period such as epidural or peripheral catheters (as those don't reimburse well but provide good service) - you may be able to contract with hospital

 

[agolden1]

Anesthesia locums may be a possibility. I just wasn't sure if there would be some kind of conflict of interest there. Interesting to see some others making this recommendation though.

 

[TIVAndy]

if it's a large ortho group and you are doing procedures at their ASC, you really shouldn't be proving anything to the group.

 

[agolden1]

if it's a large ortho group and you are doing procedures at their ASC, you really shouldn't be proving anything to the group.

Proving or providing? Sorry just unclear what you meant here.

 

[callmeanesthesia]

Proving or providing? Sorry just unclear what you meant here.

They’d be making enough dough off the facility fees on your procedures that you shouldn’t let them tell you you aren’t pulling your weight.

 

[SSdoc33]

this is easy.

just go back and do a PM&R residency. i dont see the issue.

honestly, trying to make the anesthesia side hustle work would be a big lift. those ortho guys wont be interested in changing their business model. if you are good with MSK stuff, then you will essentially be functioning like one of their physiatrists. the lack of EMG shouldnt be that big a deal.

that being said, you may be seeing a lot of large joint stuff. while those arent lucrative individually, a 99204 + 20610 + 77002 for every joint adds up if you can get quick with them

 

[bedrock]

that being said, you may be seeing a lot of large joint stuff. while those arent lucrative individually, a 99204 + 20610 + 77002 for every joint adds up if you can get quick with them

Not criticizing, just asking the question.

I thought it was a good way to get audited if you frequently bill a level 4 patient visit together with a procedure. Particularly a level 4 new patient plus a procedure.

Part two of my question concern the level of the code (3 vs 4). I could somewhat understand charging a level 4 new patient together with a same day epidural procedure.

I guess I don’t see how you can justify a level 4 new plus a peripheral joint injection?

All the orthos charge level 3 for their office visits,( even with a peripheral joint injection that day) because let’s be honest, a knee injection is a lower level of analysis, time, and risk compared to a CESI.

 

[SSdoc33]

Not criticizing, just asking the question.

I thought it was a good way to get audited if you frequently bill a level 4 patient visit together with a procedure. Particularly a level 4 new patient plus a procedure.

Part two of my question concern the level of the code (3 vs 4). I could somewhat understand charging a level 4 new patient together with a same day epidural procedure.

I guess I don’t see how you can justify a level 4 new plus a peripheral joint injection?

All the orthos charge level 3 for their office visits,( even with a peripheral joint injection that day) because let’s be honest, a knee injection is a lower level of analysis, time, and risk compared to a CESI.

you can always find ways to bill a level 4 🙂

i will often times see a patient in clinic, focus primarily on their hip, but they may have concomitant bursitis or lumbar DDD. thats a 99204 and then a separate visit for the 20610 + 77002.

if they are referred for a hip injection and im meeting them for the first time, ill ask the referring docs to say that the referral was for a "consult" for a hip injection. ill do a note AND bill the 99204 + the procedure. throw in some fluff about ddd if i have to.

orthos dont want to add any complexity to their documentation b/c it takes time and they feel like its not worth it for them b/c they make their money in the OR. but they are leaving a ton of money on the table. if you are seeing 100 patients/month and billing all level 3s instead of level 4s, you do the math. it adds up.

it isnt worth my time to do a hip injection under flouro, but it IS if i am getting a consult along with it. the consult pays more than the injection.

as far as an audit? no idea. been doing it this way x 15 years and i havent heard a peep from anyone

 

[GlowInTheDark]

With new E/M the hip issue is easily a chronic issue with exacerbation. Review imaging, others notes, discuss consideration of radicular, and risk/benefits of procedure. Easy level 4 without question.

 

[Ducttape]

2 acute illnesses or 1 acute and 1 stable with review of 3 medical literature.


would not say easy. easy means one gets cavalier regarding billing.

 

[GlowInTheDark]

2 acute illnesses or 1 acute and 1 stable with review of 3 medical literature.


would not say easy. easy means one gets cavalier regarding billing.

1 chronic that is unstable. Almost everything we deal with is a chronic problem that unstable.

