how are you all handling medicare SIJ with the new rules?

[lobelsteve]

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20610 or 20551. Spinning and drawing are free

 

[bedrock]

20610 or 20551. Spinning and drawing are free

Noble, but not realistic for non HOPD private practice docs.

A 20610 doesn’t begin to cover the time and cost of drawing the blood, Centrifuge and other equipment plus extra staff time. And PRP patients always take extra time with questions and clinic time.

Just like politics a happy medium must be found.

Charging $ 1,500 for PRP in LA=robbery

Charging only a 20610 = naive and literally lose money on each patient.

Charging $500 to do without kit (or approx $800 with kit) = the appropriate medium approach
physician makes a reasonable profit (similar to a dental procedure) and patients are helped without robbery.

 

[Dr. Ice]

Yes 1 joint. For intradiscal $1500 which frankly I’m eating cost at the asc as an owner

 

[Ducttape]

im doing diagnostic blocks but documenting both the duration of benefit from the bupiv and duration of benefit of the steroid.

i dont think any patient should have more than 4 blocks per year anyways. if you have to do an injection <2 months apart, then you have to rethink your diagnosis.

i do find benefit of local only blocks. we do them all the time for MBB, with the expectation that the MBB is not the long duration procedure. we also do them for TPI, so there is a role of them therapeutically, if you believe in TPI (i am on the fence - a few people seem to benefit overtly)



PRP would be an option if i did it, but the hospital system restricts PRP to 1 or 2 specific docs (who got grandfathered in when their practices were bought, so...)

 

[drrosenrosen]

I have the same question. Can you legally make a Medicare SIJ a cash injection just because you don’t want to follow their diagnostic injection rules ?

I’m not criticizing drusso here. I’m debating the same thing myself due to the hassle.

Also, are we seeing any other insurances follow these new guidelines for Medicare?

I’m wondering if blue cross will pick this up next?

Hey, drusso? Any follow up on this question about the ABN? I'm curious to know. Thanks

 

[SSdoc33]

Okay, done arguing so we can focus on original question. Last message on this thread

Level of evidence must be high for SI PRP for people here to offer it for cash payments.

Now I’m going to focus on my “reversible” procedure cash practice of intradiscal PRP, joint injections charging >1K per joint for PRP- so safe, no harm

so, you dont have to respond, but just listen:

the reason most seasoned docs on this forum are trying to get you to avoid SIJ fusions is that 1. they dont work and 2. we dont trust you to do the right thing.

i have seen maybe 2 cases of refractory SIJ Pain in 15 years. typically, SIJ pain is not all that severe and can be managed without gigantic screws thru bone.

i am concerned about your 30-35 injection patients per day (you are clearly not seeing these patients yourself and booking them yourself). i am concerned that you are toeing the line between legit medical practice and being a cowboy.

the point of my commentary is not to be a d-head, but rather to look out for the patients out there who may be receiving substandard care.

you can make money in this business and still be ethical. i hope that you view these comment thoughtfully rather than a knee-jerk rejection b/c you are butt-hurt.

 

[SpineandWine]

so, you dont have to respond, but just listen:

the reason most seasoned docs on this forum are trying to get you to avoid SIJ fusions is that 1. they dont work and 2. we dont trust you to do the right thing.

i have seen maybe 2 cases of refractory SIJ Pain in 15 years. typically, SIJ pain is not all that severe and can be managed without gigantic screws thru bone.

i am concerned about your 30-35 injection patients per day (you are clearly not seeing these patients yourself and booking them yourself). i am concerned that you are toeing the line between legit medical practice and being a cowboy.

the point of my commentary is not to be a d-head, but rather to look out for the patients out there who may be receiving substandard care.

you can make money in this business and still be ethical. i hope that you view these comment thoughtfully rather than a knee-jerk rejection b/c you are butt-hurt.

Look - again, don’t know who you are, your training or your practice style/patient outcomes, Whether you do advanced procedures or have cash practice model.
1) I consider these comments seriously and take them into account. I’ve mentioned several times I haven’t done a case yet and I’m excited to learn about things I have not been exposed to. Maybe I’ll go to course, talk to other pain docs who do this modality and chose not to use it-
2) i don’t make assumptions about other people on sdn forums until I’ve seen the practice. I practice ethically
3) I don’t deride people for asking questions/wanting to learn - use that against them. Sounds like insecurity on part of a “seasoned” doc

I’m not discounting your experience- just your assumptions of other peoples ethics, practice style etc. If 18 orthopods want you to consider Glenb/RFA in non surgical candidates, I don’t believe I need to see them until day of procedure. If spine surgeon want me to try a TFESI prior to considering surgery to exhaust conservative measures, don’t need to see them beforehand (as prior to me coming in, they were sending this out).
In fact, I make less money not seeing these slam dunk patients in clinic as I don’t get to bill for NP visit + procedure- rather just procedure and subsequent return visit.
Yes, some growing pains have occurred but they evaluate patients in close proximity to me and ask for frequent feedback to make sure they’re booking the procedures I want - now they no longer book any cervical TFESI, etc.

Don’t be a D-bag, don’t make assumptions and make people feel insecure for asking questions.

