Epidural Reimbursement question

[soccerpunk600]

So I got a question for everyone. I'm starting practice fresh outta fellowship, so little new to the area of billing and collections. Say I think someone is a candidate for bilateral L4 and L5 transforaminal ESI. Does that get paid if you bill that? Or is there some limit to how many epidurals you do before insurers stop paying it? What about Medicare/Medicaid specifically as that's what I'll likely be seeing most.

We didn't do 4 regions in fellowship hardly ever, though not sure if it was a billing thing or my attendings just didn't feel it made sense. Thanks!

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[lobelsteve]

Sounds like your fellowship ill prepared you clinically.
There is not, never was, never will be a role for b/l 2 level transforaminal epidurals.
64483 -50
64484 -50
J3301 for the kenalog you will surely be using.

 

[IN2B8R]

You have no worries: Medicaid pays you $0, so you are good no matter how many levels.


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[Timeoutofmind]

So I got a question for everyone. I'm starting practice fresh outta fellowship, so little new to the area of billing and collections. Say I think someone is a candidate for bilateral L4 and L5 transforaminal ESI. Does that get paid if you bill that? Or is there some limit to how many epidurals you do before insurers stop paying it? What about Medicare/Medicaid specifically as that's what I'll likely be seeing most.

We didn't do 4 regions in fellowship hardly ever, though not sure if it was a billing thing or my attendings just didn't feel it made sense. Thanks!

Wtf

Where r u doing your fellowship?

 

[soccerpunk600]

Non accredited sports/spine fellowship in York PA. I guess what we learned isn't normal....

 

[powermd]

Non accredited sports/spine fellowship in York PA. I guess what we learned isn't normal....

It's normal for pain guys that milk every cow on all four tits.

Could be worse. Back in 2010 I heard from a recruiter about a Korean guy in LA that used to do bilateral 3 level TF on almost every patient. He actively chose to max out the reimbursement policies on each and every patient, regardless of pathology. He had no referring doctors, but a line out the door due to a "unique system" involving his wife recruiting the patients. Supposedly he had been investigated multiple times by CMS and they couldn't stop him.

 

[Dr. Ice]

Non accredited sports/spine fellowship in York PA. I guess what we learned isn't normal....

I'm pretty sure Dr. Furman would not encourage two level bilateral transforaminal epidurals. Not unless his philosophy has changed but I'm very doubtful. Particularly since the flow studies which he authored demonstrate that injectate at particular volumes will flow beyond the neural foramen it is injected into. The only rationale to do this kind of procedure would be to line your pocket and to make the rest of us look bad.

 

[Pacman27]

Fellas

Just give a back brace and you will make more money

Seriously, don't do unnecessary nonsense to make a few extra bucks. There are many other "right" ways to make a living

DME is one path, but document and make sure it is necessary

 

[Dr. Ice]

I hope you also realize that by posting something like this on this forum you are gonna only fuel the anesthesia pain docs sentiment that pmr trained interventionalists are not up to par. This sentiment is frankly just not true but doing two level bilateral transforaminal injections is only going to make people in our world believe that you are not capable and don't know what you're doing. Just food for thought

 

[bedrock]

I hope you also realize that by posting something like this on this forum you are gonna only fuel the anesthesia pain docs sentiment that pmr trained interventionalists are not up to par. This sentiment is frankly just not true but doing two level bilateral transforaminal injections is only going to make people in our world believe that you are not capable and don't know what you're doing. Just food for thought

Agree with this.

If other pain docs or even smart spine surgeons see your notes and notice excessive procedures, you will get a bad reputation in your community.

Also from a billing standpoint you get paid less with each additional needle that goes into the patient. You're getting $5 for the 4th TFESI needle placement in a Medicaid patient.

So the right thing to do ethically can also be the right thing to do financially, as you'll get paid more for the next new patient you see with time saved from doing quicker procedures.

 

[nvrsumr]

If I makes u feel better local gas pain Doc who used to be an attending at well regarded university pain program does bilateral two levels all the time.

this is not unique to primary residency.

 

[Ducttape]

even if you wanted to, with possibly the exception of no-fault, you will not get paid for this. I believe Medicare and almost all carriers will pay for 1 level
TF and then 1 add on level only.

if you hurry, you could make this:
http://asipp.org/documents/0717-CCPM-brochure.pdf

 

[bronchospasm]

even if you wanted to, with possibly the exception of no-fault, you will not get paid for this. I believe Medicare and almost all carriers will pay for 1 level
TF and then 1 add on level only.

if you hurry, you could make this:
http://asipp.org/documents/0717-CCPM-brochure.pdf

I did this course 5 years ago during my Fellowship.

Also suggest spending a few hours a week going through every post on the forum and you will have more information than you need.

 

[Tapspatellas]

So I got a question for everyone. I'm starting practice fresh outta fellowship, so little new to the area of billing and collections. Say I think someone is a candidate for bilateral L4 and L5 transforaminal ESI. Does that get paid if you bill that? Or is there some limit to how many epidurals you do before insurers stop paying it? What about Medicare/Medicaid specifically as that's what I'll likely be seeing most.

