Posterior SIJ Fusion Bumped down to Category III CPT

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drusso

drusso

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The big lesson here for all of us to learn. We hang together or else we get picked off one by one...

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drusso said:
The big lesson here for all of us to learn. We hang together or else we get picked off one by one...

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Not sure what category three means?
I assume less reimbursement.

If this also means less unnecessary SIJ fusions because it pays less, then great. I’ve seen way too many people messed up by those.
 
I have no problem with this, though I worry about other procedures similarly receiving the axe.
 
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bedrock said:
Not sure what category three means?
I assume less reimbursement.

If this also means less unnecessary SIJ fusions because it pays less, then great. I’ve seen way too many people messed up by those.
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It means it won’t be paid at all (by private insurance). Category III is the CMS code for procedures they are investigating, so a clinical trial code is used. Only Medicare and Medicare replacement plans will honor the code.
 
Agast said:
It means it won’t be paid at all (by private insurance). Category III is the CMS code for procedures they are investigating, so a clinical trial code is used. Only Medicare and Medicare replacement plans will honor the code.
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So like MILD? That is a T code too
 
Agast said:
It means it won’t be paid at all (by private insurance). Category III is the CMS code for procedures they are investigating, so a clinical trial code is used. Only Medicare and Medicare replacement plans will honor the code.
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Do you think Medicare advantage plans will cover this? They love to not cover newer things that regular Medicare will cover such as genicular and SIJ RFA.
 
The advantage plans will cover a T code because it’s under clinical trial that all Medicare patients are eligible to undergo. Once there is a non-T code they can reject it at will. At least that’s my understanding.
 
Agast said:
The advantage plans will cover a T code because it’s under clinical trial that all Medicare patients are eligible to undergo. Once there is a non-T code they can reject it at will. At least that’s my understanding.
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That is correct.

That’s why there’s a national coverage determination for MILD.
 
bedrock said:
Not sure what category three means?
I assume less reimbursement.

If this also means less unnecessary SIJ fusions because it pays less, then great. I’ve seen way too many people messed up by those.
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Out of curiosity - which complications have you seen from posterior SIJ fusion and how often?

I think it’s a low risk procedure and have seen it work pretty well in patients.
 
I'm not opposed to SIJ stabilization/fusion procedures by IPM docs in patients that are well selected. One of the issues may be that, in IPM, SIJ dysfunction has been a sort of catch all for any patient with otherwise unexplained low back pain. Then, if we put steroid in the joint they get better "confirming" our presumption that it was the SIJ that was hurting. Then these (arguably) more definitive procedures become available to us and we are discouraged to find out that the same patient that responded well to quarterly SI joint injections, doesn't do well with a fusion.

So, we need to be better at selecting our patients. Also, the technology needs to improve. I'm not convinced that putting an allograft and a smidgen of BMP in the joint reliably stabilizes or fuses the joint. FWIW, I've done maybe 15 of these and although some patients did well, results were not stellar. I know that several companies are developing titanium implants that will be game changers for the posterior approach if/when they come to market.

BTW, we can talk about pain docs that select patients poorly and ruin it for the rest of us. But there are plenty of orthopods that do the same. Everyday I get a referral from orthopedics for "comprehensive pain management" . . . often times after the patient has had several injections from their own guy, a two-level fusion, and a stim trial/implant or SI joint fusion. It's not an excuse for those bad apples in our field, but still, at least we can acknowledge the fact that although we have some bad apples, so does every other field of medicine. It's not a reason to suggest that all of us need to stay in "our lane" . . . whatever that is.
 
Force440 said:
BTW, we can talk about pain docs that select patients poorly and ruin it for the rest of us. But there are plenty of orthopods that do the same. Everyday I get a referral from orthopedics for "comprehensive pain management" . . . often times after the patient has had several injections from their own guy, a two-level fusion, and a stim trial/implant or SI joint fusion. It's not an excuse for those bad apples in our field, but still, at least we can acknowledge the fact that although we have some bad apples, so does every other field of medicine. It's not a reason to suggest that all of us need to stay in "our lane" . . . whatever that is.
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The problem is there are way more IPM folks than orthopods. Sure Dr Death was a neurosurgeon, but he's one of only ~150 grads in his year. The issue with patient selection is a lot easier to notice with the 600+ accredited fellows, even before you consider the unaccredited pain providers, and the fact that a high volume interventionalists can likely churn through 2 or 3 times the procedure/evaluation/clinic volume of a comparable surgeon.
 