 

[Ducttape]

If 18 orthopods want you to consider Glenb/RFA in non surgical candidates, I don’t believe I need to see them until day of procedure. If spine surgeon want me to try a TFESI prior to considering surgery to exhaust conservative measures, don’t need to see them beforehand (as prior to me coming in, they were sending this out)

omg....

you essentially answered our concerns in one fell statement

someone who is not assessing and determining if a procedure is appropriate prior to performing such procedures should not be considering adding an invasive procedure with fair-poor evidence for long term benefit.


i can reasonably say that i see at least 20-30 patients a month that are referred for an injection that is inappropriate and/or unnecessary. while i do take their request with considerable heft, these referral sources all recognize that i am the pain physician and know more about pain and the appropriate injections - if indicated, where a lot of injections fall off - than the referrer, and my referral sources dont care that i decide that the specific procedure is not indicated. they know i am not going to cookie stamp their injection but will give a full evaluation.



at the least, please do not perform an SI fusion without assessing the patient first...



i am willing to discuss ethics with you all day long.

but in summary -
make your own assessments on the patients pain and determine independently what procedures are indicated.
make sure your treatment has been shown to have good clinical evidence for benefit.
make sure your treatment is safe and reasonably expect that it will do no harm.
do your injections in a safe manner (including using multiple images, contrast, SDV, etc.)

 

[jsaul]

Why so judgemental- I ask questions to improve myself constantly- I don’t see it as a sign of weakness. I don’t see this forum as a means to brag/but a resource to continually up my game

Rather it’s people who claim to be experts or pretend to think they know best. My patients do well and they get good relief from my blocks.

First of all, quit referring to your procedures as "blocks" unless you are doing regional anesthesia

 

[Ducttape]

education is always a good thing. i would definitely recommend taking courses.

taking courses does not obligate you to doing the procedure.


just remember that there is probably going to be bias for the procedure. even at academic institutions, which should be more neutral and more scientific based, there may still be bias. they will talk up how good the procedure is. look at the evidence later, however. anecdotal stories are not the whole truth



like most of us, i have the surgeons on my iphone, by their first names generally. when i have a question, i msg them, and they answer when they are out of OR. i also use a lot of the secure chat on epic to communicate, particularly with floor teams.

the system has a bimonthly pain and spine conference that groups together the pain team and the neurosurgical team to discuss cases.

 

[GoBeers]

Practically speaking, I get it when physicians do injections ordered by other providers. There may be some political pressures (or not) with a multi-specialty group set up. However , one should always do their own evaluation prior to considering any treatment option, whether it is injections or medications.

When a new consult comes in and says "my PCP CANT prescribe opioids and i MUST get it from you, the pain doc," I assume you chuckle and make your own assessment and decision to give opioids right?

Conversely, if you said you think a patient needs a spinal decompression because they have severe stenosis, but failed 3 epidurals, multimodal meds and physical therapy, do you think the surgeon is going do that surgery the day of? Do you think they'll meet the patient for the first time in pre-op and then cancel if they felt the need to do so and be ok with it? No, they will be pissed at you for putting a patient on their surgical schedule PERIOD without the patient having been evaluated in clinic. Why should your procedures and process be treated any differently?

It sucks if the patient lives 1-1.5hours away, but if you ended up cancelling the procedure on the day of anyway, then it's a waste of time regardless.

 

[MitchLevi]

Dude is trying to learn and get better.

Comes on here and yall start talking S to him and risk running him off like so many of yall did to Hawkeye (prob most experienced pain doc in my time on SDN, and someone with more to offer than all of you).

There are ppl on this forum who have done a good bit of SIJ fusion, you're just not hearing from them.

When they inevitably come in and mention their experiences, I hope yall talk just as much S to them.

Anu will learn and get better. He MOST LIKELY is no less safe than any of you.

He will work his way into many conversations with his colleagues about what is appropriate and what isn't.

I do this too BTW.

We figured a system in my practice that works.

There ARE times it is reasonable to have a surgeon put a pt on your procedure schedule.

 

[SSdoc33]

Dude is trying to learn and get better.

Comes on here and yall start talking S to him and risk running him off like so many of yall did to Hawkeye (prob most experienced pain doc in my time on SDN, and someone with more to offer than all of you).

There are ppl on this forum who have done a good bit of SIJ fusion, you're just not hearing from them.

When they inevitably come in and mention their experiences, I hope yall talk just as much S to them.

Anu will learn and get better. He MOST LIKELY is no less safe than any of you.

He will work his way into many conversations with his colleagues about what is appropriate and what isn't.

I do this too BTW.

We figured a system in my practice that works.

There ARE times it is reasonable to have a surgeon put a pt on your procedure schedule.

i guess i have to educate you as well.

hawkeye was booted for saying some pretty sick sh$t. we didn't "run him off".

it is good that the guy is asking questions. it is a bad sign that he doesnt seem to be able to accept constructive criticism. nobody here is being as ass just to be an ass -- including myself. the picture that he has painted of his goals and his practice is really not what most of us would like to see our field become.

 

[Taus]

Practically speaking, I get it when physicians do injections ordered by other providers. There may be some political pressures (or not) with a multi-specialty group set up. However , one should always do their own evaluation prior to considering any treatment option, whether it is injections or medications.

