another job advice post (TIA)

[BobBarker]

Each b/l rfa patient is $2000. Consult, mbb, mbb f/u, mbb, mbb f/u, rfa, 6w f/u.

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[BobBarker]

4 patients x 4 days/week x 48 weeks x $2000 is over $1.5M

 

[LineEmTubeEm]

So then really the best way to approach the question of "How much in collections am I going to bring in?" is to ask my employer about payor rates in comparison to medicare and understand my own schedule with how many advanced procedures I'll be doing a week.

Can someone give me an example of how let's say a unilateral L4-S1 LMBB RFA would be billed out with CPT codes? Versus if you did it bilateral?

 

[BobBarker]

You can’t really do unilateral planned staged in private practice. You won’t be able to do another RF for a year which you probably want to keep in your back pocket as there are many patients that have pain come back around 10-11 months. Also, you have $50-100 in disposables depending how you sharpen your pencil and calculate the time required to clean the probes per case. So staged doesn’t make any extra money.

 

[bedrock]

You can’t really do unilateral planned staged in private practice. You won’t be able to do another RF for a year which you probably want to keep in your back pocket as there are many patients that have pain come back around 10-11 months. Also, you have $50-100 in disposables depending how you sharpen your pencil and calculate the time required to clean the probes per case. So staged doesn’t make any extra money.

This is one of the few times I would disagree with bob regarding practice management.

I think you are correct to use this bilateral RFA scheduling for federal insurance (Medicare, Medicaid, Tricare).

But commercial insurance and WC pays well enough that unilateral RFA is more profitable than bilateral. And commercial insurance/WC tend to be more lenient regarding total RFA treatments per year, compared with government insurance.

 

[LineEmTubeEm]

This is one of the few times I would disagree with bob regarding practice management.

I think you are correct to use this bilateral RFA scheduling for federal insurance (Medicare, Medicaid, Tricare).

But commercial insurance and WC pays well enough that unilateral RFA is more profitable than bilateral. And commercial insurance/WC tend to be more lenient regarding total RFA treatments per year, compared with government insurance.

I was going to say - I think I've seen more unilateral (left then right or vice versa) than bilateral RFA's at this very busy PP

Is it unethical if the patient needs a bilateral RFA to space it out and do one side then the other? Or can you argue for safety sake or some other reason that two unilaterals is reasonable?

 

[BobBarker]

@bedrock I probably have much less W/C (hasn’t paid well so far) and private insurance than most other pain docs so my advise comes from that perspective. Seems like the majority of the patients have UHC Medicare Advantage of late.

 

[BobBarker]

The 2nd side is so fast for me. I already have the depth and angle figured out. Takes about a minute to place the needles. So would
Be hard for me to go back to unilateral.

 

[BobBarker]

I’m just spit balling so please forgive me for running all over this thread.

But imagine this hypothetical practice:

4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos

Take Friday’s off.

Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.

 

[GoBeers]

I’m just spit balling so please forgive me for running all over this thread.

But imagine this hypothetical practice:

4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos

Take Friday’s off.

Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.

can you post a video of your RFA one day? 🙏

 

[drusso]

I’m just spit balling so please forgive me for running all over this thread.

But imagine this hypothetical practice:

4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos

Take Friday’s off.

Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.

Many of those patients will also have tenderness to palpation over the distribution of the cluneal nerves.

 

[callmeanesthesia]

I’m just spit balling so please forgive me for running all over this thread.

But imagine this hypothetical practice:

4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos

Take Friday’s off.

Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.

But your calculations assume each of those is done daily right? So 12 f/u and 4 new pt visits plus 8 MBBs and 4 RFAs per day? Certainly doable and the MBB f/u visits are quick, but most of us don’t move at your pace. Also especially if the MBBs are “100% effective” then plenty of those follow-up conversations will be bogged down with “the RFA didn’t help. Now what?”

fwiw I agree with you on bilateral RFA being much more time and resource efficient. Procedure suite time is usually only about 5 minutes more for bilateral vs unilateral RF. Speaking of which, we should have a workflow thread where we each discuss the sequence of actions for common procedures. I’ve made many small adjustments over time to shave a few seconds here or there off and would love to share and learn from everyone else.