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Force440 said:
I'm not opposed to SIJ stabilization/fusion procedures by IPM docs in patients that are well selected. One of the issues may be that, in IPM, SIJ dysfunction has been a sort of catch all for any patient with otherwise unexplained low back pain. Then, if we put steroid in the joint they get better "confirming" our presumption that it was the SIJ that was hurting. Then these (arguably) more definitive procedures become available to us and we are discouraged to find out that the same patient that responded well to quarterly SI joint injections, doesn't do well with a fusion.

So, we need to be better at selecting our patients. Also, the technology needs to improve. I'm not convinced that putting an allograft and a smidgen of BMP in the joint reliably stabilizes or fuses the joint. FWIW, I've done maybe 15 of these and although some patients did well, results were not stellar. I know that several companies are developing titanium implants that will be game changers for the posterior approach if/when they come to market.

BTW, we can talk about pain docs that select patients poorly and ruin it for the rest of us. But there are plenty of orthopods that do the same. Everyday I get a referral from orthopedics for "comprehensive pain management" . . . often times after the patient has had several injections from their own guy, a two-level fusion, and a stim trial/implant or SI joint fusion. It's not an excuse for those bad apples in our field, but still, at least we can acknowledge the fact that although we have some bad apples, so does every other field of medicine. It's not a reason to suggest that all of us need to stay in "our lane" . . . whatever that is.
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I don’t know…I see your point and appreciate it, but at the same time, the private equity bull dozers creating KOL/pain surgeon/instagram/salesman training grounds for new grads are burning the specialty to the ground. They have a window of a few years during which they buy and sell a large practice, with no motive whatsoever except supersizing profit, and during this window they attempt to do as many of *whatever makes the most money* as possible. The model is soooo bad for this specialty and for physicians as a whole. Is this happening in other specialties right now (other than spine)? Serious question, I really have no idea. If so, I’d really like to know the specifics…what shady BS is everyone else doing? Spill da beans !
 
Orin said:
The problem is there are way more IPM folks than orthopods. Sure Dr Death was a neurosurgeon, but he's one of only ~150 grads in his year. The issue with patient selection is a lot easier to notice with the 600+ accredited fellows, even before you consider the unaccredited pain providers, and the fact that a high volume interventionalists can likely churn through 2 or 3 times the procedure/evaluation/clinic volume of a comparable surgeon.
Click to expand...

Assuming ACGME trained pain docs - how many of them do you think are actually doing posterior SIJ fusion? I bet you it’s about 10-15% total. It’s talked about a lot by KOLs and certainly ppl are doing them but not everyone is. Most probably aren’t.
 
gaspasser127 said:
Assuming ACGME trained pain docs - how many of them do you think are actually doing posterior SIJ fusion? I bet you it’s about 10-15% total. It’s talked about a lot by KOLs and certainly ppl are doing them but not everyone is. Most probably aren’t.
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Good point. I went to a sales meeting . . . sorry, a "physician roundtable" around a month ago by a well known SIJ fusion vendor. They touted that they recently had treated their 5000th SI joint. Idk. They've been in business for at least a couple of years. Overall, that doesn't seem like much.

Fortunately for me, it was in the same city that my niece and nephew were performing in their Junior High rendition of Beauty and The Beast which was the highlight of my weekend.
 
Orin said:
...and the fact that a high volume interventionalists can likely churn through 2 or 3 times the procedure/evaluation/clinic volume of a comparable surgeon.
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0% chance I can collect more money than a busy ortho surgeon. In my group we have guys that don't just blow me out of the water, they collect numbers at a level I couldn't with 3 PAs.
 
lobelsteve said:
Why stop at sij? Lets fuse hips and knees. Ignore anatomy. Ignore pathology. Ignore msk kinematics.
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Well. . . perhaps because the orthopods do hips and knees better? Who is advocating for ignoring anatomy, pathology or msk kinematics?
 