When a new consult comes in and says "my PCP CANT prescribe opioids and i MUST get it from you, the pain doc," I assume you chuckle and make your own assessment and decision to give opioids right?

Conversely, if you said you think a patient needs a spinal decompression because they have severe stenosis, but failed 3 epidurals, multimodal meds and physical therapy, do you think the surgeon is going do that surgery the day of? Do you think they'll meet the patient for the first time in pre-op and then cancel if they felt the need to do so and be ok with it? No, they will be pissed at you for putting a patient on their surgical schedule PERIOD without the patient having been evaluated in clinic. Why should your procedures and process be treated any differently?

It sucks if the patient lives 1-1.5hours away, but if you ended up cancelling the procedure on the day of anyway, then it's a waste of time regardless.

I do understand your point, but I think a significant portion of surgeons would be perfectly happy to meet the patient day of in pre-op, operate and get paid for it, and never see them again, rinse and repeat.

 

[MitchLevi]

i guess i have to educate you as well.

hawkeye was booted for saying some pretty sick sh$t. we didn't "run him off".

it is good that the guy is asking questions. it is a bad sign that he doesnt seem to be able to accept constructive criticism. nobody here is being as ass just to be an ass -- including myself. the picture that he has painted of his goals and his practice is really not what most of us would like to see our field become.

What happened to Hawkeye?

I want to hear the "sick sh$t" he said, bc I don't seem to remember that part. I can't trust your hyperbole.

Then again, I'm from Georgia so I'm really dumb and you may need to spell it out for me letter by letter.

 

[MitchLevi]

I do understand your point, but I think a significant portion of surgeons would be perfectly happy to meet the patient day of in pre-op, operate and get paid for it, and never see them again, rinse and repeat.

You don't want to do a shot and never see the pt again? You know you want to, unfortunately if you're a pain management physician your job requires you see the pt and manage their pain.

Surgeons do surgery.

If it doesn't go their way and there isn't any further surgery to do there's no reason for a surgeon to see the pt.

They can't do anything else.

A surgeon can't manage a pt. They do surgery well and that's it. They're lost in an exam room and when Rx'ing.

Your 73 yo pts need as little face time with a surgeon as possible.

Edit - Tell you something that pisses me off...Why is there FBSS but not similarly titled diagnoses for failed TKA or THA or other surgeries?

 

[GoBeers]

You don't want to do a shot and never see the pt again? You know you want to, unfortunately if you're a pain management physician your job requires you see the pt and manage their pain.

Surgeons do surgery.

If it doesn't go their way and there isn't any further surgery to do there's no reason for a surgeon to see the pt.

They can't do anything else.

A surgeon can't manage a pt. They do surgery well and that's it. They're lost in an exam room and when Rx'ing.

Your 73 yo pts need as little face time with a surgeon as possible.

Edit - Tell you something that pisses me off...Why is there FBSS but not similarly titled diagnoses for failed TKA or THA or other surgeries?

Sometimes I think if surgeons just cut and everyone accepts that, then would it be so wrong for pain physicians to just inject? I now see why there are practices that literally say "interventional specialists" (likely a marketing technique to steer med mgmt referrals away) or "spine and joints specialist" (likely to avoid pelvic, abdominal, etc. referrals).

 

[lobelsteve]

You don't want to do a shot and never see the pt again? You know you want to, unfortunately if you're a pain management physician your job requires you see the pt and manage their pain.

Surgeons do surgery.

If it doesn't go their way and there isn't any further surgery to do there's no reason for a surgeon to see the pt.

They can't do anything else.

A surgeon can't manage a pt. They do surgery well and that's it. They're lost in an exam room and when Rx'ing.

Your 73 yo pts need as little face time with a surgeon as possible.

Edit - Tell you something that pisses me off...Why is there FBSS but not similarly titled diagnoses for failed TKA or THA or other surgeries?

see my private forum post

 

[lobelsteve]

Sometimes I think if surgeons just cut and everyone accepts that, then would it be so wrong for pain physicians to just inject? I now see why there are practices that literally say "interventional specialists" (likely a marketing technique to steer med mgmt referrals away) or "spine and joints specialist" (likely to avoid pelvic, abdominal, etc. referrals).

see my private forum post

 

[Ducttape]

You don't want to do a shot and never see the pt again? You know you want to, unfortunately if you're a pain management physician your job requires you see the pt and manage their pain.

Surgeons do surgery.

If it doesn't go their way and there isn't any further surgery to do there's no reason for a surgeon to see the pt.

They can't do anything else.

A surgeon can't manage a pt. They do surgery well and that's it. They're lost in an exam room and when Rx'ing.

Your 73 yo pts need as little face time with a surgeon as possible.

Edit - Tell you something that pisses me off...Why is there FBSS but not similarly titled diagnoses for failed TKA or THA or other surgeries?