We didn't do 4 regions in fellowship hardly ever, though not sure if it was a billing thing or my attendings just didn't feel it made sense. Thanks!

I don't say never, but 99.999999% unlikely you NEED a bilateral 2 level TF. Central stenosis at level with bilateral foraminal stenosis causing 4 level bilateral radic where you can't do an infraneural approach, just isn't going to happen. Can't decide on a 2 level adjacent central stenosis? Easy, level below should flow both if not complete block.

I'd recommend looking at the Medicare LCD in your area of practice to get a good idea of what is allowable. Many are moving to the noridian LCD that states 2 TF at same time max, so unilateral 2 level, or bilateral 1 level.

 

[Ligament]

Non accredited sports/spine fellowship in York PA. I guess what we learned isn't normal....

Furman?

 

[NJPAIN]

Furman?

I spent a day with those guys about 2 or so years ago to pick his brain a bit. I don't recall seeing anything unusual (like bilateral multilevel TFESI). However, I was with Furman and his fellows. There are several other attendings.


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[unchockey21]

It's normal for pain guys that milk every cow on all four tits.

Haha. I'm going to need to borrow this. Let me know where to send the royalties.

 

[NJPAIN]

It's normal for pain guys that milk every cow on all four tits.

Could be worse. Back in 2010 I heard from a recruiter about a Korean guy in LA that used to do bilateral 3 level TF on almost every patient. He actively chose to max out the reimbursement policies on each and every patient, regardless of pathology. He had no referring doctors, but a line out the door due to a "unique system" involving his wife recruiting the patients. Supposedly he had been investigated multiple times by CMS and they couldn't stop him.

Now he is probably retired at age 50, has a mansion and yacht, billions in real estate investments in the USA and Korea and millions stuffed in a safety deposit box (we know they do that in Texas as well). Moral of the story - crime doesn't pay?

 

[Dr. Ice]

Look the facts are that insurance companies are out to crush interventional pain. They are making the criteria harder and harder each year for injections and the reimbursement is getting cut yearly too. My precert staff has their head spinning around dealing with evicore/carecore and the questionnaire circus that seems to constantly change to get this stuff authorized. Years ago you could do whatever you wanted and get paid for it..and paid well. Since injections have exploded obviously the scrutiny is going to continue to increase. For those of us fortunate enough to be able to retire in the next few years, I guess there is no stopping you from doing whatever you want. For those of us (like me) who will have to find some way over the next 30 years to make this field survive, we (I) would like to request that people consider doing the right thing.

 

[epidural man]

...pmr trained interventionalists are not up to par. This sentiment is frankly just not true ...

Prove it.

(Jk...)

I hope you also realize that by posting something like this on this forum you are gonna only fuel the anesthesia pain docs ..

There are other anesthesia pain docs on this forum?

 

[NJPAIN]

Prove it.

(Jk...)



There are other anesthesia pain docs on this forum?

My hand is raised


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[ateria radicularis magna]

Now he is probably retired at age 50, has a mansion and yacht, billions in real estate investments in the USA and Korea and millions stuffed in a safety deposit box (we know they do that in Texas as well). Moral of the story - crime doesn't pay?

I have heard a few interesting remarks about Texas. I would be interested to know more about the pain practices in Texas. Is it the Wild West?

 

[Ligament]

Prove it.

(Jk...)



There are other anesthesia pain docs on this forum?

I think 30-50% are anesthesia pain on this forum...

 

[BobBarker]

Gas man here.

 

[epidural man]

I think 30-50% are anesthesia pain on this forum...

I didn't know that. Honestly, I thought it was you and me. I see a few more have chimed in as well.

 

[powermd]

Haha. I'm going to need to borrow this. Let me know where to send the royalties.

Oh, I wish I could take credit for that gem. I had to do some digging to figure out where it came from. I found it:

Go to 40:50-

The delivery is great, but not quite on par with Sen Fred Thompson's "The Russians don't take a dump, son, without a plan" from Hunt for Red October.

GI Jane was an awful movie with some choice lines.

 

[mdvol]

Finished with Furman in 2008 and we had alot of billing and coding lectures from Furman. We also never did a bilateral two level trans. When I was there we were accredited and did some acute pain in local hospital - very small amount.

 

[geauxg8rs]

gas pain here

Waste,fraud, and abuse is not limited to one specialty.

Except peds. They are clearly in it to win it. They must be killing it with five bilateral vaccines at once!

 

[Ferrismonk]

Gas guy here as well. Also fresh out of fellowship. No one mentioned this yet, but how about a simple interlaminar ESI? I know it's posterior, blah blah blah, but it'll spread around and cover bilateral multiple levels.

 

[myrandom2003]

the cuts are definitely coming..

New Findings from Pain Management Center in the Area of Medicare and Medicaid Reported (Retrospective cohort study of usage patterns of epidural…

"... Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. Usage of epidural injections increased from 2000 to 2014, with a decline thereafter."

According to the news reporters, the research concluded: "However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.""