MitchLevi said:
0% chance I can collect more money than a busy ortho surgeon. In my group we have guys that don't just blow me out of the water, they collect numbers at a level I couldn't with 3 PAs.
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Depends on the practice setup. My PM&R spine partner and I are the 2 highest collecting docs in the Ortho/sports group. By far. Our expenses are higher though because we accomplish that with multiple mid levels and a lot of support staff.
 
callmeanesthesia said:
Depends on the practice setup. My PM&R spine partner and I are the 2 highest collecting docs in the Ortho/sports group. By far. Our expenses are higher though because we accomplish that with multiple mid levels and a lot of support staff.
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That wouldn't happen with us.
 
That’s turnabout for sure. Traditionally the injectionist in an ortho practice had a hard time making partner and even if they could the shared overhead was too high due to the surgeons.

These pain surgeries must be a financial game changer. Sounds like one million is the new 600k
 
nvrsumr said:
That’s turnabout for sure. Traditionally the injectionist in an ortho practice had a hard time making partner and even if they could the shared overhead was too high due to the surgeons.

These pain surgeries must be a financial game changer. Sounds like one million is the new 600k
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Depends on how your ancillaries are set up. If MRI is included (which I’ve seen in some groups) you probably have more conditions to order imaging for as PM&R/Pain. Plus PT. And no global period.
 
Payer contracts will slant towards the total joints though.
 
nvrsumr said:
That’s turnabout for sure. Traditionally the injectionist in an ortho practice had a hard time making partner and even if they could the shared overhead was too high due to the surgeons.

These pain surgeries must be a financial game changer. Sounds like one million is the new 600k
Click to expand...
Agast said:
Depends on how your ancillaries are set up. If MRI is included (which I’ve seen in some groups) you probably have more conditions to order imaging for as PM&R/Pain. Plus PT. And no global period.
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The group is pretty egalitarian. There are 2 non-surgical sports med guys too. The overhead is high, but mostly fixed costs. We have PT and MRI but I think each of those only brings in about 10k per partner per year. The local payor environment sucks. Everything is Medicare rates, so it’s just a volume game. Basically I run a block shop. Treat ‘em and street ‘em. No opioids though, which is nice.
 
gaspasser127 said:
Assuming ACGME trained pain docs - how many of them do you think are actually doing posterior SIJ fusion? I bet you it’s about 10-15% total. It’s talked about a lot by KOLs and certainly ppl are doing them but not everyone is. Most probably aren’t.
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Many of the KOLs advertising these interventional spine procedures are in fact not ACGME boarded pain physicians...
 
D Beall is actually interventional radiology.

I can't definitively determine that Dr. Deer is certified in Pain. I see that he is certified in Anesthesia. But I don't see listing of a pain fellowship. Guessing he grandfathered in to Pain.

Agast commented previously about Anthony Gruiffrida.
 
Ducttape said:
D Beall is actually interventional radiology.

I can't definitively determine that Dr. Deer is certified in Pain. I see that he is certified in Anesthesia. But I don't see listing of a pain fellowship. Guessing he grandfathered in to Pain.

Agast commented previously about Anthony Gruiffrida.
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I guess a reasonable question is what is the value of an ACGME accredited fellowship. I definitely did not do as many procedures as some of the spine fellowships, certainly fewer stimulator implants and there was a learning curve because I decided I wanted to be able to do them myself. One could argue it would have been safer for my first few patients to do their implants with someone who went to a non-ACGME fellowship that did implants every other week. But slogging through inpatient pain consults builds character, right 😉 I guess what I would want to see from a KOL is more participation in research that isn’t funded by the company and less of listening to someone just because they do a lot of procedures.
 
