How do y’all get your results from MBB? At my last practice we just called them the next day and said “what % relief did you get.” At my new practice we give them a sheet and it has time points 0/2/4/6 hours on it and also left side right side and also circle what % relief you got 0/20/40/60/80/100. Then they call the next day to report results. To me, this is overly complex. My partner called me yesterday and told me he had just gotten an RFA denial bc all time points weren’t 80% and he used Marcaine. Both of my practices have been private practices. Not sure if the new practice is more complex bc one of my partners does his RFA at a local hospital and their requirements are different?
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Did pt have >80% pain relief for the duration of the anesthetic? Yes/no
Did pt have functional improvement? Yes/no. Describe.
Did pt have functional improvement? Yes/no. Describe.
I do telemeds in between. 90% of patients don’t understand medial branch blocks no matter how well you explain them and give them an educational handout.
The way you are doing it now is a recipe to never do an rf again.
My opening question is “did the injection help you for a period of time the day of the injection?” Most people can answer that.
The way you are doing it now is a recipe to never do an rf again.
My opening question is “did the injection help you for a period of time the day of the injection?” Most people can answer that.
Did the shot help the day of the shot? Yes? Then you get an RF. Make up any numbers you want. Everyone can ‘walk better’ after the shot. I also like this phrase:
‘Pt has competed a full course of PTand performs a good home exercise program within the last 6 months’. You are not technically lying if the pt hasn’t done PT for this problem recently.
Also, remind me how PT will help with facet OA?
‘Pt has competed a full course of PTand performs a good home exercise program within the last 6 months’. You are not technically lying if the pt hasn’t done PT for this problem recently.
Also, remind me how PT will help with facet OA?
Hour by hour sheet that goes home with them, along with activities they did. Handout on the back of that tells patients what to expect, we verbally tell them at office visit, when scheduling, and then while doing consent that it will last a few hours only. Still have a few say it didn’t help because it wore off the next day, or even cross out the times on the sheet and write dates so they can use it to track for a whole week….
We do telehealth or in office f/u to go over results.
We do telehealth or in office f/u to go over results.
You have to play the stupid game that we didn’t start. If the limit is 80 percent, then it is-
“The insurance company will not allow me to do the Longer lasting RFA unless you say you got 80 percent relief with this test injection. So my question is, “do you think you got at least 80 percent relief from the TEST injections.””
I also explain again before i ask, that these are tests, they do not last long. No matter how many times you explain it you get the “yeah it was great for a day, i had no pain, but it came right back. I don’t want to keep doing that kind of injection.”
This isn’t a double blind placebo controlled study. It ceased being scientific when insurance got involved. It’s a roadblock. Make sure the patient knows what the game rules are before you start playing the game.
“The insurance company will not allow me to do the Longer lasting RFA unless you say you got 80 percent relief with this test injection. So my question is, “do you think you got at least 80 percent relief from the TEST injections.””
I also explain again before i ask, that these are tests, they do not last long. No matter how many times you explain it you get the “yeah it was great for a day, i had no pain, but it came right back. I don’t want to keep doing that kind of injection.”
This isn’t a double blind placebo controlled study. It ceased being scientific when insurance got involved. It’s a roadblock. Make sure the patient knows what the game rules are before you start playing the game.
I have tried several methods. Ideally, I would prefer to have a TeleMed the following day… I just do not have room on my schedule.
At this point: my MA calls patient the following day to ask % relief immediately after and knows to convert it to greater than 80% or not. Ie if whatever they say translates to little to no relief, then it’s under 80%. If their answer translates to more than that, and they’d be happy w that outcome on rfa, then it is greater than 80%. my MA knows never to document something such as 60, 70, 75% etc if the patient was happy with how they felt for duration local. I’m not denying Grandma an Rfa because she only got “75%” relief
A template is then inserted in their chart under phone note with indication for repeat MBB or rfa. Greater than 80% relief for the duration of local aesthetic, resolved pain on extension/rotation, improved function with ADLS X and Y, ODI reduction of 20 points for the duration of local aesthetic.
