New Medicare LCD Guidelines: No Sedation for ESI/facets

[paintrain]

Starting 12/12/21, Medicare no longer consider any form of IV sedation medically necessary for ESI/facets. Granted the majority of my ESI's and MBBs are done awake with local, there are a select few that I think some IV sedation (more than PO) would be helpful for all parties. And definitely Cervical RFAs are smoother with IV sedation.

What are everyone's plans now that Medicare (and likely other insurances to follow) will no longer will reimburse for IV sedation for ESI/facets.

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

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[hyperalgesia]

I don't use any sedation for any procedures. I probably lose about 1 patient a year because he insists on sedation.

This lcd seems reasonable to me. You can still use LIGHT sedation without any extra documentation.

If you want to use moderate/heavy sedation for a cervical rfa, I agree with Medicare that it should be an unusual situation that should be justified.

 

[lobelsteve]

Starting 12/12/21, Medicare no longer consider any form of IV sedation medically necessary for ESI/facets. Granted the majority of my ESI's and MBBs are done awake with local, there are a select few that I think some IV sedation (more than PO) would be helpful for all parties. And definitely Cervical RFAs are smoother with IV sedation.

What are everyone's plans now that Medicare (and likely other insurances to follow) will no longer will reimburse for IV sedation for ESI/facets.

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

View attachment 345863

You've been doing it wrong...

 

[gaspasser127]

does this actually apply to RFAs as well? Or just to MBBs? The wording isn’t clear to me.

 

[paintrain]

I don't use any sedation for any procedures. I probably lose about 1 patient a year because he insists on sedation.

This lcd seems reasonable to me. You can still use LIGHT sedation without any extra documentation.

If you want to use moderate/heavy sedation for a cervical rfa, I agree with Medicare that it should be an unusual situation that should be justified.

Are you considering LIGHT sedation as PO sedation? Or are you saying LIGHT IV sedation?

 

[paintrain]

You've been doing it wrong...

least helpful comment

 

[fathead88]

Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia

www.asahq.org

Most cases of PO or IV sedation that I do are still "minimal" sedation. FWIW, there is no such thing as "mild" or “light” sedation.

There are definitely a few patients that benefit from a deeper level of sedation than minimal. Having an IV and being able to incrementally administer sedation is safer (and simply better) than PO medications for these select patients.

 

[hyperalgesia]

Are you considering LIGHT sedation as PO sedation? Or are you saying LIGHT IV sedation?

They seem to indicate anything other than "oral anxiolysis" could be questioned.

I despise the use of reimbursement to tie the hands of physicians but I fully agree that docs are gonna need to start thinking twice about their standard IV cocktail with every single procedure. It's a great way to recruit/retain patients but it's not good practice.

 

[IAmTheOne1]

Can conscious sedation or MAC be done without reimbursement? In other words, knowing that it won't be reimbursed, is it still allowed to be done? Or will doing it (without trying to even bill for it) trigger some issues?

 

[Dr. Ice]

We contract with an anesthesiology group at our asc. For years they have been telling us that private insurance companies (and definitely Medicare) do not pay them for conscious sedation for pain management procedures. In light of that, I either don’t use it or tell the patients it will cost them $250 if they want it. Some of them opt to pay it. I will give the real anxious people a little po Xanax or Ativan prior to the procedure to get them through it. Most patients wind up telling me that the procedure was fine and that they can’t believe their friend or relative “needed to be sedated for it”

 

[SSdoc33]

Dont sedate anyone. Especially not for mbbs. Are you serious? Never needed for mbbs. 1 in a million need it for esi.

Steve's surliness is spot-on

 

[RoloTomassi]

I've had several patients who have had very traumatic procedures in the past and flat out refuse without MAC. Roughly how much does MAC even reimburse on a 15-30 min case? Is it that much that it provides profit after the extra overhead and time?

 

[gaspasser127]

So… does this apply to RFAs?

 

[lobelsteve]

Dont sedate anyone. Especially not for mbbs. Are you serious? Never needed for mbbs. 1 in a million need it for esi.

Steve's surliness is spot-on

And stop calling me Shirley. Roger roger, what’s the vector Victor?

 

[deleted131481]

I am not a fan of IV sedation.

However that document looks like it applies to ESIs only? I imagine mbb and rfa isn't far behind.

 

[Agast]

Pain seems unfairly singled out by this. If Medicare can cover sedation for cataract removal, why not an ESI. It’s not like they are making a stand for safety measures.