Easy in the sense that what I described meets criteria for moderate complexity.

 

[DrMDAware]

Not trying to get into semantics but what’s the difference between “not stable” and “not improving”?

 

[mdo1738]

Not trying to get into semantics but what’s the difference between “not stable” and “not improving”?

"Not improving" could mean it is either stable or worsening. "Not stable" means it is probably worsening (though technically it could also mean it is improving). The implied meaning for both is that "not improving" means it isn't getting better but not necessarily worse, while "not stable" means it is worsening. And thus "not stable" is implied to be worse (and thus higher complexity) than "not improving".

 

[agolden1]

They’d be making enough dough off the facility fees on your procedures that you shouldn’t let them tell you you aren’t pulling your weight.

Makes sense. The group is eat what you treat from day 1 though, so doing some anesthesia may be a way to keep myself afloat as I build things up.

Thanks for the other discussions on billing as well everyone.

 

[ironhorse8]

Did you ask if they would guarantee a low base? I am actually in a similar situation, and was about to send a contract back to ask for a well below market base, just in case I can't get my practice running in an ortho group similar to how you described. If nothing else I can PM how it went for me... good luck!

 

[Ducttape]

i would still suggest to your orthos to stick to level 3 visits.

especially if the ortho is taking less than 10 minutes with each visit.

if he is going to bill level 4s, he has to be diligent with the documentation and state why it is level 4.

if an internist is spending 45 minutes for a level 4 visit, and the ortho is spending 10...

 

[agolden1]

Did you ask if they would guarantee a low base? I am actually in a similar situation, and was about to send a contract back to ask for a well below market base, just in case I can't get my practice running in an ortho group similar to how you described. If nothing else I can PM how it went for me... good luck!

There's some negotiating which seems like it can be done, but a bit away from this as of right now. May PM you as things progress.

 

[MitchLevi]

i would still suggest to your orthos to stick to level 3 visits.

especially if the ortho is taking less than 10 minutes with each visit.

if he is going to bill level 4s, he has to be diligent with the documentation and state why it is level 4.

if an internist is spending 45 minutes for a level 4 visit, and the ortho is spending 10...

LOFL at any of my partners spending over 19 sec with a pt.

 

[DrMDAware]

LOFL at any of my partners spending over 19 sec with a pt.

Honest question - why are patients ok with a surgeon talking for 19 seconds but not a pain physician doing the same? Of course I’m generalizing a touch.

 

[MitchLevi]

Honest question - why are patients ok with a surgeon talking for 19 seconds but not a pain physician doing the same? Of course I’m generalizing a touch.

Culture and expectation.

They "fix," you "manage."

 

[callmeanesthesia]

Culture and expectation.

They "fix," you "manage."

Our specialty is much more complicated than even we give it credit for. The spine surgeons, at least around me, also really take their time with patients. I have sports doc partners who see 50+ patients in a day. Less than 10 minutes per patient, many of the new. Between reviewing imaging, referral notes, taking a history, examining the patient, and discussing treatment options, only the simplest take me less than 10 minutes.

 

[Ducttape]

Honest question - why are patients ok with a surgeon talking for 19 seconds but not a pain physician doing the same? Of course I’m generalizing a touch.

to be blunt - who says there arent pain doctors who take 19 seconds?


tbh, i have heard that complaint from many patients about a couple of the local pain docs.




but in their defense, these pain docs usually give 30 seconds...

Our specialty is much more complicated than even we give it credit for. The spine surgeons, at least around me, also really take their time with patients. I have sports doc partners who see 50+ patients in a day. Less than 10 minutes per patient, many of the new. Between reviewing imaging, referral notes, taking a history, examining the patient, and discussing treatment options, only the simplest take me less than 10 minutes.

the only time i ever see a patient in less than 10 minutes is when the patient utters the phrase "im only here for oxy".

 

[GlowInTheDark]

LOFL at any of my partners spending over 19 sec with a pt.

I’m in an orthopedic group. A lot of in house referral from the spine surgeons. I always go over MRI with my patients if relevant, mainly because I love asking “Did Dr Xyz go over your MRI with you?”

95% the reply is, “yea, but he was in and out so fast I hardly remember what he said.”