 

[BobBarker]

RFA didn’t work? Must be the SI joints or it must be the patient. Send to CBT.

 

[BobBarker]

Mbb 1/2 f/u via telemed. So that is 8 less bodies through the office.

 

[bedrock]

Mbb 1/2 f/u via telemed. So that is 8 less bodies through the office.

My experience is that in Medicare age population that at least half of them have issues with zoom, my staff has to call everyone and we have delayed and cancelled zooms frequently.

For me, I avoid telemed for Medicare age patients.

 

[bedrock]

But your calculations assume each of those is done daily right? So 12 f/u and 4 new pt visits plus 8 MBBs and 4 RFAs per day? Certainly doable and the MBB f/u visits are quick, but most of us don’t move at your pace. Also especially if the MBBs are “100% effective” then plenty of those follow-up conversations will be bogged down with “the RFA didn’t help. Now what?”

fwiw I agree with you on bilateral RFA being much more time and resource efficient. Procedure suite time is usually only about 5 minutes more for bilateral vs unilateral RF. Speaking of which, we should have a workflow thread where we each discuss the sequence of actions for common procedures. I’ve made many small adjustments over time to shave a few seconds here or there off and would love to share and learn from everyone else.

I like this idea for workflow thread

 

[BobBarker]

Doxy.me texts them a link. I usually just use the Healow chat included with ECW.

 

[bedrock]

Doxy.me texts them a link. I usually just use the Healow chat included with ECW.

Thank you but can you expand on that a bit? I’m not familiar with any of the three things you mentioned.

 

[RoloTomassi]

Thank you but can you expand on that a bit? I’m not familiar with any of the three things you mentioned.

Doxy is a free tele website anyone can use. Healow is the platform that is part of e clinical works if you have that emr

 

[BobBarker]

Doxy.me is basically free. It will send the patient a text to a link for the telemed visit.

You can do a similar thing with Doximity.

Healow is the portal feature for my emr, ECW. Patient checks in, fills out intake remotely, there is a video chat box that comes up through the EMR for the telemed. It works most of the time.

 

[CleanUp]

Correct, don’t delegate the easy work. I have my medial branch block follow ups as telemed and use macros to do the notes while we are talking. It is refreshing to get to talk to your successful patients as well.

I couldn’t agree more. I once offloaded all these visits to my PA and felt down because I wasn’t reminded of the successful outcomes. It’s nice to chat in between the 1st and 2nd MBB and provide some more nuggets of education. And then after the RFA, as well. If they get relief then it’s an opportunity for them to leave a review or tell a friend. Basically a social visit with a macro.

Now if they’re part of the 20% of patients who get relief with the MBB but not RFA then it’s not so fun. I’m open to hearing how y’all deal with those.

 

[MitchLevi]

Wouldn't you maximize billing by doing unilateral RFA per day? Do right then left on another day?

Also, not bc I care, but premedicating with Toradol makes the MBB invalid correct?

 

[BobBarker]

Yes, I am not advising anyone to actually do that. But since the patient is taking it prior to the procedure, oral, I don’t think it would catch any attention. It wouldn’t be in the procedure note.

 

[BobBarker]

I think you maximize billing by doing b/l twice per year.

 

[callmeanesthesia]

Wouldn't you maximize billing by doing unilateral RFA per day? Do right then left on another day?

Also, not bc I care, but premedicating with Toradol makes the MBB invalid correct?

If your schedule isn’t full then yes, you maximize billing by doing one side at a time. And if you are in an employed setup where cost of supplies don’t affect you, and you have staff to do all the prep work for you and walk in to the room and the patient is prepped and draped with the probes connected and laid out, and the c-arm in position.

Otherwise it’s a lot of extra time and supply and staff cost for an extra $250 or so payment. Better to spend that time doing another MBB.

