Average reimbursement for implants

[PainApp2021]

Hi,

Can anyone please let me know the average reimbursement you (physician, not hospital) get for doing an ITP or SCS implant at a hospital if you are working in PP? Do you generally negotiate your professional fee with the hospital, or is it normally a set price according to reimbursement? I want to do pumps for chronic malignant pain and stims, but if it is not economical then I will just make it a smaller part of my practice. How do you generally gauge what procedures are more "worth your time"?

I understand these are not the most patient-centered questions so I do appreciate your candor and honesty in responses. Thank you

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[callmeanesthesia]

Hi,

Can anyone please let me know the average reimbursement you (physician, not hospital) get for doing an ITP or SCS implant at a hospital if you are working in PP? Do you generally negotiate your professional fee with the hospital, or is it normally a set price according to reimbursement? I want to do pumps for chronic malignant pain and stims, but if it is not economical then I will just make it a smaller part of my practice. How do you generally gauge what procedures are more "worth your time"?

I understand these are not the most patient-centered questions so I do appreciate your candor and honesty in responses. Thank you

Oh you’ll get plenty of candor from this group regarding pumps. Are you still in fellowship?

PFS Look-Up Tool Overview | CMS

PFS Look-up Tool OverviewWhat's the PFS Look-Up Tool?The PFS Look-Up Tool gives Medicare payment information on more than 10,000 services, including:PricingAssociated relative value units (RVUs)Payment policiesThe tool doesn’t display Medicare Administrative Contractor (MAC) priced codes or...

www.cms.gov

Here you can find the Medicare fee reimbursement. You will be looking for the professional fee.

https://www.medtronic.com/content/dam/medtronic-com/professional/documents/targeted-drug-delivery-chronic-pain-reimbursement-guide.pdf

This document will list out possible CPT codes for implant, refill, and removal.

If you’re in private practice and do a procedure at the hospital or ASC, the hospital is paid the facility fee and you are paid the professional fee. If you do a procedure in office, you are paid the global fee which encompasses the professional fee and a much smaller facility fee than the hospital would get for the same procedure. It is not legal for the hospital to directly pay you a portion of their fee as that constitutes a kickback. However, there are certain arrangements that do allow them to pay you more than you would receive for the physician fee. These include a Service agreement, in which they bill and collect for your services and pay you on an RVU basis some higher amount, and/or giving you a directorship where you hold an administrative position at the hospital (eg director of the pain management department), attend a few meetings, and get a stipend.

Regarding the question you didn’t ask, don’t do pumps if you’re in private practice. Turf them to academia where they have fellows to go see the patient in the ER when the pump malfunctions on a weekend.

 

[PainApp2021]

Oh you’ll get plenty of candor from this group regarding pumps. Are you still in fellowship?

PFS Look-Up Tool Overview | CMS

PFS Look-up Tool OverviewWhat's the PFS Look-Up Tool?The PFS Look-Up Tool gives Medicare payment information on more than 10,000 services, including:PricingAssociated relative value units (RVUs)Payment policiesThe tool doesn’t display Medicare Administrative Contractor (MAC) priced codes or...

www.cms.gov

Here you can find the Medicare fee reimbursement. You will be looking for the professional fee.

https://www.medtronic.com/content/dam/medtronic-com/professional/documents/targeted-drug-delivery-chronic-pain-reimbursement-guide.pdf

This document will list out possible CPT codes for implant, refill, and removal.

If you’re in private practice and do a procedure at the hospital or ASC, the hospital is paid the facility fee and you are paid the professional fee. If you do a procedure in office, you are paid the global fee which encompasses the professional fee and a much smaller facility fee than the hospital would get for the same procedure. It is not legal for the hospital to directly pay you a portion of their fee as that constitutes a kickback. However, there are certain arrangements that do allow them to pay you more than you would receive for the physician fee. These include a Service agreement, in which they bill and collect for your services and pay you on an RVU basis some higher amount, and/or giving you a directorship where you hold an administrative position at the hospital (eg director of the pain management department), attend a few meetings, and get a stipend.

Regarding the question you didn’t ask, don’t do pumps if you’re in private practice. Turf them to academia where they have fellows to go see the patient in the ER when the pump malfunctions on a weekend.