Ask for stupid things in your LCD criteria… Get stupid templates in the chart…
If they had little to no benefit from the mbb, they get scheduled for a follow up to discuss possible options.
I tried more detailed pain diaries…. Takes time to explain, usually don’t fill it out correctly, don’t get it back to us… gave up on that years ago
At this point: my MA calls patient the following day to ask % relief immediately after and knows to convert it to greater than 80% or not. Ie if whatever they say translates to little to no relief, then it’s under 80%. If their answer translates to more than that, and they’d be happy w that outcome on rfa, then it is greater than 80%. my MA knows never to document something such as 60, 70, 75% etc if the patient was happy with how they felt for duration local. I’m not denying Grandma an Rfa because she only got “75%” relief
A template is then inserted in their chart under phone note with indication for repeat MBB or rfa. Greater than 80% relief for the duration of local aesthetic, resolved pain on extension/rotation, improved function with ADLS X and Y, ODI reduction of 20 points for the duration of local aesthetic.
Ask for stupid things in your LCD criteria… Get stupid templates in the chart…
If they had little to no benefit from the mbb, they get scheduled for a follow up to discuss possible options.
I tried more detailed pain diaries…. Takes time to explain, usually don’t fill it out correctly, don’t get it back to us… gave up on that years ago
You are flushing money down the toilet. Mbb f/u visits are the quickest and best paying thing we do.I have tried several methods. Ideally, I would prefer to have a TeleMed the following day… I just do not have room on my schedule.
At this point: my MA calls patient the following day to ask % relief immediately after and knows to convert it to greater than 80% or not. Ie if whatever they say translates to little to no relief, then it’s under 80%. If their answer translates to more than that, and they’d be happy w that outcome on rfa, then it is greater than 80%. my MA knows never to document something such as 60, 70, 75% etc if the patient was happy with how they felt for duration local. I’m not denying Grandma an Rfa because she only got “75%” relief
A template is then inserted in their chart under phone note with indication for repeat MBB or rfa. Greater than 80% relief for the duration of local aesthetic, resolved pain on extension/rotation, improved function with ADLS X and Y, ODI reduction of 20 points for the duration of local aesthetic.
Ask for stupid things in your LCD criteria… Get stupid templates in the chart…
If they had little to no benefit from the mbb, they get scheduled for a follow up to discuss possible options.
I tried more detailed pain diaries…. Takes time to explain, usually don’t fill it out correctly, don’t get it back to us… gave up on that years ago
A vigorous RF practice is the best way to cash in long term. These are yearly RFs many times
Play the long game
Everyone comes back for a 60 second follow-up visit within a week to check the box and do a quick 99213How do y’all get your results from MBB? At my last practice we just called them the next day and said “what % relief did you get.” At my new practice we give them a sheet and it has time points 0/2/4/6 hours on it and also left side right side and also circle what % relief you got 0/20/40/60/80/100. Then they call the next day to report results. To me, this is overly complex. My partner called me yesterday and told me he had just gotten an RFA denial bc all time points weren’t 80% and he used Marcaine. Both of my practices have been private practices. Not sure if the new practice is more complex bc one of my partners does his RFA at a local hospital and their requirements are different?
I don’t disagree with you… I just do not have time in my day for that. I’m booked out like six weeks for consults, routinely add on urgent consults, work through lunch, etc. even if it was just another half hour of work to do a few MBB follow ups, document, etc.… I’d rather be out of work 30 minutes earlier. I would also much rather add on another kyphoplasty consult (3-5/week) then 3-5 mbb fw.You are flushing money down the toilet. Mbb f/u visits are the quickest and best paying thing we do.
A vigorous RF practice is the best way to cash in long term. These are yearly RFs many times
Play the long game
God damn. At 3-5 kyphos a week, yeah, you’re not gonna miss a few 99213s…I don’t disagree with you… I just do not have time in my day for that. I’m booked out like six weeks for consults, routinely add on urgent consults, work through lunch, etc. even if it was just another half hour of work to do a few MBB follow ups, document, etc.… I’d rather be out of work 30 minutes earlier. I would also much rather add on another kyphoplasty consult (3-5/week) then 3-5 mbb fw.
