No thoracic facet procedures per Carelon guidelines

[Agast]

First time I’ve run into this

I’m fairly certain the patient has thoracic facet joint pain. However all MBB/facet joint procedures are considered experimental at the thoracic level per the guidelines his insurance uses. Does that mean cash pay only or is there some way around this

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[jsaul]

No way around it.

 

[BobBarker]

Most of the patients have just paid cash.

 

[Agast]

Diagnostic small joint injection?

Guy works a low paying job so cash pay is not an option

 

[lobelsteve]

Bill as TPI, use fluoro for safety, don't save images.

 

[SSdoc33]

Bill as TPI, use fluoro for safety, don't save images.

it is a nice thing to do, but is that fraud? legally speaking?

 

[Agast]

I think he’s being sarcastic

 

[lobelsteve]

it is a nice thing to do, but is that fraud? legally speaking?

Rotator longus TPI

 

[paindoc007]

I assume that’s sarcasm. Pls don’t do that. One day the fraud is for the patients benefit, the next day it’s for yours. Knee pain? OA=Crps. Scs! I see the stuff all the time around where I work

Not your fault insurance rules.

 

[Agast]

I’d rather bill a small/medium joint injection. Technically not wrong.

 

[MitchLevi]

I’d rather bill a small/medium joint injection. Technically not wrong.

Is this correct? I've been denied virtually all thoracic facet injections I've ordered, and I quit ordering them yrs ago because of it. Can you bill an MBB as a small/medium joint injection? If so, I'll do therapeutic MBB with dexamethasone.

 

[Agast]

Is this correct? I've been denied virtually all thoracic facet injections I've ordered, and I quit ordering them yrs ago because of it. Can you bill an MBB as a small/medium joint injection? If so, I'll do therapeutic MBB with dexamethasone.

Can you - probably not

But joint injections don’t require prior auth and bill very little…so it probably doesn’t attract the same scrutiny

 

[drrosenrosen]

I actually had a P2P with a Carelon doctor for thoracic MBB. She approved it on the face of pt had tried everything else, but did say I'd probably have to go through the same process again for the second MBB and again for the RFA, each time the result being dependent on the reviewer. Probably not worth it at that point...

 

[Agast]

I actually had a P2P with a Carelon doctor for thoracic MBB. She approved it on the face of pt had tried everything else, but did say I'd probably have to go through the same process again for the second MBB and again for the RFA, each time the result being dependent on the reviewer. Probably not worth it at that point...

They probably threw her into the dungeon afterwards to punish her and warn the other reviewers

 

[drrosenrosen]

They probably threw her into the dungeon afterwards to punish her and warn the other reviewers

Yes probably. I was up front with pt that even though we got this one approved we still have an uphill fight and may end up with no choice but to offer cash price for the RFA, even if the diagnostics work.

 

[SpineandWine]

Can you do cervical/thoracic MBBs at C5-7 exact location to be palpated under X-ray.

Palpate thoracic MBBs- do diagnostic there since same CPT

 

[buddababa]

Can you do cervical/thoracic MBBs at C5-7 exact location to be palpated under X-ray.

Palpate thoracic MBBs- do diagnostic there since same CPT

Fraud

 

[SpineandWine]

Fraud

I do this all the time for lumbar mbb- when I palpate, I have to change levels.
Once I guessed T7-9 and ended up doing T10-12.

But yes, potential fraud.
Luckily, have not run into thoracic facets denied in midwest- encountered a lot in NC

 

[buddababa]

I do this all the time for lumbar mbb- when I palpate, I have to change levels.
Once I guessed T7-9 and ended up doing T10-12.

But yes, potential fraud.
Luckily, have not run into thoracic facets denied in midwest- encountered a lot in NC

Changing levels for the relevant CPT code is not an issue, happens all the time, but Getting approval for cervical medial branch block, and then doing thoracic, even the same CPT code is definitely fraud.

 

[bedrock]

Changing levels for the relevant CPT code is not an issue, happens all the time, but Getting approval for cervical medial branch block, and then doing thoracic, even the same CPT code is definitely fraud.

Yep. Most of the time, If insurance doesn’t cover it, the patient just has to pay cash, period.

The only times I will bend the rules is if is a very slight modification that can’t bite me later.

Such as including TON lesion on a patient whose insurance doesn’t cover that but does cover its neighbor C3. I do a “thorough “ C3 lesion which helps the patient with their cerviogenic headaches.

 

[Ducttape]

yes, you can use flouroscopy for confirmation of the level to be targetted. that is not bending or breaking the rules.

just make sure your consent reflects this.

and like buddababa stated, dont change section of the body

 

[drrosenrosen]

Yep. Most of the time, If insurance doesn’t cover it, the patient just has to pay cash, period.

The only times I will bend the rules is if is a very slight modification that can’t bite me later.

Such as including TON lesion on a patient whose insurance doesn’t cover that but does cover its neighbor C3. I do a “thorough “ C3 lesion which helps the patient with their cerviogenic headaches.

I just "ablate the C2 medial branch"

 

[SpineandWine]

I guess based on what I’m hearing is that most ethical thing is to charge cash price for a procedure to be done in a facility such as ASC