 

[Ducttape]

this is not new. at least in my LCD this has been in place since at least the past 3-4 years.

 

[paintrain]

Some clarity IMO:
1. I don't think you can make a case for IV sedation being minimal, light, etc. and fly under the radar with this new guideline. It's either PO or Local now.
2. MBB/FJI are also included in a separate LCD guideline to also state IV sedation is not medically necessary. Also states in this guideline that frequent use of IV sedation can trigger audit. LCD - Facet Joint Interventions for Pain Management (L38803)

3. I do not believe RFA's are explicitly mentioned but currently I do not believe they are included in this restriction. In the same LCD guideline for facets, it does mention RFA under light IV sedation.

In a previous LCD guideline for facets (2019), sedation for RFAs was also addressed in the response to comments section:

4. You could provide IV sedation and not charge but you should also consider that if CMS is telling you it is not medically necessary and you have some catastrophic anesthetic event, it would be difficult to defend the use of IV sedation. Rare but you open yourself up there for liability. Curious to see what people's thoughts are on this.

5. For all those doing Local only for all ESI/MBB/FJI, kudos to your angel soft hands and technique and tough patient population. May not be completely necessary to provide IV sedation but I agree with above comments that some have had traumatic prior experiences and it would be much more kind to be able to provide the IV option as long as low anesthesia risk. For argument's sake, could also say local isn't necessary either since most of the pain receptors are at skin and there is pain with providing local there to begin with and you also cause pain along the way to the facet joint anyway. So local isn't completely necessary but more kind to use it. Converse is true as well, don't need to intubate and paralyze and give IV dilaudid to prevent the mild pain for ESI/MBB/FJI but a balance is necessary and options are always preferred to none. Really hate when insurances tie my hands.

 

[Nodolor]

Sedation with MBB are silly

1. interferes with diagnostic aspect of procedure
2. if Pt can't do a mbb without sedation they are not a good candidate for interventional procedures

 

[Dr. Ice]

Some clarity IMO:
1. I don't think you can make a case for IV sedation being minimal, light, etc. and fly under the radar with this new guideline. It's either PO or Local now.
2. MBB/FJI are also included in a separate LCD guideline to also state IV sedation is not medically necessary. Also states in this guideline that frequent use of IV sedation can trigger audit. LCD - Facet Joint Interventions for Pain Management (L38803)

View attachment 345902

3. I do not believe RFA's are explicitly mentioned but currently I do not believe they are included in this restriction. In the same LCD guideline for facets, it does mention RFA under light IV sedation.

View attachment 345903

In a previous LCD guideline for facets (2019), sedation for RFAs was also addressed in the response to comments section:

View attachment 345904

4. You could provide IV sedation and not charge but you should also consider that if CMS is telling you it is not medically necessary and you have some catastrophic anesthetic event, it would be difficult to defend the use of IV sedation. Rare but you open yourself up there for liability. Curious to see what people's thoughts are on this.

5. For all those doing Local only for all ESI/MBB/FJI, kudos to your angel soft hands and technique and tough patient population. May not be completely necessary to provide IV sedation but I agree with above comments that some have had traumatic prior experiences and it would be much more kind to be able to provide the IV option as long as low anesthesia risk. For argument's sake, could also say local isn't necessary either since most of the pain receptors are at skin and there is pain with providing local there to begin with and you also cause pain along the way to the facet joint anyway. So local isn't completely necessary but more kind to use it. Converse is true as well, don't need to intubate and paralyze and give IV dilaudid to prevent the mild pain for ESI/MBB/FJI but a balance is necessary and options are always preferred to none. Really hate when insurances tie my hands.

I don’t think you need angel soft hands after you’ve done a couple thousand of these procedures, you know what to do, what hurts, and you just don’t do that..hardly ever used sedation on patients as a fellow

 

[lobelsteve]

If a patient needs sedation for a ESI/MBB/RF, they probably need a different doctor.
I have one patient for cervical RF with PTSD that I do at hospital under MAC.
I dread it.

 

[paintrain]

I don’t think you need angel soft hands after you’ve done a couple thousand of these procedures, you know what to do, what hurts, and you just don’t do that..hardly ever used sedation on patients as a fellow

No need to be modest ice. I got a crick in my neck and will be on my way to your Downy soft hands. I agree with you, technique is important and simple. But for the people who feel like they truly need sedation, it's more an issue with them/psych, not you/technique.

I appreciate all the people who say they don't need it. But I'm curious about what people are planning to do for those who use it occasionally.