Agast said:
I guess a reasonable question is what is the value of an ACGME accredited fellowship. I definitely did not do as many procedures as some of the spine fellowships, certainly fewer stimulator implants and there was a learning curve because I decided I wanted to be able to do them myself. One could argue it would have been safer for my first few patients to do their implants with someone who went to a non-ACGME fellowship that did implants every other week. But slogging through inpatient pain consults builds character, right 😉 I guess what I would want to see from a KOL is more participation in research that isn’t funded by the company and less of listening to someone just because they do a lot of procedures.
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It was worth more before the power grab and rewriting of the PIF to make it more well rounded and less useful. At the same time it eliminated about a dozen of ACGME PMR/Pain programs.
 
lobelsteve said:
It was worth more before the power grab and rewriting of the PIF to make it more well rounded and less useful. At the same time it eliminated about a dozen of ACGME PMR/Pain programs.
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This is the aspect of choosing an ACGME vs NASS fellowship I find most puzzling. My residency has a close relationship with a top NASS fellowship (ran by Furman), but I would prefer to be ACGME accredited than to not… “Worse” ACGME > “Better” NASS?
 
Ducttape said:
D Beall is actually interventional radiology.

I can't definitively determine that Dr. Deer is certified in Pain. I see that he is certified in Anesthesia. But I don't see listing of a pain fellowship. Guessing he grandfathered in to Pain.

Agast commented previously about Anthony Gruiffrida.
Click to expand...
I believe Deer was ABPM at one point, but says he he started a new society ASPN on his interweb bio:

Tim Deer MD - The Spine and Nerve Centers of the Virginias

centerforpainrelief.com centerforpainrelief.com
 
Magnus Acus said:
This is the aspect of choosing an ACGME vs NASS fellowship I find most puzzling. My residency has a close relationship with a top NASS fellowship (ran by Furman), but I would prefer to be ACGME accredited than to not… “Worse” ACGME > “Better” NASS?
Click to expand...

ACGME is the platinum standard.
 
Magnus Acus said:
This is the aspect of choosing an ACGME vs NASS fellowship I find most puzzling. My residency has a close relationship with a top NASS fellowship (ran by Furman), but I would prefer to be ACGME accredited than to not… “Worse” ACGME > “Better” NASS?
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This conversation always seems to come back. It’s almost like watching CNN constantly bring up January 6, as if there is not anything more pressing in the world to talk about…
 
For any of you acgme docs taking weekend regen courses, maybe you shouldn’t go and learn from my brethren, many of which are not acgme pain boarded, because obviously their msk training is beneath you.

Steve Sampson is not pain boarded. Don’t ever take a tobi course

And to say it’s apples and oranges, it is not.

Im pretty sure rahul Desai is not pain boarded. Shounuk patel, max moradian, not pain boarded. Don’t ever attend a lecture or conference where these guys speak. They don’t carry the platinum shield of pain..

And most definitely, do not read Furman’s atlas on pain procedures. That would just plain be pure blasphemy. I believe fentons atas will serve you all just fine..stick with that
 
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Dr. Ice said:
For any of you acgme docs taking weekend regen courses, maybe you shouldn’t go and learn from my brethren, many of which are not acgme pain boarded, because obviously their msk training is beneath you.

Steve Sampson is not pain boarded. Don’t ever take a tobi course

And to say it’s apples and oranges, it is not.

Im pretty sure rahul Desai is not pain boarded. Shounuk patel, max moradian, not pain boarded. Don’t ever attend a lecture or conference where these guys speak. They don’t carry the platinum shield of pain..

And most definitely, do not read Furman’s atlas on pain procedures. That would just plain be pure blasphemy. I believe fentons atas will serve you all just fine..stick with that
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clearly you are being defensive. please remember i said "interventional spine procedures". that does not include msk treatments. that includes these new found gadgets that are i guess grouped under pain surgery.

doctors obviously come to pain from all sorts of training. NASS or ACGME or "im a pain doc" just because.

as a whole, certified NASS programs have well thought out curriculum with teachers that have a critical eye towards pain medicine and procedures, as i would expect most ACGME fellowships to have.

there are the others, some of whom may be fly by night, or purely family med, sports med, etc. or noctors, who portray themselves as KOLs. they are the offenders.

----
your point - PRP and regen are musculoskeletal procedures, and a physiatrist should have much better background as a teacher for musculoskeletal procedures and treatments than an anesthesiologist. doesnt mean that an anesthesiologist cant teach these treatments. now i dont see these aforementioned people posting about how their new cutting edge regenerative procedures are changing the face of pain medicine. after all, there is evidence of benefit with certain regenerative procedures.

