Orthovisc/Synvisc

[PinchandBurn]

Is the CPT code for getting a Prior Auth the same as a large joint/bursa? 20610 ?

The ICDs are the same
715.16Osteoarthritis, localized, primary (lower leg)715.26Osteoarthritis, localized, secondary (lower leg)715.36Osteoarthritis, localized, not specific whether primary or secondary (lower leg)Osteoarthritis, unspecified whether generalized or localized, mul




So it seems like you get paid the same for doing a viscoelastic supp injection as you would from doing a steroid injection? I'm talking about in terms of the physician's rvu/fee. I know the hopsital/facility gets to add a J code to recoop the costs......Am I missing something? Doesnt seem right that the MD fee is the same for a knee injection with steroids compared to that w/ viscoeslat supp.

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[pmrmd]

Do you have a different process for viscosup injections versus steroids? Why doesn't it seem right to you?
Add your 77002 as well.

 

[Pain Applicant1]

Is the CPT code for getting a Prior Auth the same as a large joint/bursa? 20610 ?

The ICDs are the same
715.16Osteoarthritis, localized, primary (lower leg)715.26Osteoarthritis, localized, secondary (lower leg)715.36Osteoarthritis, localized, not specific whether primary or secondary (lower leg)Osteoarthritis, unspecified whether generalized or localized, mul




So it seems like you get paid the same for doing a viscoelastic supp injection as you would from doing a steroid injection? I'm talking about in terms of the physician's rvu/fee. I know the hopsital/facility gets to add a J code to recoop the costs......Am I missing something? Doesnt seem right that the MD fee is the same for a knee injection with steroids compared to that w/ viscoeslat supp.

Why doesn't it seem right to you? It's essentially the same procedure. If you're referring to the cost of the hyaluronan then you have a point. However, you can recoup the cost. Either bill Medicare for the J code in addition to the CPT code or write a script out for your commercial insurers and have them send it to your office. The rep should be able to direct you.

 

[PinchandBurn]

Why doesn't it seem right to you? It's essentially the same procedure. If you're referring to the cost of the hyaluronan then you have a point. However, you can recoup the cost. Either bill Medicare for the J code in addition to the CPT code or write a script out for your commercial insurers and have them send it to your office. The rep should be able to direct you.

For example....

If you do a trigger point injections in the neck and occipital nerve injections/auric temp injections with steroids. Versus if you use botox to inject these same areas. The later is classified as 'chemodenervation'. The needles are placed in the same locations for the most part, but the presumption is that you get longer duration with the botox.

Or take for example MBBs versus RFAs. The needles end up essentially in the same areas, but the injectate (or RFA) is what distinguishes one from the other.

In the same manner, with visco sups arent you trying to get a longer duration of action with using the visco sup versus just a steroid. The techniques maybe similar, but one is theoretically supposed to respond better/longer.

On the same note, when would you guys send one of these patients to an orthopod? For example, if a patient is getting 4mo out of a steroid injection into the knee (or something similar with a visco sup) and Xray/MRI show just moderate /mild OA should you just reinject? What I dont want to to is keep injecting every 4-6mo, therby worsening it somehow and delaying a knee replacment.

Just throwing these questions out there, to get ideas. Thanks.

 

[Pain Applicant1]

For example....

If you do a trigger point injections in the neck and occipital nerve injections/auric temp injections with steroids. Versus if you use botox to inject these same areas. The later is classified as 'chemodenervation'. The needles are placed in the same locations for the most part, but the presumption is that you get longer duration with the botox.

Or take for example MBBs versus RFAs. The needles end up essentially in the same areas, but the injectate (or RFA) is what distinguishes one from the other.

In the same manner, with visco sups arent you trying to get a longer duration of action with using the visco sup versus just a steroid. The techniques maybe similar, but one is theoretically supposed to respond better/longer.

