drusso

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ASIPPNewsMast

Final CMS Payment Rules
for Interventional Pain Physicians
In-Office, ASC, and HOPD Settings

CMS released all 3 payment rules on November 1, 2019. These rules have multiplepdates including:

1. Interventional -Specific News
The good news, bad news, and ugly news continue to play out in the final rule, along with some errors, which we thought would be corrected, but have not.

1.1 Physician Payment Schedule
The CY 2020 Medicare Physician Fee Schedule (PFS) conversion factor is $36.09 (0.14% increase from CY 2019 conversion factor, was $36.04).

Overall, the cuts proposed for intercostal nerve blocks, vagus nerve block, ilioinguinal, and iliohypogastric nerve block reductions continue.

Some of the highlights include an increase in payment rates for sacroiliac joint nerve blocks, genicular nerve radiofrequency neurotomy, and sacroiliac joint nerve radiofreqency neurotomy, when performed in an office setting.

Sacroiliac joint fusion when performed in any setting.

1.2 Hospital Outpatient Department

Hospital outpatient departments continue to reap benefits wherein they are being paid double the payment of ASCs.

Of note is that interspinous stabilization device or prosthesis continues to face a 22.7% decline, along with a 62.3% decline for disc decompression.

New injection codes and genicular nerve block codes are paid appropriately in a hospital setting.

1.3 Ambulatory Surgery Centers
ASCs are paid less than 50% of hospital departments for non-implantables.

Most importantly, CMS has miscalculated payments for genicular nerve blocks and genicular radiofrequency neurotomy, which is 20% of the hospital payments instead of 50% of HOPD rate.

Multiple changes performed in the past have been preserved.

Interspinous prosthesis continues to face a 21.6% cut compared to 2019.
64421 (Injection(s), anesthetic agent(s) and/or steroid; intercostal nerves, each additional level - converted to add-on code - No payments in ASC & HOPD settings).
Disc decompression faces a significant cut of 59%.
Trigeminal nerve blocks, greater occipital nerve block, vagus nerve block, and suprascapular nerve block continue to face significant cuts.

2. Site-neutral Payments
CMS will finish phasing in a policy adapted in 2018 to make payments for clinic visits site neutral by reducing payments for hospital outpatient clinic visits provided at off campus provider-based departments. Medicare will pay doctors the same amount for a basic visit, whether it takes place in a hospital outpatient facility or a regular doctor's office.

3. Evaluation and Management, Coding, and Payment
The final sets separate payment rates for all 5 levels of coding for evaluation and management visits. The changes will be implemented on January 1, 2021.

4. Medical Record Documentation
The final rule allows physicians, physician assistants, and advanced practice registered nurses to review and verify information in a patient's medical record that is entered by other clinicians, rather than re-entering the information.

5. Telehealth Services
CMS will add a set of codes that describe a bundled episode of care for treatment of opioid use disorders, to the list of telehealth services covered by Medicare.

6. MIPS - 2020 performance period

45 points is the performance threshold (increased 15 points from PY 2019)

The Quality performance category is weighted at 45% (no change from PY 2019)

The Cost performance category is weighted at 15% (no change from PY 2019)

The Promoting Interoperability performance category is weighted at 25% (no change from PY 2019)
Here are the links Payment rates for major IPM codes:

Physician Fee Schedule:
https://www.asipp.org/Fee Schedules/2020PhysicianFinalRates.pdf

ASC Fee Schedule:
https://www.asipp.org/Fee Schedules/2020ASCFinalRates.pdf

HOPD Fee Schedule:

The following is important information on the newly released 2020 final payment rules. ASIPP and SIPMS will be sending comment letters to CMS. You may also send comment letters to them on these payment rules no later than 5 p.m. EST on December 2, 2019.
 

knoxdoc

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Thanks for all the info. I was always under the impression that MC did not pay for RF of the SIJ. What CPT and ICD-10 code pairings are they accepting for that? ...and what the hell is a sacroiliac joint nerve, the lateral branches of S1-S3? I though that was all considered "experimental". All I know is - Epstein did not commit suicide.
 

Birdstrike

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Thanks for all the info. I was always under the impression that MC did not pay for RF of the SIJ. What CPT and ICD-10 code pairings are they accepting for that? ...and what the hell is a sacroiliac joint nerve, the lateral branches of S1-S3? I though that was all considered "experimental". All I know is - Epstein did not commit suicide.
You are correct. He did not commit suicide. He committed Arkancide. Suicide and Arkancide are two different means of death. But with the same result.
 

cowboydoc

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Not sure. 1 for all 3 would suck! I believe this is supposed to start 1/1/2020.
 

The JockDoc

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It appears that they valued all genicular nerves as a single nerve. A single peripheral n block or RFA w/ imaging guidance pays the same as any number of genicular nerve blocks or RFAs w/ imaging.
 

clubdeac

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Wow welp that effectively just killed genicular and SIJ procedures. It’s really sad how these assholes can unilaterally kill a procedure by refusing to pay what it’s worth. An SIJ ablation takes waaay longer than a two level TFESI and they pay nearly the same. What a joke
 
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Before, you could only bill 64450 x1 for geniculars ($78). Now it pays over $200 just for the block. Ablation (64640) was $120 per nerve now it’s about $420 for all 3, so basically a wash. I don’t see where this is bad.
 