 

[bedrock]

I agree that Toradol would guarantee almost MBB are positive!

Couldn’t do it though. I can handle a patient who failed MBB. It is a much harder discussion if they pass MBB and then fail RFA.

Currently in my hands I only see about 3-4 RFA failures per year.

 

[cowboydoc]

I agree that Toradol would guarantee almost MBB are positive!

Couldn’t do it though. I can handle a patient who failed MBB. It is a much harder discussion if they pass MBB and then fail RFA.

Currently in my hands I only see about 2-3 RFA failures per year.

How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.

I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.

 

[bedrock]

How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.

I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.

Depends on your definition of success. I consider successful RFA to provide at least 50% relief, though obviously I prefer 80%+.

I do a lot of ablations. 18-20 per month.

I trained with Dreyfuss during my fellowship so I’m extremely rigorous with technique for both MBB and RFA.
It likely takes me an extra 2 min to do a MBB and an extra 5-7 minutes to do an RFA compared to others on this board. But I get very few false positive MBB, and very few true RFA failures.

Using 50% relief as a cutoff for successful RFA, I only see about 3-4 RFA failures per year out of those 220 RFA cases per year.

 

[CleanUp]

How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.

I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.

Cowboy honest question how do you deal with RFA failures?

I wish mine were 3-4 a year but sadly they’re not.

I find lower success rate in patients who are older AND obese.

 

[bedrock]

I find lower success rate in patients who are older AND obese.

Older obese patients tend to be discogenic. Many of them likely need intracept over RFA.

Really important to do the MBB with contrast, readjust needle if contrast not spreading over MB, and don’t inject more than 0.4ml bup per MB.

I expect you’re having more false positive MBB than RFA failures in the elderly obese group.

 

[CleanUp]

Older obese patients tend to be discogenic. Many of them likely need intracept over RFA.

Really important to do the MBB with contrast, readjust needle if contrast not spreading over MB, and don’t inject more than 0.4ml bup per MB.

I expect you’re having more false positive MBB than RFA failures in the elderly obese group.

You could be right. I’ll see what comes of it. Thanks.

Do you put much stock in the pain with flexion (discogenic) vs extension (facet)?

Not trying to trip you up or pigeonhole you into an answer just trying to see what I’m overlooking or accepting as dogma

 

[bedrock]

Do you put much stock in the pain with flexion (discogenic) vs extension (facet)?

Not trying to trip you up or pigeonhole you into an answer just trying to see what I’m overlooking or accepting as dogma

Physical exam puts a thumb on the diagnosis scale, but is not the end all and often not overly specific.

Plenty of older patients have stenosis, not bad enough to cause claudication, but enough to make end range extension uncomfortable.

Some younger patients will have disc annular tears which can be uncomfortable in extension.

I always examine my patients but I also always keep those two exceptions to extension based pain in my mind.

 

[mdo1738]

How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.

I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.

RFA failure? Sprint PNS to multifiuds. No luck? Now you have non-surgical back pain. SCS time.

 

[cowboydoc]

Cowboy honest question how do you deal with RFA failures?

I wish mine were 3-4 a year but sadly they’re not.

I find lower success rate in patients who are older AND obese.

As others describe above (not not doing Sprint to multifidi). Occasionally IA facet if I’m really convinced it’s facet despite RF failure. Usually updating MRI if not recent. Thinking intracept if covered.

 

[bedrock]

As others describe above (not not doing Sprint to multifidi). Occasionally IA facet if I’m really convinced it’s facet despite RF failure. Usually updating MRI if not recent. Thinking intracept if covered.

agree with this

 

[CleanUp]

Physical exam puts a thumb on the diagnosis scale, but is not the end all and often not overly specific.

Plenty of older patients have stenosis, not bad enough to cause claudication, but enough to make end range extension uncomfortable.

Some younger patients will have disc annular tears which can be uncomfortable in extension.