Sometimes I think if surgeons just cut and everyone accepts that, then would it be so wrong for pain physicians to just inject? I now see why there are practices that literally say "interventional specialists" (likely a marketing technique to steer med mgmt referrals away) or "spine and joints specialist" (likely to avoid pelvic, abdominal, etc. referrals).

respectfully disagree.

a surgeon is above all else a physician - a doctor.

surgeons need to do more than just cut.

a surgeon that is only cutting is not treating the condition for surgery. for example, surgeons dont do "appendicitis surgery", they treat appendicitis.




fyi, there is failed joint syndrome. T84.019A. if you want failed joint syndrome sequelae, that is T84.019S.
Failed total knee replacement, sequelae. ICD-10: T84.018S, Z96.659
Failed total hip arthroplasty, sequelae. ICD-10: T84.018S, Z96.649
(change the S to A if you dont want "sequelae" part)

 

[SSdoc33]

ducttape is the kid in class that reminds the teacher to assign homework

love it

 

[SC Tian]

Practicing in 1. multispecialty clinic: referral from non-interventional spine pmr doctors; 2. ortho group: from ortho-spine surgeons do injection before and also do conservative management; 3. standing alone pain clinic: referral from outside ortho. Do we manage referrals differently? thanks.

 

[epidural man]

Still want to focus on my original questions

However, for the second discussion going on…for hypermobile SIJ you do PRP injection including the ligaments.

If PRP fails then you proceed to SIJ RFA.

No neither of these two procedures are covered by insurance.

However there is huge reason to choose them over SIJ fusion. Because SIJ PRP and SIJ RFA are REVERSIBLE!!

A fusion is a terrible answer to any medical issue. Should only be the last resort. Which it isn’t, 99% of the time.

When your SIJ fusion fails then what? Now you have zero options to treat the patient, and you have personally doomed them to a lifetime of pain.

I guess people don't have a good answer.

I don't have any wisdom to add - just a question.

I have zero experience with billing and insurance -

BUT -

Would it be possible to tell all your patients

"We do not bill insurance. My staff will help YOU bill the insurance and ask for reimbursement. We know our way around the paperwork so please lean on us for help. We will let you delay payment so you can work with your insurance company (including medicare) for 3 months. Because insurances are evil and varied, we have found this works best. Please understand that we do what is right for your condition, not what insurance will pay for. Because of this, sometimes our treatments are at odds with what insurances will cover. If you decide to take your insurance company to small claims, we will provide support by way of scientific data on why we provided the treatment. "

 

[Dr. Ice]

I guess people don't have a good answer.

I don't have any wisdom to add - just a question.

I have zero experience with billing and insurance -

BUT -

Would it be possible to tell all your patients

"We do not bill insurance. My staff will help YOU bill the insurance and ask for reimbursement. We know our way around the paperwork so please lean on us for help. We will let you delay payment so you can work with your insurance company (including medicare) for 3 months. Because insurances are evil and varied, we have found this works best. Please understand that we do what is right for your condition, not what insurance will pay for. Because of this, sometimes our treatments are at odds with what insurances will cover. If you decide to take your insurance company to small claims, we will provide support by way of scientific data on why we provided the treatment. "

This is great in theory. I for one have no time to discuss payment for procedures after I’ve gone over the mri which the surgeon really didn’t, gone over their symptoms, meds, prior treatment, done an exam and discussed the actual procedure. The insurance portion should really should not be a long winded conversation. Unless I copy and paste what you just said and gave it then on a separate sheet of paper. Actually that might not be a bad idea lol. But it would not involve me sitting in front of their face and saying this. I feel like everyone should just get an ABN form for every procedure we do and just call it a day

Also, if we are still talking about Medicare SIJ, I think I’m getting reimbursed like $50 or something ludicrous like that. Is all of this even worth it? I am likely going to send any Medicare patients who really actually might have SIJ pathology (not many) to another practice and have them deal with it

 

[epidural man]

This is great in theory. I for one have no time to discuss payment for procedures after I’ve gone over the mri which the surgeon really didn’t, gone over their symptoms, meds, prior treatment, done an exam and discussed the actual procedure. The insurance portion should really should not be a long winded conversation. Unless I copy and paste what you just said and gave it then on a separate sheet of paper. Actually that might not be a bad idea lol. But it would not involve me sitting in front of their face and saying this. I feel like everyone should just get an ABN form for every procedure we do and just call it a day

oh, I was thinking it was a hand-out every patient got.

Also, you would have a 10$/hr 18 year old who would help patients with the billing questions.

 

[MitchLevi]

respectfully disagree.

a surgeon is above all else a physician - a doctor.

surgeons need to do more than just cut.

a surgeon that is only cutting is not treating the condition for surgery. for example, surgeons dont do "appendicitis surgery", they treat appendicitis.




fyi, there is failed joint syndrome. T84.019A. if you want failed joint syndrome sequelae, that is T84.019S.
Failed total knee replacement, sequelae. ICD-10: T84.018S, Z96.659
Failed total hip arthroplasty, sequelae. ICD-10: T84.018S, Z96.649
(change the S to A if you dont want "sequelae" part)

Is there an entire industry built on the diagnosis of failed joint syndrome in similar manner to FBSS?

Surgeons - I'm talking post op. I should have been more clear.

 

[Ducttape]

that should be us.


but we dont have great alternatives to FBSS to market. after all, look at what is "done for FBSS"...
1. PT
2. epidural
3. MBB
4. RFA
5. repeat epidural from different approach (ie TF). maybe series of 3
6. SCS trial
7. SCS implant.
8. Revise SCS implant.
9. remove SCS implant
10. ITP trial
11. ITP implant
12. Remove ITP implant.
13. refer back to surgeon to extend fusion.

what do we have for failed knee or failed hip? maybe PT, 1 genicular or hip block and 1 RFA?

