Maximum Number Of Procedures in a year.

IPSIS: Formerly the Spine Intervention Society
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
N

NEA

Full Member
10+ Year Member
Joined
Jul 12, 2012
Messages
30
Reaction score
4
How many injections can one do in a year on one patient in different areas taking into account steroid dosing and without getting red flagged by the insurance carrier or a suggestion of malpractice?

One of my patient comes in every month with a new complaint and in the past 9 months she has had b/l lumbar MBB's followed by RF, b/l cervical MBB's followed by RF, B/L Hip injections, b/l shoulder injections, right wrist injection. I saw her again today and she stated that all the above areas are pain free but now her knees are bothering her and she brought MRI from her PCP showing moderate OA in all compartments and she wanted an injection!!!

Really!!!! I told her let me make sure I am not exceeding any limit or doing something which is not standard of care.

Any comments would be greatly appreciated.
Members don't see this ad.
 
NEA said:
How many injections can one do in a year on one patient in different areas taking into account steroid dosing and without getting red flagged by the insurance carrier or a suggestion of malpractice?

One of my patient comes in every month with a new complaint and in the past 9 months she has had b/l lumbar MBB's followed by RF, b/l cervical MBB's followed by RF, B/L Hip injections, b/l shoulder injections, right wrist injection. I saw her again today and she stated that all the above areas are pain free but now her knees are bothering her and she brought MRI from her PCP showing moderate OA in all compartments and she wanted an injection!!!

Really!!!! I told her let me make sure I am not exceeding any limit or doing something which is not standard of care.

Any comments would be greatly appreciated.
Click to expand...

Synvisc. And quit your whining. Sounds like a college fund. :)
 
Members don't see this ad :)
i have a number of these patients, and i always feel bad like i am sticking them everytime i see them. Every month its either the hip, knee, shoulder, back or neck, then rotate. They could get 1 year out of an RF, but after, after i have addressed every other body part, its back to the low back for another RF, despite my last injection was like 2 months ago...

i always worry about what some other doc would be thinking if he read my notes. Because i know it looks bad, but i am honestly trying to NOT inject these people, but they are old, no secondary gain, and do very well with each body part for like 4-6 months, they just have too many bad parts...

im glad you posted this...
 
Jcm800 said:
i have a number of these patients, and i always feel bad like i am sticking them everytime i see them. Every month its either the hip, knee, shoulder, back or neck, then rotate. They could get 1 year out of an RF, but after, after i have addressed every other body part, its back to the low back for another RF, despite my last injection was like 2 months ago...

i always worry about what some other doc would be thinking if he read my notes. Because i know it looks bad, but i am honestly trying to NOT inject these people, but they are old, no secondary gain, and do very well with each body part for like 4-6 months, they just have too many bad parts...

im glad you posted this...
Click to expand...

Exactly my point. I just hope that no one is thinking that all we are concerned about is milking the insurance without having any regards for our patients!!! Although they are the ones that have all these complaints and get good help from these 'shots'

How much is too much??
 
Yes, this sounds like my typical VA patient. I basically treat them for everything... a one stop shop. And they are very grateful. I typically don't give steroid (regardless of route) more frequently than every 3 mos. This is all the more frequent my schedule allows and is probably good medicine
 
Ligament said:
Sounds like my typical elderly patient. You are doing a great service by keeping them off meds and keeping them mobile
Click to expand...

i'm glad the original poster posted this.

I would have posted somethign similar but I knew SSDIC would have said something so I deferred.

I agree, these patients do well. AND I think if we can do something to lessen the opioid consumption in America, that is a success. Someone once told me, the most dangerous things we do in Pain Medicine is opioids. Everything else, we can directly control it to a certain degree.
 