Have you considered getting a mid-level though? MBB follow ups are great for filling their schedules.
3-5 Kypho consults…. Not all will end up needing or wanting it. I do kyphoplasty/week.God damn. At 3-5 kyphos a week, yeah, you’re not gonna miss a few 99213s…
Have you considered getting a mid-level though? MBB follow ups are great for filling their schedules
Yes, I have thought about a mid-level, I could certainly use one
You don’t have time to make $100 in 3 minutes? Please reconsider.I don’t disagree with you… I just do not have time in my day for that. I’m booked out like six weeks for consults, routinely add on urgent consults, work through lunch, etc. even if it was just another half hour of work to do a few MBB follow ups, document, etc.… I’d rather be out of work 30 minutes earlier. I would also much rather add on another kyphoplasty consult (3-5/week) then 3-5 mbb fw.
Definitely true for a positive mbb. Negative mbb visits, however, can be awful as they frequently will have no good options left.You don’t have time to make $100 in 3 minutes? Please reconsider.
“Well, that is why we do the test blocks. We have a few other options but they are more invasive. Let’s discuss them in person so I can show you on the spine model what else we can do.”
its a good problem to have.Definitely true for a positive mbb. Negative mbb visits, however, can be awful as they frequently will have no good options left.
but each mbb f/u is a 99214. if they have a positive response, it is 1 click for the note. if you pick out the right patients, you should have mostly positive responses. and you also know as soon as they get off the table. if they feel better, 1-2 week f/u with me. if its equivocal, or they speak portuguese, they can see the extender.
when you get busy enough, you can choose who you want to see. and the simple MBB f/u is a no brainer. dont let the NP get the easy work.
Lot of my patients have high deductible plans. I know it's not my problem but having them pay 400-500 for those two MBB f/u that take 2 mins each can rub people the wrong way. Even if they're just paying 25-50 copays each time, I can see a lot complaining about time spent per visit which is already my most common complaint.
Lot of my patients have high deductible plans. I know it's not my problem but having them pay 400-500 for those two MBB f/u that take 2 mins each can rub people the wrong way. Even if they're just paying 25-50 copays each time, I can see a lot complaining about time spent per visit which is already my most common complaint.
I have a very low income patient population. I’ve done a telehealth visit for every single post-MBB patient for over 2 years now. There have been zero complaints from patients about it. Very quick and easy to do, solid reimbursement/time ratio, and it ensures that you aren’t losing out on many of these successfully making it to RFA.
They aren’t paying $500 for a telemed with a high deductible health plan. I have a UHC HDHP. A major employer in my hometown has a UMR HDHP most employees are on. It goes to the negotiated rate for a level 3 telemed. Not to the office charge.
Also, if you delegate this task to a MA (some mid levels are guilty of this too) you are going to give up at minimum 50% of your RFAs. They don’t care about coaching the patient to the correct decision.
Also, if you delegate this task to a MA (some mid levels are guilty of this too) you are going to give up at minimum 50% of your RFAs. They don’t care about coaching the patient to the correct decision.
Yes mbbs and the ability to make patients understand continues to be one of the most frustrating parts of ipm. Delegating to an MA is a recipe for disaster.
We bill and collect standard E&M contracted codes for our tele. Last time I checked our payers don't use the new tele codes. 500 was an estimate for the two MBBs. Def leaving money on the table, for the long game of patient satisfaction and moving things forward. Perhaps not worth it.They aren’t paying $500 for a telemed with a high deductible health plan. I have a UHC HDHP. A major employer in my hometown has a UMR HDHP most employees are on. It goes to the negotiated rate for a level 3 telemed. Not to the office charge.
Also, if you delegate this task to a MA (some mid levels are guilty of this too) you are going to give up at minimum 50% of your RFAs. They don’t care about coaching the patient to the correct decision.
Not concerned about MAs though. They know the drill. Negatives get kicked back to my PA who is probably even more aggressive than me.
yes, $500 per mbb is accurate. But you said mbb f/u hence my comment.
500/2 MBB fus (250 per 99214) is what I meantyes, $500 per mbb is accurate. But you said mbb f/u hence my comment.