 

[Dr. Ice]

No need to be modest ice. I got a crick in my neck and will be on my way to your Downy soft hands. I agree with you, technique is important and simple. But for the people who feel like they truly need sedation, it's more an issue with them/psych, not you/technique.

I appreciate all the people who say they don't need it. But I'm curious about what people are planning to do for those who use it occasionally.

Come visit me in the spring, my hands get dry in the winter..charge them cash or you can have them sign an ABN for those patients who are convinced it’s a covered service because their so and so person they know always had it done with sedation and never had to pay for it...

 

[IAmTheOne1]

Is it permissible to charge Medicare patients cash for non-covered services? If a patient is absolutely adamant about having sedation and willing to pay cash for the sedation, can they?

 

[Orin]

I have always assumed this is driven by the lack of significant benefit of ESIs in general and the significant billing volume. I suspect they are hoping to slow high volume practices down by forcing PO sedatives rather than faster IV agents. Time for some intranasal sedation?

It seems silly though to financially pressure an anxious, needlephobic patient with PTSD/Bipolar/etc towards larger surgeries under general anesthesia or systemic meds in lieu of needle based procedures under IV sedation or MAC.

The only things I like IV sedation or MAC for are genicular ablations and implants, but would much rather do everything awake.

 

[IAmTheOne1]

If you look at the reimbursement trend, the balance has swung far in favor of office visits / medication management vs procedures. We are getting to the point where doing 4 or 5 medication management follow ups (99214) per hour is making more sense than doing procedures, at least from a financial perspective (when you factor in over head costs). So now when gabapentin/meloxicam/PT/Ice doesn't work, and you've exhausted the ever-dwindling procedures that can be done in a rolling 12 month window (hampered by innumerable limitations) and the patient does not want surgery.... When I say Oxy, you say Contin! Oxy! Contin!

 

[Dr. Ice]

Is it permissible to charge Medicare patients cash for non-covered services? If a patient is absolutely adamant about having sedation and willing to pay cash for the sedation, can they?

Regen is not covered and people pay cash for it

 

[deleted875186]

If you look at the reimbursement trend, the balance has swung far in favor of office visits / medication management vs procedures. We are getting to the point where doing 4 or 5 medication management follow ups (99214) per hour is making more sense than doing procedures, at least from a financial perspective (when you factor in over head costs). So now when gabapentin/meloxicam/PT/Ice doesn't work, and you've exhausted the ever-dwindling procedures that can be done in a rolling 12 month window (hampered by innumerable limitations) and the patient does not want surgery.... When I say Oxy, you say Contin! Oxy! Contin!

This x 100.

An unintended consequence of this insurrance crackdown on all procedures will be more chronic opioids, more follow ups. Definitely not in the patients best interest.

Seriously, you only got 50% relief on that MBB, too bad, I think your pains coming from your facet joint but nothing I can do.

 

[paintrain]

Hey all. Sorry to beat dead horse but maybe not so dead. The newest Facet LCD Guidelines don't seem to have any specific info on sedation for RFAs (whereas the old one seemed to mention that sedation not being medically necessary for FJI/MBB did not apply to RFAs). My group's interpretation of this newest facet LCD seems to be that Medicare is no longer covering sedation for RFA's either.

1. Are most of you not using sedation for RFAs?
2. If you are, what are you planning to do if Medicare says it is no longer covering and repeated use may trigger audit?

I get it with ESI/MBB, but a cervical RFA can be quite stimulating.

LCD - Facet Joint Interventions for Pain Management (L38803)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

 

[lobelsteve]

1 case of cervical Rf every 18 mo or so. Same guy. Hoping he doesn’t require any more. I do general anesthesia for gasserian RF.

 

[deleted875186]

1 case of cervical Rf every 18 mo or so. Same guy. Hoping he doesn’t require any more. I do general anesthesia for gasserian RF.

Badass, I don’t think I would have the courage to do a gasserian ablation. How did you learn to do them. Seems like a great tool to have for these patients that have failed gamma knife and meds.

 

[lobelsteve]

Badass, I don’t think I would have the courage to do a gasserian ablation. How did you learn to do them. Seems like a great tool to have for these patients that have failed gamma knife and meds.

Just looked at the pics and read a few articles. Oh, and did them in my fellowship.

 

[paintrain]

1 case of cervical Rf every 18 mo or so. Same guy. Hoping he doesn’t require any more. I do general anesthesia for gasserian RF.

