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I'm trying to have a patient admitted for 48-72 hours for an indwelling IT catheter trial.

Have any of you done this recently? I am concerned that insurance will reimburse for the catheter placement in the ASC but not the inpatient stay.

In fellowship we did this routinely, but different state, different insurance mix. I am told insurance will cover inpatient stay with "appropriate diagnosis code"

Guy has Medicare A/B. I'm hospital employed.

Thanks
 

lobelsteve

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One trial every 2 years or so. In office single shot IT. Monitor for 4-6 hours and do functional tasks.
 
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BobBarker

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I don’t understand doing it in the ASC and then moving him to the hospital and keeping him. Just do it in the hospital and keep him.
 
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I don’t understand doing it in the ASC and then moving him to the hospital and keeping him. Just do it in the hospital and keep him.
yes that is an option too but hard to book cases like that electively in Main OR's without getting bumped. We can do inpatient cases in our ASC and admit from there.

We did 5-7 day catheter trials in fellowship. I haven't trialed a patient in years. This guy is legit and has failed everything else. I don't want him to be on the hook for a non-reimbursed inpatient stay.

I'm more comfortable doing a 2-3 day trial then single shot.
 

BobBarker

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So it isn’t really a ASC, it is a second HOPD.
 
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How much do you believe in the IT pump for this guy? Single shot IT fentanyl, monitor for a couple hours and have the patient walk around pre-post.
Patient of mine for 3 years. Debilitating axial pain primarily with prolonged sitting so he can't eat in restaurants, watch a movie. Had laminectomy remotely. Pain improves with recumbency. Has had exhaustive workup, failed facet interventions, SCS, has taken oral Opioids in the past, hates them, does OK with Tramadol.

I participated in about 100 pump trials in fellowship, we had 500 pump patients in our system..I haven't done a trial in years since being on my own.

I know what the PACC guidelines say but I wanted to observe this guy over 2-3 days with cont. IT therapy to see if this very specific pain pattern improved, hence my ambivalence about single shot.
 

lobelsteve

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Non specific axial LBP. Trial not indicated just cuz he failed everything else. Tramadol and stretches. Avoid prolonged sitting. And deal with it. Gimme mets or some crazy complications. Or turf to some jackhole to pump and dump.
 

Ferrismonk

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Maybe consider a back brace, preferably one with a removal hard piece so he can adjust to his comfort level. If he's just on Tramadol, I would continue it. Maybe rotate to Tramadol ER.

Pumps are old-school tech that are only really indicated in high-dose opiate patients with cancer who have intolerable side effects with other delivery methods or baclofen pumps for spinal cord injury patients with spasticity.

Pump for relatively opiate naive patient with axial low back pain? That's a never situation for me.
 
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Ducttape

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He hates opioids.
Unless you are doing prialt, why are you putting him on chronic continuous opioids?

sonetimes doing nothing is much harder but better than doing something....
 

Baron Samedi

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My understanding is that fentanyl rapidly disperses out of the intrathecal space -- if you are going to do a single shot I'd probably do hydromorphone or morphine.

Someone please correct me if I'm wrong about this.
 
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My understanding is that fentanyl rapidly disperses out of the intrathecal space -- if you are going to do a single shot I'd probably do hydromorphone or morphine.

Someone please correct me if I'm wrong about this.
Epidural fentanyl is very questionable impact because it’s probably absorbed by the epidural fat and systemically faster than it crosses the dura. Intrathecal fentanyl definitely works, but only lasts for a couple hours. Which is good, because it doesn’t have time to spread cephalad and cause respiratory depression hours later like Morphine.
 
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Ducttape

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prialt mentioned as the only non-opioid pain option for ITP (obviously baclofen is not for pain).
 
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I appreciate the replies. No one actually answered my question which was: is there a way to preemptively ensure that Medicare will cover an inpatient stay for a catheter trial.
 

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Most hospitals have a team of people who help ensure an admission is medically necessary and get you in the right DRG. The easiest way would be to reach out to the hospitalist as they likely know who that person is for you.

Which LCD/region are you in?

Are you planning a buried catheter trial or just a percutaneous trial?

I would much rather you do this as a single shot 12.5 to 25 mcg fentanyl boluses in the outpatient setting, unless you are burying the catheter/anchor/etc and running a low rate infusion
 

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My understanding is that fentanyl rapidly disperses out of the intrathecal space -- if you are going to do a single shot I'd probably do hydromorphone or morphine.

Someone please correct me if I'm wrong about this.
Because fentanyl is so lipophilic it is absorbed quickly and doesn't hang around in the IT space. I recall from residency they said it was basically equinalgesic to IV fentanyl. It does work though. Morphine hangs around because of is relative hydrophilicity (which is why we give it in OB spinals for postop pain)
 

Ducttape

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that's also why monitoring of respiratory rate up to 24 hours post IT morphine is suggested.
Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration | Anesthesiology | ASA Publications (yes, it is from 2009, but as far as I am aware, still appropriate)

Monitoring after Administration of Single-injection Neuraxial Lipophilic Opioids ( e.g., Fentanyl): Both the consultants and the ASA members agree that monitoring should be performed for a minimum of 2 h after administration, and that continual (i.e. , repeated regularly and frequently in steady rapid succession)6monitoring should be performed for the first 20 min after administration, followed by monitoring at least once per hour until 2 h has passed. The ASA members agree and the consultants strongly agree that after 2 h, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.
Monitoring after Administration of Single-injection Neuraxial Hydrophilic Opioids ( e.g., Morphine, Not Including Sustained- or Extended- release Epidural Morphine): Both the consultants and the ASA members agree that (1) monitoring should be performed for a minimum of 24 h after administration; (2) monitoring should be performed at least once per hour for the first 12 h after administration, followed by monitoring at least once every 2 h for the next 12 h (i.e. , from 12 to 24 h); and (3) after 24 h, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.
 
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prialt mentioned as the only non-opioid pain option for ITP (obviously baclofen is not for pain).
God help those doctors that mess around with Prialt. Some of the worst inpt trials I ever did were Prialt, and in my experience maybe one pt didn't hallucinate or experience neuropsych issues forcing an abort of the trial.

One of my attendings was one of the initial researchers who helped get it through the initial trials.
 
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