Where are you practicing that a 99214 nets you $250?500/2 MBB fus (250 per 99214) is what I meant
Southeast, commercial ratesWhere are you practicing that a 99214 nets you $250?
I can understand Telehealth, but making patients come in (esp if they live 30+ min away) for a 2 min mbb follow up apt seems like a lot. No one complains about that?
We get about $85-100.
Where I live, everyone lives close enough and if they have to drive they are used to it as a part of their life. Everyone comes back in all the time..and everyone else’s doctor around here makes them do the same so it is the norm and it can be questioned of course, but the scope of practice is the same in this region
99214. You ordered a new procedure and explained risks/benefits.Everyone comes back for a 60 second follow-up visit within a week to check the box and do a quick 99213
Lot of my patients have high deductible plans. I know it's not my problem but having them pay 400-500 for those two MBB f/u that take 2 mins each can rub people the wrong way. Even if they're just paying 25-50 copays each time, I can see a lot complaining about time spent per visit which is already my most common complaint.
Blame the insurance. They're the ones who require this requirement. My patient's grumble but they understand. All my MBBs get an in-person OV 2 weeks later to document everything. APPs primarily do these visits.I can understand Telehealth, but making patients come in (esp if they live 30+ min away) for a 2 min mbb follow up apt seems like a lot. No one complains about that?
Don’t worry they’ll soon be down coding that 99214 to a 9921399214. You ordered a new procedure and explained risks/benefits.
Blame the insurance. They're the ones who require this requirement. My patient's grumble but they understand. All my MBBs get an in-person OV 2 weeks later to document everything. APPs primarily do these visits.
Aetna and Cigna Announce Automatic Downcoding Policies
Background:
• Aetna and Cigna have announced automatic downcoding policies for complex Evaluation & Management (E/M) services -- specifically, level 4 and level 5 office visits.
• Aetna and Cigna are using algorithms or claims data alone to automatically downgrade the codes physicians assign to cases -- without reviewing individual patients' medical records.
• The result is that claims for complex visits will be paid at a lower level. Physicians who disagree with this automatic downcoding will have to appeal.
○ That process will require submitting a significant amount of paperwork and patient case documentation -- something many practices will not have the capacity or wherewithal to do.
• This "deny first, pay later" system presumes physicians are guilty of "upcoding" until proven innocent.
Issues we are facing:
• These new policies from Aetna and Cigna do not put patients first. They're not about catching bad actors. They're about boosting insurer profits at the expense of patient access and timely care.
• These policies threaten the viability of independent physician practice. Automatic downcoding will accelerate the collapse of independent practices that communities rely on for accessible, affordable care.
• Insurers are acting in bad faith. Aetna and Cigna are rewriting the rules of medical coding unilaterally, disregarding physician expertise and nationally recognized standards.
Read the full story here: Important News: Aetna and Cigna Announce Automatic Downcoding Policies - American Society of Interventional Pain Physicians
Just remember how far we have come. It is called reimbursement because insurance would reimburse for the work done. Now it is something far, far removed.Don’t worry they’ll soon be down coding that 99214 to a 99213
Aetna and Cigna Announce Automatic Downcoding Policies
Background:
• Aetna and Cigna have announced automatic downcoding policies for complex Evaluation & Management (E/M) services -- specifically, level 4 and level 5 office visits.
• Aetna and Cigna are using algorithms or claims data alone to automatically downgrade the codes physicians assign to cases -- without reviewing individual patients' medical records.
• The result is that claims for complex visits will be paid at a lower level. Physicians who disagree with this automatic downcoding will have to appeal.
○ That process will require submitting a significant amount of paperwork and patient case documentation -- something many practices will not have the capacity or wherewithal to do.
• This "deny first, pay later" system presumes physicians are guilty of "upcoding" until proven innocent.
Issues we are facing:
• These new policies from Aetna and Cigna do not put patients first. They're not about catching bad actors. They're about boosting insurer profits at the expense of patient access and timely care.
• These policies threaten the viability of independent physician practice. Automatic downcoding will accelerate the collapse of independent practices that communities rely on for accessible, affordable care.