---
which was the point of my post - some of this KOL marketing for spine surgery procedures is by doctors and noctors who do not have any real good background in pain medicine, and we should be circumspect when these salesmen are posting their brand new cutting edge procedures.
 
Dr. Ice said:
This conversation always seems to come back. It’s almost like watching CNN constantly bring up January 6, as if there is not anything more pressing in the world to talk about…
Click to expand...
I know that this has been hashed and rehashed a plethora of times on this board (and I have read nearly every comment on the topic), but your collective comments are invaluable for residents like me.

If I may ask one finer question, particularly about what Dr. Lobel and Dr. Russo brought up- What are your thoughts on previously ACGME accredited fellowships that switched to NASS because of added requirements of pain inpt, ect?
An example would be Dr. Furman’s (I believe to be a fairly universally respected member in the field) fellowship in York, PA which was both pain and sports ACGME accredited and is now only NASS.
Is the “platinum standard” of ACGME unwavering, or are there big name exceptions- particularly for historically ACGME accredited fellowships?
 
Do an acgme fellowship and then take weekend courses to hone up your skills..taught (potentially) by non acgme trained “charlatans”
 
RoloTomassi said:
He taught my Intracept course, was excellent. Don't see how having ACGME would've made him better.
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Since my name is attached to this, I feel like I should clarify the specific issue was about who should be front and center rebutting spine surgeons who state that pain physicians lack adequate training to operate on the spine, and maybe it would look better if someone who was traditionally board-certified did it. I’m not against anyone doing and teaching procedures.
 
So… Does this translate into docs getting it while it’s hot and burning it to the ground before January?

What is the impact of that code change for commercial carriers or is it per the individual carrier?
 
I did an orthobiologics course with Shounuk Patel. I thought he did a great job and presented himself professionally and demonstrated great technique.

Not sure I learned anything new TBH, but I was able to reinforce current practices which is just as beneficial.
 
Dr. Ice said:
For any of you acgme docs taking weekend regen courses, maybe you shouldn’t go and learn from my brethren, many of which are not acgme pain boarded, because obviously their msk training is beneath you.

Steve Sampson is not pain boarded. Don’t ever take a tobi course

And to say it’s apples and oranges, it is not.

Im pretty sure rahul Desai is not pain boarded. Shounuk patel, max moradian, not pain boarded. Don’t ever attend a lecture or conference where these guys speak. They don’t carry the platinum shield of pain..

And most definitely, do not read Furman’s atlas on pain procedures. That would just plain be pure blasphemy. I believe fentons atas will serve you all just fine..stick with that
Click to expand...
Michael Furman, MS, MD is a board-certified physiatrist (Physical Medicine and Rehabilitation specialist) with ACGME subspecialization in Pain Medicine and in Sports Medicine.

That’s cool about regen bro…
 
Jigsaw said:
Michael Furman, MS, MD is a board-certified physiatrist (Physical Medicine and Rehabilitation specialist) with ACGME subspecialization in Pain Medicine and in Sports Medicine.

That’s cool about regen bro…
Click to expand...
Yeah..thanks for telling me what I already know “bro.” Well he’s now training the “enemy” because he lost the platinum shield to train which is so coveted. We all have learned the same stuff though. Interestingly, I was 6 months too late to be able to sit for the bs exam. My senior fellows at the time, 6 months ahead, have the “shield”

Still don’t regret the training or experience

I’m also sure those who followed me,
many of which are department chairs, Elkins award winners, etc don’t regret the training or experience.

Yeah yeah, I know..I’ll save you the message and whatever else might come along with with it…”cool story bro”
 
I was in the same boat. First year the private spine fellowships lost their acgme accreditation. Super tough year to get a pain fellowship for a pmr doc.
 
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thankfully, you guys still get to work in pain medicine without that "diploma" saying you are certified. grandfathered in, as it were.


i had to leave a profession because of that.


---

getting back to my original post, because some are conflating the issue - i commented about the KOLs advertising these brand spanking new interventional spine surgeries.


as far as i am aware, doctors such as Dr. Furman are not online boasting about their brand new interventional spine fusion surgery procedure that is curing back pain. i have and am targetting posers who wear pointy shoes and boast how great they are, and the fact that many of them are pure snake oil salesmen, not respected leaders in our field.
 
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