 

[callmeanesthesia]

that should be us.


but we dont have great alternatives to FBSS to market. after all, look at what is "done for FBSS"...
1. PT
2. epidural
3. MBB
4. RFA
5. repeat epidural from different approach (ie TF). maybe series of 3
6. SCS trial
7. SCS implant.
8. Revise SCS implant.
9. remove SCS implant
10. ITP trial
11. ITP implant
12. Remove ITP implant.
13. refer back to surgeon to extend fusion.

what do we have for failed knee or failed hip? maybe PT, 1 genicular or hip block and 1 RFA?

See, that’s because you’re not thinking like a KOL. For failed hip or knee you can certainly still do an epidural and an SI joint injection, just in case it’s referred or radicular pain. A few sympathetic blocks too, followed by DRG, then revising or adding DRG leads. Then you could probably even try an ITP.

 

[oreosandsake]

Noble, but not realistic for non HOPD private practice docs.

A 20610 doesn’t begin to cover the time and cost of drawing the blood, Centrifuge and other equipment plus extra staff time. And PRP patients always take extra time with questions and clinic time.

Just like politics a happy medium must be found.

Charging $ 1,500 for PRP in LA=robbery

Charging only a 20610 = naive and literally lose money on each patient.

Charging $500 to do without kit (or approx $800 with kit) = the appropriate medium approach
physician makes a reasonable profit (similar to a dental procedure) and patients are helped without robbery.

Don’t negotiate against yourself
It becomes a race to the bottom dollar

And I know dentists that charge 10-20x what insurance pays them.

It is a Free market. People pay for experience and expertise. Sometimes they fall for great marketing and poor skills.

Patient called me today and asked me for a referral for another Regen doc in northern CA. The last one I sent him to was helpful (when Mayo MN and AZ couldn’t figure it out) but charged $6000 per treatment.

This doesn’t condone the 20k chiro “stem cell” mills but it’s a free market. Buyer beware. If CMS covers this it will be good for 2-3 years then die off like every other abused code

 

[SSdoc33]

Don’t negotiate against yourself
It becomes a race to the bottom dollar

And I know dentists that charge 10-20x what insurance pays them.

It is a Free market. People pay for experience and expertise. Sometimes they fall for great marketing and poor skills.

Patient called me today and asked me for a referral for another Regen doc in northern CA. The last one I sent him to was helpful (when Mayo MN and AZ couldn’t figure it out) but charged $6000 per treatment.

This doesn’t condone the 20k chiro “stem cell” mills but it’s a free market. Buyer beware. If CMS covers this it will be good for 2-3 years then die off like every other abused code

disagree.

you are taking advantage of the vulnerable. you are scamming them. conning them. is that what a doctor is supposed to do?

dont devalue yourself, but change a reasonable fee with a reasonable margin.

 

[RoloTomassi]

dont devalue yourself, but change a reasonable fee with a reasonable margin

I think that's what @oreosandsake is doing, y'all just disagreeing on what "reasonable" is. I, for one, don't think Medicare should be used as any sort of benchmark. Look at a CESI, a procedure you've gone through 13 years of education and training for so you don't paralyze somebody. Medicare has devalued it to the cost of an oil change.

 

[oreosandsake]

disagree.

you are taking advantage of the vulnerable. you are scamming them. conning them. is that what a doctor is supposed to do?

dont devalue yourself, but change a reasonable fee with a reasonable margin.

That’s a mighty high horse. Scam and con are strong words.

Do you feel the same way when the Michelin star restaraunt charges you $50 for eggs and sugar as crème brûlée when you know you can get it for $5 at the local dessert bar?

If you don’t like the pricing you can always shop and dine elsewhere.

 

[oreosandsake]

I think that's what @oreosandsake is doing, y'all just disagreeing on what "reasonable" is. I, for one, don't think Medicare should be used as any sort of benchmark. Look at a CESI, a procedure you've gone through 13 years of education and training for so you don't paralyze somebody. Medicare has devalued it to the cost of an oil change.

At my county hospital a CESI pays me $50

And we… accept this. And I still
Do them because they work.

By RVU, the system has been re structured so that e&m codes 99214 are essentially same value as a CESI.

Just like other people have advocated for only performing certain procedures under cash pay….

We already have enough people against us.

Negotiating against yourself is a bad habit I had to work to unlearn.

A Great pain doctor from the east coast wanted to refer his patient to me for evaluation and PRP. Asked me what I charged. Then said “isn’t the standard $500?”

If your patient is willing to get on a plane to come see me, there must be a reason when the local needle jockey isn’t cutting it.
$500 is a lot to some people. $50000 is nothing to others.

 

[SSdoc33]

That’s a mighty high horse. Scam and con are strong words.

Do you feel the same way when the Michelin star restaraunt charges you $50 for eggs and sugar as crème brûlée when you know you can get it for $5 at the local dessert bar?

If you don’t like the pricing you can always shop and dine elsewhere.

the difference is that pain patients are a vulnerable population. i could sell them on anything. its not like creme brulee'. are medical treatments a right, or a luxury like creme brulee? that is the crux of the question

im not at all worried about oreosandsake. im worried about the LOL with FMS and no money who shells out 10K to a charlatan and gets no results.