• Insurers are acting in bad faith. Aetna and Cigna are rewriting the rules of medical coding unilaterally, disregarding physician expertise and nationally recognized standards.
Read the full story here: Important News: Aetna and Cigna Announce Automatic Downcoding Policies - American Society of Interventional Pain Physicians
that is probably not possible in a HOPD clinic. all the "requirements" that have to be checked off before they walk in to the room....You don’t have time to make $100 in 3 minutes? Please reconsider.
telehealth is possible but thus far my system has not specified a way that i can create a telehealth visit on my own...
Most HOPD docs have a MA call and fill out the the MIPS stuff before on the telephone and then the doc does a telemed at the scheduled time. There really aren’t any requirements anymore. Regular visit codes and modifier 93 or 95 depending on phone only or A/V. You can do the A/V for free with doxy.me or Doximity.
I'd love to start doing some telehealth for MBB follow ups.Most HOPD docs have a MA call and fill out the the MIPS stuff before on the telephone and then the doc does a telemed at the scheduled time. There really aren’t any requirements anymore. Regular visit codes and modifier 93 or 95 depending on phone only or A/V. You can do the A/V for free with doxy.me or Doximity.
how do you suggest setting up the schedule to accommodate these? overbook with a consult, block off 15 minutes to get through like 3 of these, over lunch or at end of the day after clinic?
I just do them at lunch. I would give yourself around 4 minutes per visit.
its not fasterI'd love to start doing some telehealth for MBB follow ups.
how do you suggest setting up the schedule to accommodate these? overbook with a consult, block off 15 minutes to get through like 3 of these, over lunch or at end of the day after clinic?
I thought telehealth reimbursement for this sort of thing was going away?I just do them at lunch. I would give yourself around 4 minutes per visit.
unclear. has not been decided yet.
This is my problem. I’m not sure what else there is to offer. And frustrating for those who got some fair relief even if not 80%.Definitely true for a positive mbb. Negative mbb visits, however, can be awful as they frequently will have no good options left.
???? If they get any relief then do the RF. Eff those LCDsThis is my problem. I’m not sure what else there is to offer. And frustrating for those who got some fair relief even if not 80%.
Do what you think is right for the patient, not what you think is right for the insurance companies' guidelines which were written to increase their profit margin.This is my problem. I’m not sure what else there is to offer. And frustrating for those who got some fair relief even if not 80%.
But what about when you do the RFA on these people with <80% relief and they still have pain after the RFA????? If they get any relief then do the RF. Eff those LCDs
"If the pain relief was worth it and you want to proceed, the insurance has to hear that you had 80% relief."This is my problem. I’m not sure what else there is to offer. And frustrating for those who got some fair relief even if not 80%.
But what about when you do the RFA on these people with <80% relief and they still have pain after the RFA?
So because they didn’t get 100% relief, you should offer them 0% relief?
i have a patient that gets <50% reduction of pain from the RFA (cut off for repeat) but gets increase in lumbar range of motion by about double with RFA. insurance has paid for repeat RFA...
I used to try and do an in person visit for patients who are close and telemed visits for those who are far away in between the MBBs but now I just do one in person follow up after the second MBB and ask how they both went at that time.
The visit in between felt like it was asking too much from patients and honestly if the first MBB is a failure there is often no other option but hoping the second works out so it seemed pointless to me. I am also busy enough that it wasn't worth it to keep the appointment in between due to the potential headaches of a failed first MBB.
The visit in between felt like it was asking too much from patients and honestly if the first MBB is a failure there is often no other option but hoping the second works out so it seemed pointless to me. I am also busy enough that it wasn't worth it to keep the appointment in between due to the potential headaches of a failed first MBB.
Strengthening the core and the multifidi is like wearing a back brace. Stabilizes and supports facet joint limiting movement and pain.Did the shot help the day of the shot? Yes? Then you get an RF. Make up any numbers you want. Everyone can ‘walk better’ after the shot. I also like this phrase:
‘Pt has competed a full course of PTand performs a good home exercise program within the last 6 months’. You are not technically lying if the pt hasn’t done PT for this problem recently.
Also, remind me how PT will help with facet OA?