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you are saying opioids dont kill people?
Clinic Ins and Outs- MA’s, Scribes, APP’s
Started by TeslaCoil
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what complications happened? would love to learn to recognize dangers
Of course not.
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Should this thread shift to the private forum?
From my understanding patient had critical stenosis, epidural was done at that level and caused spinal cord injury. Patient became essentially hemiplegic, bed bound, shortly thereafter passed of further complications, the details of which Im not aware.
I mean Id rather we stuck to the topic at hand.
Tough situation
in fellowship, i rotated with PMR pain (im anes), and he did 0 cervical anything, always referred to anes pain (outside group) for anything cervical related. There's something to having that kind of practice tbh; was with a large ortho group so plenty of internal volume where he could be this selective
My only point is that people are always so laser focused on opiates being high risk while downplaying the risks of everything else we do. I think that there is a place for opiate prescribing within medically and medico-legally reasonable bounds. There are those docs out there who have no idea what they are doing, or those who are unethical, or reckless. I dont think thats the vast majority of pain mgmt docs.
Duh. But the ish happens.
you are so clearly missing the point or are obfuscating to try to justify your tenuous stance on chronic opioid therapy.
99% of the cervical epidurals dont cause harm.
dont do cervical epidurals if you think the harm is so great.
you cannot say the same of chronic opioid use.
45-90% develop significant constipation.
22% of long acting opioid users develop OUD.
from CDC:
99% of the cervical epidurals dont cause harm.
dont do cervical epidurals if you think the harm is so great.
you cannot say the same of chronic opioid use.
45-90% develop significant constipation.
22% of long acting opioid users develop OUD.
from CDC:
Hmm. Doesn't seem right.
Cuz it aint.
And out of those, the OD numbers on those prescribed the drug for a legitimate medical purpose and during the course of usual care was only a few percent. Still too many. But less than those that died from GI bleeds due to NSAID use (yes-greater N).
Well what are your prescribing practices then? Just dont prescribe opiates at all?
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Great answer. I do have my finances in order other than continuing to pay off student loans. Have 10 years left on those. Financials are not a concern. Im well on target for an early semi-retirement. I probably will stay 5 days a week for now. Maybe go 4 days/week in 5 years or so.
What does your daily and weekly schedule look like in those 4 days? How many patients? Is it a block schedule? How many procedure days? How is your scribe operating with you specifically? Does your scribe prep charts and then scribe during the patient encounter as well?
Not all of the people who got their steroids from NECC were trying to cut costs. Some at least claim that they were trying to find steroids that were preservative free. They at least claim that they were trying to be “safer.” I can only relay what they say.
How
I still do cervical facets with bupivicaine and depo. They work great in the right setting. Curious, any idea what happened with your partner who got the high spinal. That kinda freaks me out
Don’t argue with duct. It’s an exercise in futility.
I still do cervical facets with bupivicaine and depo. They work great in the right setting. Curious, any idea what happened with your partner who got the high spinal. That kinda freaks me out
we can quibble over percentages, but clearly this few percent is significantly higher than the percent of people dying from epidural misuse syndrome.
and i am not routinely recommending long term NSAID or gabapentin use.
i do find it somewhat discomforting that, as an anesthesiologist, i probably spend more time discussing home exercise and functional improvement than most, spend some time introducing patients to pain psychology therapies,
not for chronic nonmalignant pain. for cancer, end of life are appropriate but they probably should come from the person treating those conditions such as onc or palliative care. i will consider in certain conditions (such as those >85 with no functional capacity)
and i am not routinely recommending long term NSAID or gabapentin use.
i do find it somewhat discomforting that, as an anesthesiologist, i probably spend more time discussing home exercise and functional improvement than most, spend some time introducing patients to pain psychology therapies,
Yea he had to intubate the patient right there in the recovery area and ventilate via bag ventilator until they could get patient transferred to ICU to be ventilated overnight. Patient recovered fully. As I recall the patient had a previous posterior fusion which may have predisposed to spread of anesthetic toward cord? Not sure of details but it def happened.
Wow that’s terrifying. Yeah if I do them in posteriorly fused cervical spines I’ll leave out the anesthetic just in case the potential contiguous facet epidural space is actually intrathecal due to altered anatomy
Hold up, how are you getting paid? You don’t really do procedures and now you’re telling us you don’t prescribe? CBT all day every day certainly can’t pay the bills
Looks like ya spooked’im 😂
Duct has often lamented the size of the paycheck.
Also that high spinal case from a facet is bananas. I have to imagine that the risk only exists (and even then rare) from a facet injection not an MBB even with weird anatomy. I say this hopefully as I don't do any IA facets, just MBB/RFA.
