NJPAIN

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Interested in people's thought on the need for sedation in cervical MB RFN. IV sedation? PO sedation ? None?
If PO sedation - what and when?
 

lobelsteve

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1 per every few years if they had too much screaming with local only.
Routine use is bad for everyone except the anes company.
 

lobelsteve

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One of the frequents on this forum got sued for a cervical RF when the patient did not say that she had eaten that morning. She claimed to be NPO she had a little Benadryl and versed then aspirated and died a few days later.
 

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One of the frequents on this forum got sued for a cervical RF when the patient did not say that she had eaten that morning. She claimed to be NPO she had a little Benadryl and versed then aspirated and died a few days later.
Extremely unfortunate about the patient. Bad things can happen no matter the best of care.

By the nature of what we do, there are inherent risks as we live in a world of entropy.
 

Dr. Ice

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Interested in people's thought on the need for sedation in cervical MB RFN. IV sedation? PO sedation ? None?
If PO sedation - what and when?
I'm assuming NJpain means you practice in the great garden state as do I. My precert department is telling me that no insurance (except some Medicaid plans ironically) will cover cs for any pain management procedure. I've been doing everything with po sedation..Valium mainly.
 
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NJPAIN

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I'm assuming NJpain means you practice in the great garden state as do I. My precert department is telling me that no insurance (except some Medicaid plans ironically) will cover cs for any pain management procedure. I've been doing everything with po sedation..Valium mainly.
I am told that it is an issue mainly for Medicare unless they have a well documented anxiety disorder. Otherwise it seems like in the Garden State they even give sedation for TPI.


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Lecithin5

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Tough call. I always hate giving any type of sedation for any cervical work if I can help it. The problem is that sometimes with sedation, patients can get a little bit disinhibited and non-redirectable if they start moving. It's nice for the patient to have a lucid mind, and have the wherewithal to know that they absolutely cannot move. Just like getting an IV-it might hurt a little bit, but the patient stays still. You can get away with a lot with (good) local only.
 

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I think the MBB is the worst part. RFN anesthetize the heck out of it on the way down, and almost inevitably the patients say the MBB was the worst part. I try to talk everyone out of sedation, but some opt, and I oblige. I tell them I want them to be able to talk to me and tell me if something feels wrong.
 

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No sedation for cervical MBB, I use 25G or 27G needles for those.

Except for ancient stalwart patients, all cervical RFA get some sedation as it's mentally harder not to stress about needles close to your head vs your low back. Most just get PO xanax, but a minority of cases do get IV sedation. Similar to you all, I keep the IV doses modest so communication is still clear.
 
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clubdeac

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I'll give a little fentanyl for pain but no versed. Usually they're lucid enough to tell me what's going on the entire time
 

nvrsumr

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Nothing new to that "expert" consensus. Just will make it harder for me to get paid $40. I have actually gone the opposite direction over time. Used to perform without or a xanax. I have found that patients like the option and just the thought of having sedation decreases their anxiety.
 
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IN2B8R

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Patient dependent....


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Dr. Ice

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True no one "needs" conscious sedation for most of what we do. This is just more fodder to push everything towards office based practice. I think in a short time period many insurances will not cover spine injections in an asc setting..where I am horizon and Aetna definitely don't cover it and some of the others are following suit..been doing Valium or xanax for rfa without an issue
 

painfree23

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True no one "needs" conscious sedation for most of what we do. This is just more fodder to push everything towards office based practice. I think in a short time period many insurances will not cover spine injections in an asc setting..where I am horizon and Aetna definitely don't cover it and some of the others are following suit..been doing Valium or xanax for rfa without an issue
They only cover it in the clinic??
 

Dr. Ice

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They only cover it in the clinic??
No..they don't cover it at all. I can't speak for hospital employees but this is my world as a private practice doc. So if they don't cover it then the argument can be made that you don't need to do it in an asc in the first place.
 

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I'd personally take sedation of some sort for a cervical RFA. About 50% for pain and 50% for boredom of lying there during the procedure.
 