On the same note, when would you guys send one of these patients to an orthopod? For example, if a patient is getting 4mo out of a steroid injection into the knee (or something similar with a visco sup) and Xray/MRI show just moderate /mild OA should you just reinject? What I dont want to to is keep injecting every 4-6mo, therby worsening it somehow and delaying a knee replacment.

Just throwing these questions out there, to get ideas. Thanks.

Oh, I see your point. CPT reimbursements are not typically based on how long the treatment response should last. They're based for the most part on three different RVUs, none of which include length of treatment. The reason Botox has a different reimbursement than a nerve block and the reason why RF has a different reimbursement than MBB is more likely based on the risk, skill, intensity and training required to perform the procedure and the cost of malpractice to cover and the ancillary cost to actually perform the procedure.

If I can pull 4 months of relief out of steroid injection I would typically repeat 3 times per year. However, I would look for the reason that pain is present. If the patient is young, I would be very weary of injecting steroid as it's likely that the cause can be corrected. Also, I don't typically inject acute issues. However, I have no problem with my older patients with moderate OA, even severe if I can get prolonged relief. My goal is to try and keep patients away from the OR in most circumstances.

 

[Jcm800]

you need to go to a billing seminar. SPPM has a good one, so does ASIPP. if you are new to billing/practice, these are invaluable.


bill 20610, 77002 and jwhatever...you can bill s code for lido and bupiv for commercial. the injection is exactly the same, jsut putting something different in, without any different possible complications (theoretically) so its the same code.

go to a few of these courses they will help

For example....

If you do a trigger point injections in the neck and occipital nerve injections/auric temp injections with steroids. Versus if you use botox to inject these same areas. The later is classified as 'chemodenervation'. The needles are placed in the same locations for the most part, but the presumption is that you get longer duration with the botox.

Or take for example MBBs versus RFAs. The needles end up essentially in the same areas, but the injectate (or RFA) is what distinguishes one from the other.

In the same manner, with visco sups arent you trying to get a longer duration of action with using the visco sup versus just a steroid. The techniques maybe similar, but one is theoretically supposed to respond better/longer.

On the same note, when would you guys send one of these patients to an orthopod? For example, if a patient is getting 4mo out of a steroid injection into the knee (or something similar with a visco sup) and Xray/MRI show just moderate /mild OA should you just reinject? What I dont want to to is keep injecting every 4-6mo, therby worsening it somehow and delaying a knee replacment.

Just throwing these questions out there, to get ideas. Thanks.

 

[PinchandBurn]

you need to go to a billing seminar. SPPM has a good one, so does ASIPP. if you are new to billing/practice, these are invaluable.


bill 20610, 77002 and jwhatever...you can bill s code for lido and bupiv for commercial. the injection is exactly the same, jsut putting something different in, without any different possible complications (theoretically) so its the same code.

go to a few of these courses they will help

been to ASIPP course. Youre right, it's very helpful. However, no one brought up synvisc. I didnt even remember to ask about it, since it wasnt on my radar at that time...

 

[facets]

I will try to be a reality check as opposed to Debbie Downer-forget it, Synvisc is too expensive, ins will reimburse at $50 less than your cost, and you cant make that up on volume. Add to that waste due to people scheduling it and not showing up so it goes out of code. I quit offering it unless patients pay it themselves. So far only 1 had done so, a guy who wanted it in his hip, I told him upfront ins would not reimburse because its off label, he paid for it anyway. That was a 20 min hip inj, I felt so guilty about possibly wasting any, I kept checking films till I glowed, plus trying to inject concrete into a closed arthritic hip, argh, I coulda RF somebody

 

[Jcm800]

I will try to be a reality check as opposed to Debbie Downer-forget it, Synvisc is too expensive, ins will reimburse at $50 less than your cost, and you cant make that up on volume. Add to that waste due to people scheduling it and not showing up so it goes out of code. I quit offering it unless patients pay it themselves. So far only 1 had done so, a guy who wanted it in his hip, I told him upfront ins would not reimburse because its off label, he paid for it anyway. That was a 20 min hip inj, I felt so guilty about possibly wasting any, I kept checking films till I glowed, plus trying to inject concrete into a closed arthritic hip, argh, I coulda RF somebody

I don't know about that. We get reimbursed full plus a few bucks on euflexxa and hyalgan...
I don't use synfisc so i don't know specifically about that. I like doing it. Web do it better than blind ortho injections and want it to work...Plus I have never had anyone not show for it. Plus the syringes are sterile and are never wasted...