 

[Ducttape]

By RVU, the system has been re structured so that e&m codes 99214 are essentially same value as a CESI.

if i am spending 25 minutes in direct consultation with the patient, or 10 minutes to do a CESI, the time and effort should be comparable.

one of the reasons we are seeing lower and lower reimbursements for procedures is because of how we are incentivized to do as many procedures as possible for highest revenue.

but does that lead to better heatlhcare?

8 million or so epidurals per year in the US, and a 99% increase in epidural injections from 2000 to 2014 (where i found easily accessed data), but an increase in the rate of lumbar fusion in that same time period.....

 

[bedrock]

if i am spending 25 minutes in direct consultation with the patient, or 10 minutes to do a CESI, the time and effort should be comparable.

one of the reasons we are seeing lower and lower reimbursements for procedures is because of how we are incentivized to do as many procedures as possible for highest revenue.

but does that lead to better heatlhcare?

8 million or so epidurals per year in the US, and a 99% increase in epidural injections from 2000 to 2014 (where i found easily accessed data), but an increase in the rate of lumbar fusion in that same time period.....

A CESI is 10x more risky and requires 10x the specialized skill compared to a 99214 which any mid level can do.

If you’re averaging 25 minutes of FaceTime, so 30 min per patient, that is slow as mud…or a resident.
If your patients are that psychologically screwed up to frequently need 30 min visits then they need pain psych or addiction not a pain physician. I know you are boarded in addiction but most of us are not, as our interests in pain treatment does not extend to the brain.

So unfair to compare your addiction medicine practice to the regular pain practices that >90% of us have.

Personally I prevent over hundred fusion surgeries a year, which cost $20,000 to the system compared to my two $800 epidurals (including ASC fee).

I don’t defend docs doing ESI for generic DDD.

And the fusion rate is dependent on unscrupulous surgeons.

I’m doing my job. I can’t help it if dishonest surgeons fuse everyone who walks in the surgeons door (without seeing me first).

 

[RoloTomassi]

the difference is that pain patients are a vulnerable population. i could sell them on anything. its not like creme brulee'. are medical treatments a right, or a luxury like creme brulee? that is the crux of the question

im not at all worried about oreosandsake. im worried about the LOL with FMS and no money who shells out 10K to a charlatan and gets no results.

Basic healthcare is a right. That's why we have ambulance, ER, government plans. Top tier care is a luxury, like it or not, that's how our world works. Seems like your gripe should be with the fraudsters pretending to offer top tier treatment.

 

[RoloTomassi]

if i am spending 25 minutes in direct consultation with the patient, or 10 minutes to do a CESI, the time and effort should be comparable.

That's silly. Much more inherent value than time and effort like @bedrock said. That would mean that a skilled doc who can do a procedure in half the time and effort as another doc should get paid half as much.

 

[Ducttape]

A CESI is 10x more risky and requires 10x the specialized skill compared to a 99214 which any mid level can do.

If you’re averaging 25 minutes of FaceTime, so 30 min per patient, that is slow as mud…or a resident.
If your patients are that psychologically screwed up to frequently need 30 min visits then they need pain psych or addiction not a pain physician. I know you are boarded in addiction but most of us are not, as our interests in pain treatment does not extend to the brain.

So unfair to compare your addiction medicine practice to the regular pain practices that >90% of us have.

Personally I prevent over hundred fusion surgeries a year, which cost $20,000 to the system compared to my two $800 epidurals (including ASC fee).

I don’t defend docs doing ESI for generic DDD.

And the fusion rate is dependent on unscrupulous surgeons.

I’m doing my job. I can’t help it if dishonest surgeons fuse everyone who walks in the surgeons door (without seeing me first).

i dont have an addiction medicine practice.

in case you forgot, 99214 technically is 25 minutes of face time, if using time based billing. i had been told by admin that there was a push amongst CMS last year to make all billing time based... (but truth be told, i do not use time based billing, except maybe those patients that demand opioids)


and do we really prevent fusion? the data suggest otherwise, as the fusion rates have risen the past 15 years even while we have all been doing more epidurals.

That's silly. Much more inherent value than time and effort like @bedrock said. That would mean that a skilled doc who can do a procedure in half the time and effort as another doc should get paid half as much.

because it is so difficult to determine the quality difference between interventionalists, like any population based medicine, we are all averaged out.

---
i can also cogently argue that the way i do procedures is significantly safer yet slower than one of the competitors, who does only single AP views for his epidurals. taking AP, CLO with contrast then AP with contrast is a lot slower than 1 AP with blobogram and calling it a day...

should i get paid less?

---

i suspect that all patients prefer doctors to spend more time talking to them than less.

 

[clubdeac]

disagree.

you are taking advantage of the vulnerable. you are scamming them. conning them. is that what a doctor is supposed to do?

dont devalue yourself, but change a reasonable fee with a reasonable margin.

Says the guy who’s admitted to making up histories and physical exam findings so his injections will be covered. Oooook

 

[drusso]

the difference is that pain patients are a vulnerable population. i could sell them on anything. its not like creme brulee'. are medical treatments a right, or a luxury like creme brulee? that is the crux of the question

im not at all worried about oreosandsake. im worried about the LOL with FMS and no money who shells out 10K to a charlatan and gets no results.