I always examine my patients but I also always keep those two exceptions to extension based pain in my mind.

Great points

 

[Ducttape]

I guess it must be the clinic visits. All the easy follow ups and new patients go to my mid-levels. I do lots of RFAs, mostly bilateral. Usually at least 4 per day. Relatively few lower-reimbursing procedures like peripheral joints.

given your volumes and what you have posted, it seems like you should be bringing in much more.

the majority of my visits are in the office. the injections are at ASC. the office visits are not generating as much as procedures.

last figure i had were $2 million.


BUT...
a lot of that is funny money because of ASC fees... and 2-4 inpatient consults/injections a week...

 

[Ducttape]

Wouldn't you maximize billing by doing unilateral RFA per day? Do right then left on another day?

Also, not bc I care, but premedicating with Toradol makes the MBB invalid correct?

technically, RFA sessions are based on the injections done at 1 sitting. at least 1 of the local insurers claim that each unilat RFA represent a session, so doing 2 unilat RFA is 2 separate sessions.... and you only get 4 sessions per spine region in a rolling 12 months...


premedicating with toradol shouldnt invalidate as you are not giving sedation. there is nothing in the LCD to this concern.

 

[MitchLevi]

premedicating with toradol shouldnt invalidate as you are not giving sedation. there is nothing in the LCD to this concern.

Toradol makes the world spin slower. I've had it 3x or so. Everything feels better.

 

[bedrock]

premedicating with toradol shouldnt invalidate as you are not giving sedation. there is nothing in the LCD to this concern.

an LCD is not god. It’s just whatever the insurance bureaucrats decided to include. Certainly not infallible.

Toradol the day of a MBB completely invalidates MBB results. I don’t need an LCD to make a decision for me. My MD makes the decision.

We discussed RFA failures earlier in this thread. False positive MBB are the most common source of an RFA failures.

Bogduk and Dreyfuss would never allow Toradol the day of a MBB

 

[MitchLevi]

Toradol the day of a MBB completely invalidates MBB results.

I mean, I don't have a problem with it because elderly people with back pain virtually always need an ablation, but common medical sense would tell you facetogenic pain is mechanical, nociceptive pain...Which Toradol treats nearly 100% of the time.

Not sure how anyone could argue otherwise, but again, I'm not upset with it.

 

[Ducttape]

an LCD is not god. It’s just whatever the insurance bureaucrats decided to include. Certainly not infallible.

Toradol the day of a MBB completely invalidates MBB results. I don’t need an LCD to make a decision for me. My MD makes the decision.

We discussed RFA failures earlier in this thread. False positive MBB are the most common source of an RFA failures.

Bogduk and Dreyfuss would never allow Toradol the day of a MBB

if you dont follow LCD, you may not be able to keep the money you took from Medicare.



does ibuprofen invalidate MBB results? aleve?

tylenol?

i know you get 100% reduction of pain with all of your procedures. im guessing your patients get 100% relief with toradol.

something that takes away 100% of pain and invalidates injection results will be made a controlled substance soon.

 

[Agast]

I’d only let patients have pain meds the day of their MBB if they had been getting them on other days and know what their pain feels like with that on board. Toradol probably wouldn’t fall into that category since it’s not a chronic daily medicine.

 

[bedrock]

[/QUOTE]

I’d only let patients have pain meds the day of their MBB if they had been getting them on other days and know what their pain feels like with that on board. Toradol probably wouldn’t fall into that category since it’s not a chronic daily medicine.

Agreed.

 

[MitchLevi]

Toradol isn't Aleve. Not even close.

 

[po_boy]

Older obese patients tend to be discogenic. Many of them likely need intracept over RFA.

Really important to do the MBB with contrast, readjust needle if contrast not spreading over MB, and don’t inject more than 0.4ml bup per MB.

I expect you’re having more false positive MBB than RFA failures in the elderly obese group.

What views are you using to check contrast spread for MBBs, and what exactly should it look like?

Exactly what technique are you using for RFAs?

Thanks!