Steve how many patients do see in a day and how many procedures in a month. Wondering if our practices are inherently different based on technique or time. I'm guessing maybe also heavily dependent on patient demographics and what they perceive as an acceptable amount of pain during a procedure.

 

[SSdoc33]

Steve how many patients do see in a day and how many procedures in a month. Wondering if our practices are inherently different based on technique or time. I'm guessing maybe also heavily dependent on patient demographics and what they perceive as an acceptable amount of pain during a procedure.

unlikely.

a 22g in florida hurts the same as a 22g in chicago

get better at your technique and get rid of sedation

 

[lobelsteve]

Steve how many patients do see in a day and how many procedures in a month. Wondering if our practices are inherently different based on technique or time. I'm guessing maybe also heavily dependent on patient demographics and what they perceive as an acceptable amount of pain during a procedure.

28-34 total.
8-14 are procedures.
2-5 are new.
Friday afternoon off or OR for 1-3 cases of SCS, gasserian, or kypho.

Will break 15000 wrvu this year. I have a staff of 3- LPN, RN, MA.

 

[DOctorJay]

zero sedation for RFA in my practice. I typically do 6 cases each week (cervical, thoracic, lumbar, SIJ, geniculate). Have exactly one patient I sent to a colleague for sedation in hospital because she vasovagaled with MBB and didn't want to try again.

probably 75% of my patients say the MBB is worse than the RFA.

 

[paindoc007]

28-34 total.
8-14 are procedures.
2-5 are new.
Friday afternoon off or OR for 1-3 cases of SCS, gasserian, or kypho.

Will break 15000 wrvu this year. I have a staff of 3- LPN, RN, MA.

Wow. 15k is insane. Good job. My record was 12k in 2019 and I felt I worked too hard and not worth the money that year.. Gonna hit about 10.5k this year

 

[paintrain]

28-34 total.
8-14 are procedures.
2-5 are new.
Friday afternoon off or OR for 1-3 cases of SCS, gasserian, or kypho.

Will break 15000 wrvu this year. I have a staff of 3- LPN, RN, MA.

That's it?

 

[paintrain]

unlikely.

a 22g in florida hurts the same as a 22g in chicago

get better at your technique and get rid of sedation

Not true. Chicago needles are colder. Hot FL 22's cut through subQ like butter. Need to work on your geography bruh

 

[SSdoc33]

Not true. Chicago needles are colder. Hot FL 22's cut through subQ like butter. Need to work on your geography bruh

i won the geography bee in 8th grade, "bruh". its been a long downhill slide since then

 

[paintrain]

i won the geography bee in 8th grade, "bruh". its been a long downhill slide since then

I can see that bruv

 

[callmeanesthesia]

Not true. Chicago needles are colder. Hot FL 22's cut through subQ like butter. Need to work on your geography bruh

Well, the patients themselves in the South are also composed of a substantial amount more butter…

 

[xvaderx]

Some clarity IMO:
1. I don't think you can make a case for IV sedation being minimal, light, etc. and fly under the radar with this new guideline. It's either PO or Local now.
2. MBB/FJI are also included in a separate LCD guideline to also state IV sedation is not medically necessary. Also states in this guideline that frequent use of IV sedation can trigger audit. LCD - Facet Joint Interventions for Pain Management (L38803)

View attachment 345902

3. I do not believe RFA's are explicitly mentioned but currently I do not believe they are included in this restriction. In the same LCD guideline for facets, it does mention RFA under light IV sedation.

View attachment 345903

In a previous LCD guideline for facets (2019), sedation for RFAs was also addressed in the response to comments section:

View attachment 345904

4. You could provide IV sedation and not charge but you should also consider that if CMS is telling you it is not medically necessary and you have some catastrophic anesthetic event, it would be difficult to defend the use of IV sedation. Rare but you open yourself up there for liability. Curious to see what people's thoughts are on this.

5. For all those doing Local only for all ESI/MBB/FJI, kudos to your angel soft hands and technique and tough patient population. May not be completely necessary to provide IV sedation but I agree with above comments that some have had traumatic prior experiences and it would be much more kind to be able to provide the IV option as long as low anesthesia risk. For argument's sake, could also say local isn't necessary either since most of the pain receptors are at skin and there is pain with providing local there to begin with and you also cause pain along the way to the facet joint anyway. So local isn't completely necessary but more kind to use it. Converse is true as well, don't need to intubate and paralyze and give IV dilaudid to prevent the mild pain for ESI/MBB/FJI but a balance is necessary and options are always preferred to none. Really hate when insurances tie my hands.

This is very helpful and I appreciate your take on things brah.