Yes I'm in fellowship right now finishing up and I've done probably two dozen implants for chronic malignant pain.

 

[Ferrismonk]

Callmeanesthesia answered all your questions perfectly. Let me summarize.

1. Pump/Stim implants pay crap if you are private practice and only collecting professional fee. The hospital does it's own billing which you don't get a slice of.
2. Pump refills pay crap. Definitely not worth the risk for you in private practice.
3. Pumps for chronic malignant pain belong in an academic center, which is probably where you're doing them. Don't do them in private practice.
4. Stim trials pay well. Implants don't. Remember you have to figure in the cost of actually going to the hospital, doing your thing, them coming back as well. The only reason to do your own implants, especially in the hospital, is for continuity of care or nobody else will do them for you.

 

[RoloTomassi]

The pro fee is based on your contract with the payer, hospital not involved

 

[Orin]

Callmeanesthesia answered all your questions perfectly. Let me summarize.

1. Pump/Stim implants pay crap if you are private practice and only collecting professional fee. The hospital does it's own billing which you don't get a slice of.
2. Pump refills pay crap. Definitely not worth the risk for you in private practice.
3. Pumps for chronic malignant pain belong in an academic center, which is probably where you're doing them. Don't do them in private practice.
4. Stim trials pay well. Implants don't. Remember you have to figure in the cost of actually going to the hospital, doing your thing, them coming back as well. The only reason to do your own implants, especially in the hospital, is for continuity of care or nobody else will do them for you.

The payments don't take into account the costs of the pump vs the SCS, but just for completeness' sake

https://flowonix.com/sites/default/files/pl-19535-10_-_hospital_coding_and_payment_guide_2022.pdf

https://www.medtronic.com/content/dam/medtronic-com/professional/documents/spinal-cord-stimulation-reimbursement-guide.pdf

CPT Code	wRVU Value per Unit
62350 - IT Cath	6.05
62362 - IT pump	5.60
63650 - SCS lead	7.15
63685 - SCS IPG	5.19

Pumps though can be lucrative if you do them right.
Keep it simple. Reduce the calls and costs.

The way to answer this is to ask your Medtronic rep for the practice area you're looking at to build you a business plan and show you the expected numbers.

 

[BobBarker]

In PP every minute that you are out of your office costs you money. If you go to the hospital and do a Vertiflex you will get paid like $400 and have a 90 day global. You will lose hundreds of dollars vs just staying in your office and doing anything else or going out to market. Just sleeping in or going for a walk would be a better use of your time. Pumps are even worse.

 

[BobBarker]

@Orin do you mean by keep it simple just staying with 10mg/ml morphine? My rep said there is some spread on that J code.

 

[Agast]

It’s fine if you take your cases to an ASC that you have ownership in. Otherwise after you trial a patient, you are going to refer out to someone else for the implant. Make friends with a hospital-employed pain doc if you want perc leads, they get paid well based on the high RVUs of an implant. Or spine surgeon if you want the paddle.

 

[callmeanesthesia]

Yes I'm in fellowship right now finishing up and I've done probably two dozen implants for chronic malignant pain.

I did a fellowship with a bunch of cancer pain pumps - probably also around 2 dozen. Absolutely wonderful for that indication. I was sure I would do them in practice, even set up meetings with local oncologists when I started. Thankfully there was a serendipity of them never sending me any referrals for pumps, and me learning how private practice reimbursement works and what a hassle those pumps really were.

 

[bedrock]

I did a fellowship with a bunch of cancer pain pumps - probably also around 2 dozen. Absolutely wonderful for that indication. I was sure I would do them in practice, even set up meetings with local oncologists when I started. Thankfully there was a serendipity of them never sending me any referrals for pumps, and me learning how private practice reimbursement works and what a hassle those pumps really were.

Exactly. In the real world all pumps are/should be done at a tertiary medical center.

 

[Orin]

@Orin do you mean by keep it simple just staying with 10mg/ml morphine? My rep said there is some spread on that J code.

Keep it simple as in taking steps to reduce the overhead/calls/complications.

No systemic opioids
1 drug in the pump, ideally morphine as it's cheap
Wean orals prior to implant

The drug costs can be passed off to compounding pharmacies but the big thing to me is that the device links the patient to you unlike SCS/PNS.