 

[Jcm800]

been to ASIPP course. Youre right, it's very helpful. However, no one brought up synvisc. I didnt even remember to ask about it, since it wasnt on my radar at that time...

Yes, you are right, these kinds of things don't really come up at those course... Is always weird pump questions or something like "my doctor does an inter laminar and tfesi at this same time, how can he bill for both of those at the same time..."

 

[Pain Applicant1]

I will try to be a reality check as opposed to Debbie Downer-forget it, Synvisc is too expensive, ins will reimburse at $50 less than your cost, and you cant make that up on volume. Add to that waste due to people scheduling it and not showing up so it goes out of code. I quit offering it unless patients pay it themselves. So far only 1 had done so, a guy who wanted it in his hip, I told him upfront ins would not reimburse because its off label, he paid for it anyway. That was a 20 min hip inj, I felt so guilty about possibly wasting any, I kept checking films till I glowed, plus trying to inject concrete into a closed arthritic hip, argh, I coulda RF somebody

I think something's not right here. Medicare should cover the cost and your shouldn't have to purchase it for the commercials. It should already be purchased, either by patient or insurance, prior to you receiving it.

What kind of business model would exist by a provider losing $50 on each injection? It doesn't make sense. Nonetheless, if insurance did cover less than the cost, I would just make the patient aware of this and require the patient to cover the difference prior to injection.

 

[facets]

I quit doing it around 2007 because I was being paid less than the cost at that time by some insurers. The syringes, whether sterile or not, do require refrig and go out of code and must be discarded if not used within that time so unless you have a really high volume they will and should be discarded and you lose $250. It is a lousy business model and is not sustainable, hence I quit doing thoses injections. A lot of things are reimbursed at less than cost, it varies from year to year.MC sets reimbursment at the average wholesale cost. Do you know any doctor who pays wholesale? I don't. Insurance will only pay for approved procedures, hyalgan in the hip is off label and hence not paid, big shock if u are paying the bill. Look sometime at your EOB and see first hand what u are being reimbursed, You may be shocked

 

[Jcm800]

I quit doing it around 2007 because I was being paid less than the cost at that time by some insurers. The syringes, whether sterile or not, do require refrig and go out of code and must be discarded if not used within that time so unless you have a really high volume they will and should be discarded and you lose $250. It is a lousy business model and is not sustainable, hence I quit doing thoses injections. A lot of things are reimbursed at less than cost, it varies from year to year.MC sets reimbursment at the average wholesale cost. Do you know any doctor who pays wholesale? I don't. Insurance will only pay for approved procedures, hyalgan in the hip is off label and hence not paid, big shock if u are paying the bill. Look sometime at your EOB and see first hand what u are being reimbursed, You may be shocked

i only do knees with it, and we get paid right at what we pay for them, like i said, we make a few bucks. May be we get a good deal on the Euflexxa...

 

[Gauss]

don't buy the med then, send to pharmacy and have them deal with it. bring to office for injection

 

[facets]

That's what I did with the hip, I knew the insurance would not pay or worse, pay then come back in a few years and demand a refund and tell us to charge the patient, yeah, good luck with that. I told him to get it himself then I would inject it, no I don't buy it and u pay me then have me try to get reimbursement, you buy it and deal with your own insurance company.
If you have been around a while u have dealt with carriers paying for something initially, then demanding repayment years down the road when it is too late to bill the patient or the "correct insurance" (working pts on MC)
I think the key here, esp for the younger ones, is to know the cost of what u are injecting and what insurance actually pays. Even if you pay $250, and insurance reimburses $260, if your biller misses the hyalgan checkbox once, or the insurance denies it, or it goes to the deductable, or the check bounces, etc, etc, u do it the next 25 times for free. If u want to work for free thats fine as long as u know u are doing it. I am not willing to take that risk for a procedure that reimburses $40 when orthopods do it in their office, I'll let them take the hit

