Medicare to stop audit on third and fourth level?
Started by SpineandWine
No my biller just told me last week that they will no longer cover 3rd level even with appeal.
Prior authorization (PA)for facet joint intervention
www.novitas-solutions.com
Note: The following CPT codes were removed on August 16, 2024, and no longer require prior authorization:
64492 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s))
64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s))
Three (3) or four (4) level procedures are not medically necessary and therefore are non-covered.
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Love how SIS sent out an email announcing the change as some advocacy win for them.
LMAO
They just updated that email
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A perfect example of how the insurance system is a broken: medicare can arbitrarily say 3 levels isn’t “necessary” as a blanket statement, yet approve COT for MSK pain despite no good evidence to support it… and plenty of downstream ill effects, which ends up hurting patient and costing the health system and society plenty of $$$
This could be a good thing if you have the time to explain an ABN and patients that are willing to pay another $100 per injection for another level bilaterally. I probably won’t go to that effort but some will.
at HOPD, the extra level is $3-4K
Hard to justify
I’d have a hard time shelling that out for additional level RFA
it is not justifiable. i dont even offer it. i tell them to find a PP guy if they want that 3rd level. nobody has yet, though
that's what I've been doing as well!
I do it occasionally as well.
Not happy about it as we’re just screwing ourselves in long term/getting scammed
I might see if hospital may let me charge less for additional levels.
Do you know what process I need to charge patients for additional levels? Is there a Medicare form they have to fill out?
Not happy about it as we’re just screwing ourselves in long term/getting scammed
I might see if hospital may let me charge less for additional levels.
Do you know what process I need to charge patients for additional levels? Is there a Medicare form they have to fill out?
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I do but I still do what you describe since it’s not one size fits all
I do b/l L3-4 and L5-S1 if patient needs it
Which I feel we as pain specialty is screwing itself
Of course.
I still will do it and pick based on level of pathology on MRI.
Just sucks to not get reimbursed from either pro fees or even facility
I’m telling you - pain is done in next 10 years or so
I still will do it and pick based on level of pathology on MRI.
Just sucks to not get reimbursed from either pro fees or even facility
I’m telling you - pain is done in next 10 years or so
I've been having them pay out of pocket the whole time. It's the right thing to do when the government second guesses your medical decision making.
Just remember: The status quo is not an accident or unintended consequence. It's the direct result and a failure by design of actions and inactions.
What action do you use to charge?
Is there a form you have to make them sign?
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If they say something to the effect of it not hitting the right spot, yes, or just do a repeat and see if the second one works better.
If the first shot felt too low or too high, I adjust based on that. Otherwise based on pain location and referral pattern, and imaging.
I do the same. It’s a slippery slope. Government and insurance companies take advantage of our altruism. I will frequently do 3rd levels or uncovered procedures for cash, because I refuse to let them take advantage of me.
Eventually they will just expect us to work for the salary of a postal worker, despite our superior intelligence, large student debts, and sacrifice of a dozen years + of our twenties and thirties.
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its more of the fact that pain physicians had taken advantage of the system that these rules, however punitive they may be to the patient, are put in place. we reaped what we sowed.
it should not be standard of care to do 3-4 level RFAs every 3-4 months or 3 level bilateral TFESI every month x3. but this was the modus operandi of many a pain doc.
No. It's because of juicing the Vig on the SOS. Too many employed pain docs were willing to trade their gold (independence) for magic beans (SOS) and turn a blind eye to SOS arbitrage and facility fee fraud.
The pro fee on an additional level is pennies on the dollar compared to a ESI in a HOPD.
no, its not. you are trying to divert the discussion back to SOS. stay on target.
juicing the whatever you call it has been going on since 2000. remember, we are talking about limiting the injections by eliminating additional levels. that really has nothing to do with site of service because the same HOPD fees apply for 1 level or 3.
64623, each additional level, was $116 per level. so technically the additional 3rd level bilaterally would be at least $116, if not $230.
juicing the whatever you call it has been going on since 2000. remember, we are talking about limiting the injections by eliminating additional levels. that really has nothing to do with site of service because the same HOPD fees apply for 1 level or 3.