SOS is a giant scam, but you don't give a shyte about that.

 

[SSdoc33]

SOS is a giant scam, but you don't give a shyte about that.

look, i know you have a crusade, but SOS or no SOS, dont take advantage of people. its not that hard. dont turn this into something that its not

 

[drusso]

look, i know you have a crusade, but SOS or no SOS, dont take advantage of people. its not that hard. dont turn this into something that its not

Tell that to your employer. Often, cash prices are lower than negotiated insurance prices. #freemarkets

Hospital care may cost less with cash than with a copay

Insurance is supposed to help make health care bills more bearable, but Johns Hopkins Carey Business School Accounting Professor Ge Bai, professor of health policy and management at the Bloomberg School of Public Health, has discovered that’s not always true.

carey.jhu.edu

"The newly-published study shows that individuals with high-deductible health plans may benefit from paying with cash rather than using their insurance for the procedures the study evaluated. For example, the median negotiated price for a colonoscopy is $5,000 or more, but the median cash price is about $1,600. Individuals who have to meet a deductible higher than $5,000 would have to pay that full amount, more than three times what they might pay if they did not use their insurance. Though these prices are median, Bai’s study shows that there is wide variation across the board."

Paying $1000 for a regen procedure that would otherwise save a $10,000 HOPD procedure is a no-brainer. If someone put steroids in my knee and referred me to a knee surgeon for an HOPD-based meniscectomy, I'd be pissed.

 

[SSdoc33]

Says the guy who’s admitted to making up histories and physical exam findings so his injections will be covered. Oooook

what happened to the olive branch? i guess you burned it.

yeah, ill call pain a 6 instead of a 5 or say a patient did 6 weeks of PT instead of 5 to get a shot approved. you want to play by the arbitrary insurance rules, go right ahead.

TBH, i have so many patients, it really doesnt change things for me all that much if i have to wait a bit longer or do an addendum to a note, but this just gets the patients the treatments they need quicker with less red tape.

 

[SSdoc33]

Tell that to your employer. Often, cash prices are lower than negotiated insurance prices. #freemarkets

Hospital care may cost less with cash than with a copay

Insurance is supposed to help make health care bills more bearable, but Johns Hopkins Carey Business School Accounting Professor Ge Bai, professor of health policy and management at the Bloomberg School of Public Health, has discovered that’s not always true.

carey.jhu.edu

"The newly-published study shows that individuals with high-deductible health plans may benefit from paying with cash rather than using their insurance for the procedures the study evaluated. For example, the median negotiated price for a colonoscopy is $5,000 or more, but the median cash price is about $1,600. Individuals who have to meet a deductible higher than $5,000 would have to pay that full amount, more than three times what they might pay if they did not use their insurance. Though these prices are median, Bai’s study shows that there is wide variation across the board."

Paying $1000 for a regen procedure that would otherwise save a $10,000 HOPD procedure is a no-brainer. If someone put steroids in my knee and referred me to a knee surgeon for an HOPD-based meniscectomy, I'd be pissed.

you overinflate your worth

most of my patients are on medicare or caid. few of them high deductibles. vast majority pay very little, but you want me to charge them out of pocket?

in the tiny subset of patients with high deductibles who would actually benefit from a regenerative procedure, you may have a point.

PRP fixes meniscal tears now? thats news to me

 

[drusso]

you overinflate your worth

most of my patients are on medicare or caid. few of them high deductibles. vast majority pay very little, but you want me to charge them out of pocket?

in the tiny subset of patients with high deductibles who would actually benefit from a regenerative procedure, you may have a point.

PRP fixes meniscal tears now? thats news to me

I wish that you would keep up with the scientific literature. Though this trial did not control for possible treatment contamination from effects related to intercessory prayer and psychokinesis, its results are compelling.

Randomized Controlled Trial

Int J Mol Sci. 2019 Feb 16;20(4):856.
doi: 10.3390/ijms20040856.

Short-Term Outcomes of Percutaneous Trephination with a Platelet Rich Plasma Intrameniscal Injection for the Repair of Degenerative Meniscal Lesions. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study​

Rafal Kaminski 1, Marta Maksymowicz-Wleklik 2, Krzysztof Kulinski 3, Katarzyna Kozar-Kaminska 4, Agnieszka Dabrowska-Thing 5, Stanislaw Pomianowski 6
Affiliations expand

• PMID: 30781461
• PMCID: PMC6412887
• DOI: 10.3390/ijms20040856

Free PMC article

Abstract​

Meniscal tears are the most common orthopaedic injuries, with chronic lesions comprising up to 56% of cases. In these situations, no benefit with surgical treatment is observed. Thus, the purpose of this study was to investigate the effectiveness and safety of percutaneous intrameniscal platelet rich plasma (PRP) application to complement repair of a chronic meniscal lesion. This single centre, prospective, randomized, double-blind, placebo-controlled study included 72 patients. All subjects underwent meniscal trephination with or without concomitant PRP injection. Meniscal non-union observed in magnetic resonance arthrography or arthroscopy were considered as failures. Patient related outcome measures (PROMs) were assessed. The failure rate was significantly higher in the control group than in the PRP augmented group (70% vs. 48%, P = 0.04). Kaplan-Meyer analysis for arthroscopy-free survival showed significant reduction in the number of performed arthroscopies in the PRP augmented group. A notably higher percentage of patients treated with PRP achieved minimal clinically significant difference in visual analogue scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS) symptom scores. Our trial indicates that percutaneous meniscal trephination augmented with PRP results in a significant improvement in the rate of chronic meniscal tear healing and this procedure decreases the necessity for arthroscopy in the future (8% vs. 28%, P = 0.032).