Pumps come back for replacement more reliably with ongoing refills and continuity for ancillary procedures.

 

[Ducttape]

in all this discussion - you guys all fail to factor in the ongoing issues with managing these patients, their medication side effects and the problems with the pumps themselves.

not only do they have to be seen roughly every 2 months for that pump refill, but since they are on opioids, almost all of them develop tolerance and will ask for dose changes. almost all of them will request oral medication ("because the on demand doesnt do anything"). in addition, pump problems, tubing problems, granuloma formation at higher doses, and of course tolerance (yes i mentioned before, but needs to be mentioned again).



at least with a SCS, after implant, you can see them on an as needed basis, with little required in terms of constant maintenance.

 

[PainApp2021]

Well I think this thread convinced me to not do pumps in a few months. Much appreciated

 

[Baron Samedi]

I remember when opioid pump "microdosing" was a supposed thing, and now those exact same patients are all on 600+ OME/day.

 

[Ronin1]

I think most fellows get excited about the surgical type of procedures stims etc, in reality the advanced procedures are a minimal percentage of most practices. Get efficient at the basics it will serve you well

 

[Ferrismonk]

I still find myself getting excited by the new stuff and how to help patients in new ways, but since I'm private practice, don't do my B&B procedures in an OR, and insurance's denying anything new, and it never pencils out.

It's hard to justify doing SCS implants, Vertiflex, Intracept, etc when just 2x ESI per hour in the clinic pays more.

 

[DrMDAware]

So you’re telling me the following is a no-brainer?

Choice 1. Perform a two hour spinal cord stimulator implant in a facility where I get no facility fee.

Choice 2. See and bill 10 level 4s and 2 level 3s two hours in clinic or virtually. Assume 80-90$ per wRVU that hits my bank account

 

[Baron Samedi]

So you’re telling me the following is a no-brainer?

Choice 1. Perform a two hour spinal cord stimulator implant in a facility where I get no facility fee.

Choice 2. See and bill 10 level 4s and 2 level 3s two hours in clinic or virtually. Assume 80-90$ per wRVU that hits my bank account

With choice 1 you'll be the last case of the day and get bumped for an emergency breast aug on the surgical chair's wife or the CRNA will cancel your case entirely because the patient had palpitations a year ago.

 

[lobelsteve]

With choice 1 you'll be the last case of the day and get bumped for an emergency breast aug on the surgical chair's wife or the CRNA will cancel your case entirely because the patient had palpitations a year ago.

You know me. You really know me.

 

[Ducttape]

best would be to do mostly choice 2 mixed with some choice 1 so you dont lose your skills or your mind

 

[DrMDAware]

best would be to do mostly choice 2 mixed with some choice 1 so you dont lose your skills or your mind

Good idea. That’s what I plan to do.

I might look into doing more in office procedures for B&B stuff.

And also look to be more non interventional and work people up (get PT, imaging etc, hold their hand and talk about the best mattress).

Never thought I’d be more non interventional but my contract doesn’t really financially reward being in the fluoro suite. I am sure I am not the only one.

 

[sdnuser001]

Good idea. That’s what I plan to do.

I might look into doing more in office procedures for B&B stuff.

And also look to be more non interventional and work people up (get PT, imaging etc, hold their hand and talk about the best mattress).

Never thought I’d be more non interventional but my contract doesn’t really financially reward being in the fluoro suite. I am sure I am not the only one.

Interesting. Is your bonus mostly based on the volume of clinic patients you see?

 

[GoBeers]

Interesting. Is your bonus mostly based on the volume of clinic patients you see?

he probably can see more patients in clinic and get paid more that way than doing slow-turnover procedures in an ASC he has no ownership in

 

[DrMDAware]

Interesting. Is your bonus mostly based on the volume of clinic patients you see?

More or less yes

 

[DrMDAware]

he probably can see more patients in clinic and get paid more that way than doing slow-turnover procedures in an ASC he has no ownership in

Bingo.

There is an element of ownership but it gets diluted so much and like you said some things are out of my control (terrible supply chain management, inability to recruit other surgeons, over staffing)

 

[Laryngospasm]

I’ll summarize- pumps suck. There, you’re welcome.