64623, each additional level, was $116 per level. so technically the additional 3rd level bilaterally would be at least $116, if not $230.
his answer to everything is juicing the vig on SOS.
Pain docs doing questionable things? Juicing the vig on SOS
Patient sues doctor? Its because he/she juiced the vig on SOS
Global warming? Humans juiced the vig on SOS.
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i had one patient sign whatever paperwork to do additional level, turns out her supplemental plan covered it. go figure
my attending in fellowship, would make sure everyone got 3-4 esi, rfa, tpi and finally offer stim. SMH
Bad attendings are one of the reasons were in this mess
No sij?
Dx only, then fusion.
Saw this on Facebook. Seems relevant.
Are you juicing the vig on that SOS and getting that affiliate link money?
😆
waiting for facet fusions to become a thing.
Do 1 facet at a time. Really gonna juice that SOS vig. /s
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I’m confused, do you not think the SOS differential is a thing or not a significant cost to patients or the system as a whole?
Have you yourself ever had to get an MRI or colonoscopy and looked at the out of pocket difference bw HOPD and an outpatient stand alone facility? I’ve done both. Got royally screwed with the colonoscopy when I thought I was doing the right thing. Found out I could’ve had it done at a fraction of the cost at the facility down the street not associated with the hospital, same practice.
OOP difference for MRI was $150 instead of $1250. I fortunately chose correctly on that one despite two different people from the insurance company telling me otherwise on the phone. It’s truly a corrupt system and that corruption, I would argue, dwarfs the few bad apple physicians duct sanctimoniously bemoans
Most patients have no idea the 10x difference in cost for the same service/procedure. It’s a complete racket
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…and exactly why private practice groups and solo docs are slowly becoming a thing of the past.
Systems buying practices en masse. You cannot compete.
Seems like everything is contracting into a few small entities in every industry.
The largest healthcare expenditures are administrative costs, primarily administrative salaries and payroll, not this SOS vig juicing BS.
Yep, I've had MRIs done. I specifically go to freestanding centers that charge minimal to my deductible. If I am maxed on my OOP, then IDGAF where I go as long as its most convenient and quickest.
If you have such an issue, juice the vig, send out that SOS, whatever you call it, and then drop the patient portion. Patients dont pay much, insurers pay like they are supposed to, and you get paid appropriately.
The bloat is paid for by the SOS differential. Without the SOS differential there would be much less bloat.
Whoever doesn’t believe, want to believe, is in denial about believing or is actually part of the SOS machine…is actually the problem
Hospitals need to stop hiding behind emtala as reason to “squeeze everyone’s juice dry”
Im fairly certain Harris and her boy toy are just going to continue to drive docs into more “controllable” massive systems which are themselves out of control from a cost perspective.
It’s funny how she wants to talk about grocery stores price gauging but can’t comprehend how much hospitals price gauge bandaids…
Hospitals need to stop hiding behind emtala as reason to “squeeze everyone’s juice dry”
Im fairly certain Harris and her boy toy are just going to continue to drive docs into more “controllable” massive systems which are themselves out of control from a cost perspective.
It’s funny how she wants to talk about grocery stores price gauging but can’t comprehend how much hospitals price gauge bandaids…
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What’s wrong with bloat?
That’s exactly why nothing will ever change and just continue to worsen. The facility will never take a pay cut..but we will continuously
But you’re back handed paid if wRVU (depending on negotiated price, you make out more than collections) or own shares in ASC
So its good for physicians as well
So it appears bloat is not bad
But what you’re getting at is feeling of unfairness in pro fee cut, which I agree is bad
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You don’t find something wrong with your payment being mostly (and if it continues, solely) based on under what roof you place the needle and not that fact that YOU acquired the skill to place it?
Ofcourse - only reason I care is that my pro fees are not high
I don’t mind facility being high (is what I’m getting at- other people are arguing facility should be lowered). I’m arguing facility remains as is or higher
Pro fees go much higher