Before we go patting ourselves on the back for preventing complications from opioid use for chronic pain: The side effects of repeated steroids are osteoporosis, sometimes massive weight gain (one doc in my town eventually suspended by the medical licensing board caused scores of patients to gain over 100lbs in less than one year through monthly steroid injections), psychosis/neurosis, difficult to control hypertension, sometimes out of control diabetes, permanent disfigurement from Cushingoid features, subcutaneous significant atrophy of fat, permanently painful crystal deposits in muscle and subcutaneous and intrabursal, reactivation of previously quiescent hepatitis C, increased risk of infection, hypercortisolism resulting in hospitalization or shock, and tendon rupture, and many patients that have suffered permanent paralysis or death. And this is all if they are performed correctly. We have ample evidence that our pain physician population has a significant number of doctors that will stoop to utilizing illegal compounding pharmacies to pad their bottom line, resulting in exposure of tens of thousands of patients to potentially long term and lethal side effects from steroid contamination. Malpositioning of the needle can cause another entire set of complications that are significant. And all of these for very transient, short term relief.... All of these side effects cost hundreds of millions of dollars each year in treatment and diagnostic costs.

Therefore, I am not so sure that we can conclude pain physicians administering repeated steroid injections are any safer than pain physicians prescribing opioids..... That would be an interesting analysis. Most patients dying from opioids are not through administration by trained or board certified pain physicians.
 
Just to add to the list, OB/GYN has been annoyed with us because of an increase in referrals for changes in menstruation after the patient happened to get a kenalog injection (typically a knee or shoulder).
 
I'm surprised there isn't a more well-defined answer to the question. I guess I just always assumed there was.
 
lol...funny. There indeed is no answer. I am aware of a patient that received 200 stellate ganglion blocks over one year (in office, no fluoroscopy, no monitoring). Seems a bit extreme to me, but insurance paid for them all... go figure. It appears the only reason the patient did not receive 365 is that he wasn't open on weekends. Or perhaps the doc developed the dreaded syringe barrel callus syndrome (SBCS), known to cause a physician to become eligible for permanent disability....
 
I think this question is quite complex, because there are many factors involved to. Such as what steroid was used, how much was used,etc.

3 ESIs with 120mg of depomedrol vs 3 ESIs with 40mg of depomedrol are clearly two different scenarios.....

Can those side effects occur with 40mg of depomedrol. yes. but it is less likely. I think in medicine it's always about weighing the possibilities. it's risk mitigation, especially when there's so much gray...
 
For those of us outside your specialty, it seems we've always heard 'only 3 epidurals per year, and no more', as though the involved dosage maximums were completely understood. But when it comes to the cumulative dosage from injections around the rest of the body, we have no idea what the max doses are? That surprises me.
 
facetguy said:
For those of us outside your specialty, it seems we've always heard 'only 3 epidurals per year, and no more', as though the involved dosage maximums were completely understood. But when it comes to the cumulative dosage from injections around the rest of the body, we have no idea what the max doses are? That surprises me.
Click to expand...

the "only 3 epidurals per year" were based on flimsy anecdotal evidence from the 1980s, and were a recommendation made by a particular group, since they were seeing cushings syndrome when patients were getting 3 epidurals with very high doses of steroids each injection.
 
I take from your callous tone that you do not believe in syringe barrell callous syndrome (SBCS).
I have it and it flares up every day. the only thing that helps me is high dose dilaud-uh.
someone told me to start injecting with my other hand and I cried at their insensitivity!
 
I had to do so much reaching across my patients that I tore my rotor cup
 
My calluses are healing nicely given the very high insurance deductables (many in my area went from $0 to $3000-5000 this year) that have made injections financially impossible for patients early in the year :)
 
You must log in or register to reply here.
Next unread thread

Similar threads

P
In office procedures
Replies
21
Views
1K
PainMD23
P
2
Are advanced procedures critical during fellowship year
Replies
18
Views
2K
Espn123
E
C
maximum time allowed between 2nd MBB and 1st RFA?
Replies
4
Views
348
cowboydoc
cowboydoc
D
Oral sedation for procedures.
2
Replies
68
Views
2K
lobelsteve
lobelsteve
P
Ability to do Bread and butter procedures coming out of fellowship
Replies
34
Views
1K
AlvinKamara
A
Top