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nvrsumr

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I would think cash pay no problem if insurance doesn't pay and they sign an ABN. The issue may be if insurance bundles the sedation with the procedure code...
 

nvrsumr

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Fee For Service Advance Beneficiary Notice of Noncoverage
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied. Guidelines for mandatory and voluntary use of the ABN are published in the Medicare Claims Processing Manual, Chapter 30, Section 50.
 
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Pain_doc

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Pretty much all RF's have an iv and I'd guess 99% patients want some sedation. Their choice. Maybe I just have wimpy patients. Most just a little midazolam. Add a little fentanyl if needed. It calms them and that way I don't have a moving target. I'm anesthesia trained so I perhaps feel more comfortable with giving sedation than other specialties. No one gets "knocked out". No one is making money on iv sedation. If its paid, its around $40 in the office, and $11 bucks if at a facility. The billing service hasn't told me that I'm not getting paid....but then again I'm bringing billing in house as they don't tell me much...

I'm using more ABNs now as more and more commercial insurances are not providing/performing predetermination/authorization for RF. We just get a letter or the office staff are told over the phone....no authorization required and pre-d not performed.
 
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NJPAIN

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Pretty much all RF's have an iv and I'd guess 99% patients want some sedation. Their choice. Maybe I just have wimpy patients. Most just a little midazolam. Add a little fentanyl if needed. It calms them and that way I don't have a moving target. I'm anesthesia trained so I perhaps feel more comfortable with giving sedation than other specialties. No one gets "knocked out". No one is making money on iv sedation. If its paid, its around $40 in the office, and $11 bucks if at a facility. The billing service hasn't told me that I'm not getting paid....but then again I'm bringing billing in house as they don't tell me much...

I'm using more ABNs now as more and more commercial insurances are not providing/performing predetermination/authorization for RF. We just get a letter or the office staff are told over the phone....no authorization required and pre-d not performed.
Are most willing to sign the ABN? I understand that you wont proceed without it but my sense is that my patient population will skip the procedure if there is a hint that it will cost them anything. Rural/blue collar population. The dog gets his ACL done for cash. The pickup truck gets it chrome tail pipes for cash. But pay for healthcare, NO.
 

lobelsteve

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Pretty much all RF's have an iv and I'd guess 99% patients want some sedation. Their choice. Maybe I just have wimpy patients. Most just a little midazolam. Add a little fentanyl if needed. It calms them and that way I don't have a moving target. I'm anesthesia trained so I perhaps feel more comfortable with giving sedation than other specialties. No one gets "knocked out". No one is making money on iv sedation. If its paid, its around $40 in the office, and $11 bucks if at a facility. The billing service hasn't told me that I'm not getting paid....but then again I'm bringing billing in house as they don't tell me much...

I'm using more ABNs now as more and more commercial insurances are not providing/performing predetermination/authorization for RF. We just get a letter or the office staff are told over the phone....no authorization required and pre-d not performed.
Iv?

Thought that went out in the mid 2000s.
 

IN2B8R

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Easier to titrate fentanyl and versed IV than having to guess how much P.O. Valium/Xanax a patient needs. A heck of a lot faster onset too. But I do agree with you, it is an extra chore/expense that you won’t get paid for....


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nvrsumr

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I also put ivs in most procedures. Lumbar mbbs and lesi only if sedation. Of course it is the young healthy guys getting an epidural who like to vagal the most on me so not totally logical.

I am a solo doc in an office with no one but a dentist across the hall. Have an extremely low tolerance for risk for my patients and litigation. If a bad outcome and no iv will be plenty of docs willing to say I should have performed in asc.

I think it is a little of the art of medicine as well. I treat the procedure seriously and patients therefore take it that way. My procedure suite has a separate pre/post iv room with two lazyboys and my MAs have a special “iv certificate”. It is seemless and doesn’t hold me up one bit.

On the other hand after 50k+ cases I have never opened my crash cart...
 
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painfree23

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I also put ivs in most procedures. Lumbar mbbs and lesi only if sedation. Of course it is the young healthy guys getting an epidural who like to vagal the most on me so not totally logical.