Keywords: PRP; chronic meniscal lesion; horizontal meniscal tear; meniscus; meniscus repair; meniscus tear; platelet-rich plasma; trephination.

 

[SSdoc33]

I wish that you would keep up with the scientific literature. Though this trial did not control for possible treatment contamination from effects related to intercessory prayer and psychokinesis, its results are compelling.

Randomized Controlled Trial

Int J Mol Sci. 2019 Feb 16;20(4):856.
doi: 10.3390/ijms20040856.

Short-Term Outcomes of Percutaneous Trephination with a Platelet Rich Plasma Intrameniscal Injection for the Repair of Degenerative Meniscal Lesions. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study​

Rafal Kaminski 1, Marta Maksymowicz-Wleklik 2, Krzysztof Kulinski 3, Katarzyna Kozar-Kaminska 4, Agnieszka Dabrowska-Thing 5, Stanislaw Pomianowski 6
Affiliations expand

• PMID: 30781461
• PMCID: PMC6412887
• DOI: 10.3390/ijms20040856

Free PMC article

Abstract​

Meniscal tears are the most common orthopaedic injuries, with chronic lesions comprising up to 56% of cases. In these situations, no benefit with surgical treatment is observed. Thus, the purpose of this study was to investigate the effectiveness and safety of percutaneous intrameniscal platelet rich plasma (PRP) application to complement repair of a chronic meniscal lesion. This single centre, prospective, randomized, double-blind, placebo-controlled study included 72 patients. All subjects underwent meniscal trephination with or without concomitant PRP injection. Meniscal non-union observed in magnetic resonance arthrography or arthroscopy were considered as failures. Patient related outcome measures (PROMs) were assessed. The failure rate was significantly higher in the control group than in the PRP augmented group (70% vs. 48%, P = 0.04). Kaplan-Meyer analysis for arthroscopy-free survival showed significant reduction in the number of performed arthroscopies in the PRP augmented group. A notably higher percentage of patients treated with PRP achieved minimal clinically significant difference in visual analogue scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS) symptom scores. Our trial indicates that percutaneous meniscal trephination augmented with PRP results in a significant improvement in the rate of chronic meniscal tear healing and this procedure decreases the necessity for arthroscopy in the future (8% vs. 28%, P = 0.032).

Keywords: PRP; chronic meniscal lesion; horizontal meniscal tear; meniscus; meniscus repair; meniscus tear; platelet-rich plasma; trephination.

Ha. what a crappy article. you shouldnt be doing arthroscopy for chronic meniscal tears anyway.

"chronic meniscal tears" = arthritis. no problem if you want to inject PRP for arthritis. although charging 1K for it when steroids or visco are also an option may not be the wisest.

there is an issue big problem if you want to inject PRP for acute meniscal tear in a younger patient. that is not SOC. you really will convince yourself of anything to straight for their checkbooks, dont you? dirty

 

[Paindude11]

Sounds like CMS/Medicare is responding to over utilization of SI fusion technologies by limiting the SI diagnostic and therapeutic blocks. Almost like limiting a scs trial , by adding psych clearances and extra steps… IMO sacroiliitis is rarely a catastrophic condition .

If you look at the scs Medicare lcd’s and possibly the new SI injection lcd you just need psych inventories or screening , not necessarily a psychiatrist or LSW. If people are limited in resources (due to location or access to psych) consider doing your own psych inventories.it’s not that difficult .

Also the pain guys that are running state pain societies, you really need to fight this at a state level and then take it nationally if you want to reverse this crap.

Unfortunately Medicare isn’t limiting SI fusions. In fact they are reimbursing very well for them. So now I’m seeing many many unnecessary screws being placed in Medicare pts who will likely end up much worse off (or certainly no better) down the road. Makes no sense why they will cover this, but not a simple, harmless steroid injection? But alas… that is the nature of this field and playing the insurer games.

 

[Spine MD]

I haven’t done it yet, but I’m leaning towards learning more about fusio

Ligament laxity is most likely cause- will help with adjacent segmental disease as well if someone is fused from L5-S1, which is what I see frequently. Like I said, haven’t done it yet but seems like it’s delivering some promising results for other people

What evidence is there that the 1st or 2nd strongest ligament in the body develops laxity, how is that diagnosed, etc. etc.?

 

[DrMDAware]

You’re a kid. In 5 years you will realize everything you were taught is now wrong. If you see an article or a post on a newer procedure: it is marketing. KOLs lie to get paid.

Steve, genuinely asking you and others with experience what procedures have you seen fizzled out or not up to snuff? I believe you. I'm looking for some historical perspective. TIA