Also fwiw I'm also a zero COT guy. I'll write maybe 10 controlled rx a month at the absolute most. 8 are for 2 tabs of diazepam for MRI or procedural anxiolysis. The other 2 are for 5-10 pills of oxy pending imaging/procedure. No refills on opioids ever. No chronic opioids ever.
Also fwiw I'm also a zero COT guy. I'll write maybe 10 controlled rx a month at the absolute most. 8 are for 2 tabs of diazepam for MRI or procedural anxiolysis. The other 2 are for 5-10 pills of oxy pending imaging/procedure. No refills on opioids ever. No chronic opioids ever.
1. i really dont get paid, at least not what you guys are getting paid. im guessing i make as much a year that you do by tax day.
2. i do procedures, just not as much. they are an adjunct, not the key to a successful practice. the population i see is generally not that interested in injections.
3. i dont look at SDN on the weekend or when im off. so yesterday was New Years. ton more fun stuff to do - like shoveling large pack snow in 14 degree weather, picking up insta-freeze dog poop - than refuting lies and falsehoods on any forum.
This explains a lot 😂
You don't have a PA even in PP?
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Dr. Bob is like a world-class athlete having a really tough time being a coach in their discipline. Most people aren't readily capable of doing things the way he does it. He's a 1%'er. Some of his processes don't work well for mere mortals.
I just don't know how or why one would want to do med refills or follow-ups, unless perhaps it's a money-losing endeavor in HOPD.
Dumb it down for me.
You have to pay a midlevel and here until last year you had to send the prescriptions for them. I had problems with the last one I had also. My partner doesn’t ever bother me and I have enough on my plate without looking over a midlevels shoulder. I enjoy having a physician in the office to bounce cases off of also. I was pretty lonely for years and now that isn’t the case.
HOPD is all about wRVU pellets
99214 + G2211 = 1.92 + .33 = 2.25
99204 + G2211 = 2.6 +.33 = 2.93
99244 + G2211 = 2.69 +.33 = 3.02
I do 15 minute follow ups and 30 minute new/consults so you can see the controlled substance med refills and follow ups where you're ordering procedures are actually more valuable per unit time.
I could probably cut my consult time to 20 minutes but I like my current flow.
99214 + G2211 = 1.92 + .33 = 2.25
99204 + G2211 = 2.6 +.33 = 2.93
99244 + G2211 = 2.69 +.33 = 3.02
I do 15 minute follow ups and 30 minute new/consults so you can see the controlled substance med refills and follow ups where you're ordering procedures are actually more valuable per unit time.
I could probably cut my consult time to 20 minutes but I like my current flow.
are you hopd or pp?
and this, folks, is why we see all the mbb f/u patients in person and bill each time
HOPD for 7.5 years, now PP last 3 years
yea i would argue that the market demands and influences are different for the two settings.
my understanding is that 99244 is being phased out.
also, are you using the g2211 for everyone? or specific situations?
so, in HOPD if you walk into a visit behind a midlevel you capture the RVU credit for the visit. Its called shared decision making. All you do is add an attestation at the end of the note. This does not occur in pp. In HOPD the best situation you could possibly hope for is having 2 midlevels, going into new pt visits behind them and getting the RVU credit, in between doing nothing but procedures in a hospital clinic setting all day. In this way you can see a whole bunch of news and do 25 procedures in a day easy.
this is the way
Typically not how it is done here. Most midlevels have their own RVU goals and get credit for their visits. Conversion factor around $40
for all patients that the code applies to
Im just not sure where to use it…
By the letter of the law, it applies to any patient you are not discharging from your care.
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hmm ok. Solid.
I agree it’s often mindless, occasionally annoying, but one can efficiently burn thru these visits and charge for a 99214 for pretty good $/hr.
Theoretically, a mid level would take most of the low-hanging fruit and leave you the challenging patients.
Personally, I have PA working in my clinic concurrently, treating like a resident . I see the patient and cosign the note, so I get RVU credit. She also independently sees the follow ups when I’m in the procedure suite.
My med refills are some of my favorite visits. Most are Butrans and tramadol, occasionally some legacy norco 20 MME or less. I probably have 3 of these a day.
Like you my follow-ups are 15 minutes. I'll ask a question about their dog or holiday and let them go on for 5 minutes while I finish up the charting. Usually the whole visit takes me 7 or 8 minutes so I can slow my pace or catch up if needed.
These visits are easy, highly productive, low stress and mental energy, and slightly social (yes even my 80 year old cat lady).
8 minutes is an eternity.
me: did the MBB help?
patient: yes
me: see you in a week or 2 for the next one.
buh bye
templated note, 99214, next patient
what EHR are you using? and does it have the ability to template the entire note ahead of time? or are you just using dot phrases?