 

[Pain Applicant1]

I quit doing it around 2007 because I was being paid less than the cost at that time by some insurers. The syringes, whether sterile or not, do require refrig and go out of code and must be discarded if not used within that time so unless you have a really high volume they will and should be discarded and you lose $250. It is a lousy business model and is not sustainable, hence I quit doing thoses injections. A lot of things are reimbursed at less than cost, it varies from year to year.MC sets reimbursment at the average wholesale cost. Do you know any doctor who pays wholesale? I don't. Insurance will only pay for approved procedures, hyalgan in the hip is off label and hence not paid, big shock if u are paying the bill. Look sometime at your EOB and see first hand what u are being reimbursed, You may be shocked

Yes, agreed. It won't be covered for hip injections...yet. In that case, I would charge the patient outright and only purchase the product after he or she pays me.
I check all of my EOBs. As the checks role in, I check off what I've been reimbursed in a folder my front desk keeps of my entire schedule. This way, I audit the biller and know exactly what I have or have not been paid for. It only takes a few minutes per day and makes the biller work A LOT harder.

What do we get reimbursed less than cost for? I know some meds/contrast, etc but I just factor the cost into what I get reimbursed for the procedure. Are there other things we lose money on?

 

[facets]

Yes, a lot of things but as you say, just figure it into the cost (gag) of the procedure and its easier to face, at least if its a $200 epidural, harder when its a low buck procedure like a $40 knee. For example, last time I checked, which was years ago I got so discouraged and as Algo so elegantly put it "being in the twilight of my carreer" I just don't check anymore, everything was at a loss, i dont get wholesale prices, they go up with shortages, for example kenalog reimburses at 80 cents for 10 mg, do u pay that? I pay more like $1.30. Versed, fentanyl, brevital, diprovan, depomedrol all are reimbursed at less than cost last I checked. We are not the only ones, the FP are being asked to pay $10 for a vaccine that reimburses $4,90. Thats why every drug store is giving vaccines, the docs that plan to stay around just give u a script to go get it.
BTW those are u dealing with drug shortages for sedation should try nitrous

 

[nvrsumr]

BTW those are u dealing with drug shortages for sedation should try nitrous

Is that a serious comment? As a PMR guy my sedation experience has pretty much been limited to PO valium, midazolam and fentanyl.

I am having to get a compund pharmacy to make my midazolam now. ugh.

Would love a second inexpensive option.

 

[facets]

serious as a heart attack, dentists use nitrous, its ez

 

[PinchandBurn]

serious as a heart attack, dentists use nitrous, its ez

Ya....

how many offices have scavengers for waste Nitrous. Throw in possible laryngo spasm....interesting...

 

[facets]

Are u an anesthesiologist? I don't know how dentists do it, they have some kind of mask. We use the anesthesia machine which is attached to a scavenging system.Spasm is listed as a possiblity but I've never seen it with nitrous, that could happen with versed also. Fentanyl reduces the incidence. It seems ez to me but I've been an anesthesiologist for 25 years. Maybe its not such a good idea for a PMR doc.

 

[PinchandBurn]

Are u an anesthesiologist? I don't know how dentists do it, they have some kind of mask. We use the anesthesia machine which is attached to a scavenging system.Spasm is listed as a possiblity but I've never seen it with nitrous, that could happen with versed also. Fentanyl reduces the incidence. It seems ez to me but I've been an anesthesiologist for 25 years. Maybe its not such a good idea for a PMR doc.

I did an anesthesia residency. Not a bad idea if you have a scavenger. Only other concern is the occupational hazard it poses to you and staff (pregnant gals, etc).....Definitely interesting idea