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Err, I’ll speak for everyone by saying we would all bill 64450x3 for a genicular block.
Then you were doing it wrong, for Medicare at least. Yes, it makes no sense since they aren’t even all branches of the same nerve, but that’s how Medicare looked at it. One example source here. You could bill 64640 x3 for the ablation though.
 

Orin

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Right, the question now will be how many genicular nerves do you really need to burn/block/etc for the new 64624 CPT and how often they will be allowed by insurance. Based on that I suspect we'll see more folks doing just targeting one or two genicular branch, doing medial/lateral burns on different days, or some other shenanigans to bill that more frequently.
 
Apr 13, 2016
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Right, the question now will be how many genicular nerves do you really need to burn/block/etc for the new 64624 CPT and how often they will be allowed by insurance. Based on that I suspect we'll see more folks doing just targeting one or two genicular branch, doing medial/lateral burns on different days, or some other shenanigans to bill that more frequently.
How long have you been seeing the geniculars last? I’ve had several people coming back about 4 months. Doesn’t seem to be quite as long as it is for spine RF. Not sure if it’s the angle of the probe relative to the nerve (conventional RF for me).
 

Ducttape

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I think their point is that you are treating a condition, not a nerve.

just like lumbar RFAs we treat 1 joint, 2 nerves are ablated.

if they didn't do it this way, what is to prevent some unscrupulous pain doc from doing 2 separate lesionings per each genicular nerve, for total of 6 lesions? or say doing 4 level TF bilaterally for radicular back pain that one could treat with 1 ESI?
 

The JockDoc

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I've seen them range from not working to 1-2 years of pain relief.

Agree that it could be abused by coding for single nerves but I really wish they assigned a higher wRVU for the procedure. It takes a 40-60 min slot in my facility to get the procedure done with positioning, etc.
 
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BobBarker

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You put the patient supine on a table. You have them bend the operative knee about 30 degrees and support it themselves with their foot on the table. This takes 1 minute.
 

thecentral09

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You put the patient supine on a table. You have them bend the operative knee about 30 degrees and support it themselves with their foot on the table. This takes 1 minute.
I do a lot of genicular. Most patients are either 400 pounds or too old to be surgical candidates, and I promise you that perfect positioning with the C-arm takes much longer than one minute. I agree to do multiple lesions along the entire possible tract of all the appropriate genicular nerve takes well over 20 to 30 minutes.
 

The JockDoc

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My genicular RF patients aren't spry or thin and move slowly. I'm meticulous about the procedure, use US localization when I can and do at least 2 burns to maximize treatment area. I've had to pause and use a lot more local than expected on some during the RFA or needle placement. All of this adds time. I feel that my results are consistent and favorable though. I rarely hit 60 min, usually around 40-45 min.
 
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Using US is a waste of your time and won't change your outcomes IMO.

Use your bony landmarks and just make sure to take a few extra moments to get your initial fluoro image just right.
 

The JockDoc

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Using US is a waste of your time and won't change your outcomes IMO.

Use your bony landmarks and just make sure to take a few extra moments to get your initial fluoro image just right.
I typically don't bother with US in the superior nerves and it is probably is equal to or faster than getting fluoro just right when I do use it.

Returning to the problem at hand - the new codes are undervalued for the amount of work and time needed compared to other procedures, say a 2 level TFESI which now pays more. I feel like I shouldn't even be surprised b/c this happens frequently in medicine nowadays.
 
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Ronin1

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I do a lot of genicular. Most patients are either 400 pounds or too old to be surgical candidates, and I promise you that perfect positioning with the C-arm takes much longer than one minute. I agree to do multiple lesions along the entire possible tract of all the appropriate genicular nerve takes well over 20 to 30 minutes.
Come on. This honestly takes less than 10 minutes.
 
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DrMDAware

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Going into pain.

Questions
1. For suboxone management what would be a type payment (and CPT)?
2. What's the difference of 64575 vs 64581 vs 64555 vs 64561 vs (all 'implant neuroelectrodes)?
3. Are there any very common CPT codes for office procedures? Just like 3-5 of them.
4. In your experience which procedures offer the best ratio of payment vs time to do/hassle to bill ?

Looking to understanding and learn more so I don't get taken advantage of and can budget accordingly. Thx
 
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Come on. This honestly takes less than 10 minutes.
Maybe if your patients are deeply sedated and you don’t have to worry about adequate local anesthetic. I’ve definitely had them take 45 minutes when there’s a spot that won’t numb up. When it goes smoothly, 20 minutes (including positioning). 3 burns, in office with Xanax only for sedative.
 

Ferrismonk

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Mine take about 30 minutes. Takes 5-10 min to lie on table, position, and prep. Another 5-10 min to drape, flouro, local, wait for it work. 2-3 minutes for needle placement, 3 minute burn, clean up/bandaids, walk out.
 
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The JockDoc

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lobelsteve

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I can see why we're getting paid less to do the same thing now.
You can consider me a pioneer. I was teaching the procedure for Neurotherm in 2014 and did several workshops. Maybe it’s experience.
 
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drusso

drusso

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You can consider me a pioneer. I was teaching the procedure for Neurotherm in 2014 and did several workshops. Maybe it’s experience.

"You may want to consider procedures that can help repair the damaged knee structures rather than kill the nerves. However, if you have severe arthritis and insurance reimbursement is a must, then nerve ablation knee treatment is a procedure to consider."


Not everything covered works; not everything that works is covered.

Coverage =/= Care