The ultimate issue at hand is that we are losing the authority to make our own decisions, and most seem to be fine with that.

Sedating people in the office slows down my day, adds risk to procedures and is reimbursed very poorly, but I have patients that either need it or want it.

But here we are.

 

[macman]

MAC for RFA is reasonable and should be the doc/pt decision

MAC for ESI should be rare (special cases)

MAC for MBB is counterproductive

 

[Ronin1]

MAC for RFA is reasonable and should be the doc/pt decision

MAC for ESI should be rare (special cases)

MAC for MBB is counterproductive

I would differ and say MAC is not reasonable for anything we do other than implants.

 

[deleted875186]

MAC for RFA is reasonable and should be the doc/pt decision

MAC for ESI should be rare (special cases)

MAC for MBB is counterproductive

I agree … mild-mod IV sedation or PO benzo may be appropriate for RFA, but the vast majority of injections should be done with just local.

 

[SSdoc33]

This is very helpful and I appreciate your take on things brah.

The ultimate issue at hand is that we are losing the authority to make our own decisions, and most seem to be fine with that.

Sedating people in the office slows down my day, adds risk to procedures and is reimbursed very poorly, but I have patients that either need it or want it.

But here we are.

nobody NEEDS it

 

[RoloTomassi]

Maybe my patients are special but do you local-only purists not get patients that scream bloody murder with insertion of numbing needle and get even louder when the lido is injected, no matter how slowly or if buffered? Not common but definitely more than a handful a year. I would say a handful a month.

I think age is a factor. The less Medicare I did, the more screamers I got.

 

[Ferrismonk]

Maybe my patients are special but do you local-only purists not get patients that scream bloody murder with insertion of numbing needle and get even louder when the lido is injected, no matter how slowly or if buffered? Not common but definitely more than a handful a year. I would say a handful a month.

I think age is a factor. The less Medicare I did, the more screamers I got.

My clinic gives a lot of sedation (despite my many arguments against). This is largely because I'm doc #6 and the other 5 have been doing everyone under sedation forever. There is definitely a culture I'm working against. That being said, I make it known I prefer no sedation for all my procedures and don't have an issue for those that buy in and try it.

Here's my 2cents on your situation.

1. The people who scream the most are Medicaid patients, smokers, and those on opioids. The less you have of each of these the less screaming you'll get.

2. I stopped using skin local except for needles bigger than a 22G. I found the local hurts a lot more than just the Quinke itself.

3. Wherever possible, convert to a 25G quinke with a bent tip instead of a 22G. It's a little more finesse to steer (more bevel control vs fulrum), but it hurts WAY less. Unless I need more than 3.5 inches to get to my target, I'm using a 25G for everything. I use 20G RF cannulas, so I'll use local first for those.

If you want to confirm, next time you do a bilateral SIJ or facet explain to the patient you're trying new techniques to make it hurt less and do one side one way and the other side a different way. Ask the patient which side hurt more.

 

[RoloTomassi]

My clinic gives a lot of sedation (despite my many arguments against). This is largely because I'm doc #6 and the other 5 have been doing everyone under sedation forever. There is definitely a culture I'm working against. That being said, I make it known I prefer no sedation for all my procedures and don't have an issue for those that buy in and try it.

Here's my 2cents on your situation.

1. The people who scream the most are Medicaid patients, smokers, and those on opioids. The less you have of each of these the less screaming you'll get.

2. I stopped using skin local except for needles bigger than a 22G. I found the local hurts a lot more than just the Quinke itself.

3. Wherever possible, convert to a 25G quinke with a bent tip instead of a 22G. It's a little more finesse to steer (more bevel control vs fulrum), but it hurts WAY less. Unless I need more than 3.5 inches to get to my target, I'm using a 25G for everything. I use 20G RF cannulas, so I'll use local first for those.

If you want to confirm, next time you do a bilateral SIJ or facet explain to the patient you're trying new techniques to make it hurt less and do one side one way and the other side a different way. Ask the patient which side hurt more.

Appreciate the tips, but I've tried most of them.

I don't do med mx anymore, so most of my pts are chronic opioid naive. I was actually thinking that having to tolerate chronic pain and having opioids in their system increases procedure tolerance.

The typical screamers are already anxious and the psychological effect of not using local makes it hurt worse it seems.

Did 25s for a year or two. Requires more adjustments, which makes procedure take longer, more fluoro, at least for me. I also like the lower level of resistance injecting though 22s.

Like the bigger burn of 18s.