I am a solo doc in an office with no one but a dentist across the hall. Have an extremely low tolerance for risk for my patients and litigation. If a bad outcome and no iv will be plenty of docs willing to say I should have performed in asc.

I think it is a little of the art of medicine as well. I treat the procedure seriously and patients therefore take it that way. My procedure suite has a separate pre/post iv room with two lazyboys and my MAs have a special “iv certificate”. It is seemless and doesn’t hold me up one bit.

On the other hand after 50k+ cases I have never opened my crash cart...
Can you bill for the IV (at least for the supplies) even if u don't give sedation?
 

nvrsumr

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If u run an iv with saline there is a code but never paid for by commercial insurers/Medicare.
 

lobelsteve

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I also put ivs in most procedures. Lumbar mbbs and lesi only if sedation. Of course it is the young healthy guys getting an epidural who like to vagal the most on me so not totally logical.

I am a solo doc in an office with no one but a dentist across the hall. Have an extremely low tolerance for risk for my patients and litigation. If a bad outcome and no iv will be plenty of docs willing to say I should have performed in asc.

I think it is a little of the art of medicine as well. I treat the procedure seriously and patients therefore take it that way. My procedure suite has a separate pre/post iv room with two lazyboys and my MAs have a special “iv certificate”. It is seemless and doesn’t hold me up one bit.

On the other hand after 50k+ cases I have never opened my crash cart...
https://c.ymcdn.com/sites/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_IV_Placement.pdf

I have a kit in the procedure suite. Pharmacist checks it monthly and disposes of outdated meds. Nurses sign daily. Has benadryl, epipen, decadron...
 

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There's this doc who comes to our asc who sedates everything. Takes her 5 hours to do 11 patients. I just think if you need to sedate everything, there must be some level of incompetence there, just my .02
 

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Easier to titrate fentanyl and versed IV than having to guess how much P.O. Valium/Xanax a patient needs. A heck of a lot faster onset too. But I do agree with you, it is an extra chore/expense that you won’t get paid for....


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Last I read, IV fentanyl and IV midazolam fo have risks that extend beyond the 5 min of deep sedation one gets. The elimination half life for both fentanyl and midazolam is roughly 3 hours, so patients have over half their meds for at least 2 hours after they go home.

More than enough time to grab a couple of percs or a 12 ouncer...
 

lobelsteve

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Last I read, IV fentanyl and IV midazolam fo have risks that extend beyond the 5 min of deep sedation one gets. The elimination half life for both fentanyl and midazolam is roughly 3 hours, so patients have over half their meds for at least 2 hours after they go home.

More than enough time to grab a couple of percs or a 12 ouncer...
In my first year at this gig (10 year anniversary last November) we had optional sedation for folks who begged. LPN did the nursing, hooked up monitor, I gave the directions and did the procedure. I do not think I ever went over 4/4. But had one lady get CESI just to get the sedation. Egg on my face.
 

IN2B8R

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Ducttape: in my practice, sedation is the exception rather than the rule. Hardly anyone gets over 2mg of midazolam and 50-100mcg of Fentanyl—all go home and told no driving for 24 hours or pain meds x6 hours after discharge. And after 14 years + of working in cardiac anesthesiology, I know who will be fine with my sedation and who will not be, even after they leave my office.... Sure, anyone can go out and purposely overdose on heroin, but most of my patients are neither on opioids, nor are they drug seekers. And for the record, you are absolutely correct: the context sensitive half life can go a lot longer than 2 hours, depending on what other meds, hydration status and the underlying hepatic-renal function. At the end of the day, some patients who do not take opioids simply will not tolerate a cervical rhizo for a variety of reasons—needles phobia, psychogenic overlay, etc.... sedation makes the procedure a lot faster and smoother....


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Ducttape

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Smoother? Maybe from a patient’s perspective.

Faster? Not in this multiverse...


However you want to practice is fine (with maybe the exception of sedation + CESI). but we can’t get cavalier about simple sedation. I’m certain no anesthesiologist with 10 years of cardiac cases would do so.