Sedation for MB RF

[NJPAIN]

Going back 5 or so years and in response to Medicare LCD changes, I stopped routinely doing iv sedation for MB RFN in my NJ practice based out of ASC. Never regretted. In my current practice environment, there is a strong institutional tradition of moderate sedation for all RF cases. The suggestion of local anesthesia only is reacted too as if cruel and inhuman.
Though I suspect that sedation has not been reimbursed for quite some time (and this fact was ignored or missed), it wasn’t until a week ago that we were informed that Medicare is denying authorization of any RF submitted for PA with a request for moderate sedation.
My recommendation has been to cease the routine use of moderate sedation, inform patients and reassure them that this is very common practice. If procedure fails under local anesthesia only, document that and use to justify necessity for sedation. Others are suggesting adding SmartPhrases that claim medical necessity based upon the need to maintain immobility in order to reduce potential harm. In addition, they are suggesting “careful documentation” of any intolerance of MBB to justify sedation. To me this seems like a lot of work and BS SmartPhrases to justify service that is not in fact medically necessary. I’m clearly in the minority on this, but I am also one of the very very few who have not trained and practiced exclusively in this institution.

Opinions??

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[BobBarker]

Make the patient pay $300 cash or local only.

 

[runfastnow]

2 mg Versed or they can go to the pill mill practice down the road that moderate sedation everyone for everything.

 

[DOctorJay]

Maybe suggest polling the fellowship graduates on their practices and experiences.

I don’t do any IV sedation but have had maybe 5 patients over 11 years in practice request the RFA be done with IV.

 

[CleanUp]

Like you said it’s all culture and institution specific.

If you have a community demanding sedation and not willing to pay then, well…. that’s rough.

They’ll go to the guy/gal down the street who does do sedation and eats the cost. It seems like they love this guy/gal. In reality they’re just using them.

 

[NJPAIN]

Make the patient pay $300 cash or local only.

That’s exactly what we did in my prior practice. Here they looked at me as if I was a member of the mafia when I suggested a patient pay for something out of pocket.

 

[kstarm]

My partners are all about IV sedation, I stopped last year routinely doing it and now offer oral valium. I let the patients know it is either MAC and waiting months for the OR or oral valium. It has worked well so far. It is tough if the practice pattern and partners are not on the same page as you though

 

[NJPAIN]

Maybe suggest polling the fellowship graduates on their practices and experiences.

I don’t do any IV sedation but have had maybe 5 patients over 11 years in practice request the RFA be done with IV.

Good idea.

 

[callmeanesthesia]

In my practice most patients get PO sedation in office. Maybe 1/10 will elect for IV sedation at the ASC. Maybe you could convince them to offer PO sedation as an option.

 

[BoardingDoc]

I'm new to the game as a fellow only 1 month in, but I've done 10 MB RFAs and seen maybe a dozen more. None of them got anything besides local except for one CMBB RFA I did where the patient got 2 of versed. Obviously my N is exceedingly small compared to y'alls, but moderate sedation for pretty much any in office procedure doesn't seem to be a thing around here.

 

[lobelsteve]

If anyone routinely uses sedation for RFA, then they are incompetent.

 

[Ducttape]

Going back 5 or so years and in response to Medicare LCD changes, I stopped routinely doing iv sedation for MB RFN in my NJ practice based out of ASC. Never regretted. In my current practice environment, there is a strong institutional tradition of moderate sedation for all RF cases. The suggestion of local anesthesia only is reacted too as if cruel and inhuman.
Though I suspect that sedation has not been reimbursed for quite some time (and this fact was ignored or missed), it wasn’t until a week ago that we were informed that Medicare is denying authorization of any RF submitted for PA with a request for moderate sedation.

for clarification, you can use moderate sedation for RFA.

1. The use of Moderate Sedation for RFA or cyst rupture/aspiration will be considered in individual cases with documentation of medical necessity such as a longstanding well-documented history of inability to cooperate, medical conditions that would prohibit performance of the procedure, or inability to remain motionless. Patient anxiety or preference alone is not sufficient justification. Routine use of Moderate Sedation or Monitored Anesthesia Care (MAC) or use of General Anesthesia or Deep Sedation for RFA is not considered reasonable and necessary.13

LCD - Facet Joint Interventions for Pain Management (L34892)

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

www.cms.gov

 

[SSdoc33]

ive never used oral or IV sedation. for anything.

N of probably 20,000.

maybe 2-3000 RFs.

somehow the patients survive. and come back yearly.

might i suggest that he patients who feel that hey "need" sedation might now actually "need" an injection? just a thought

 

[hopefulgasman]

For those prescribing oral valium an hour or so prior to the procedure, when do you obtain consent?

 

[Tboned]

For those prescribing oral valium an hour or so prior to the procedure, when do you obtain consent?

Do consent. Have patient chew it. Kicks in pretty fast.

 

[paindoc007]

ive never used oral or IV sedation. for anything.

N of probably 20,000.

maybe 2-3000 RFs.

somehow the patients survive. and come back yearly.

might i suggest that he patients who feel that hey "need" sedation might now actually "need" an injection? just a thought

It’s a business. Don’t get too stingy now. Boats don’t pay for themselves

 

[callmeanesthesia]

For those prescribing oral valium an hour or so prior to the procedure, when do you obtain consent?

The patient still signs the paper the day of the procedure, but the consent process started in clinic when the injection was discussed, and the patients are given a document detailing the procedure (all the things I would tell them when obtaining consent) to take home. They’re usually also not so out of it that they can’t talk, just calm.

 

[SSdoc33]

It’s a business. Don’t get too stingy now. Boats don’t pay for themselves

HA! a boat. i wish.

you want to fry a spinal nerve while the patient is sedated, be my guest.

it is just better medicine.

 

[MitchLevi]

Local competitor of mine was doing propofol for TPI.

On my life this is true.

Pretty sure I posted that procedure note in this forum somewhere.

He was bought by PE, fired 6M later and the entire practice was shut down within 24M. Created a ton of opiate refugees.

 

[BoardingDoc]

Local competitor of mine was doing propofol for TPI.

On my life this is true.

Pretty sure I posted that procedure note in this forum somewhere.

He was bought by PE, fired 6M later and the entire practice was shut down within 24M. Created a ton of opiate refugees.

I feel like the needle used to start an IV, even a 22g, would be more painful than the tpi itself.

 

[TIVAndy]

I've noticed a lot of difference in practices East vs west. West tend to be more sedation heavy. (E.g. California)

 

[BobBarker]

Yes, I interviewed at Cedars Sinai and they had two old anesthesiologists giving everyone propofol for basic spine injections.

 

[clubdeac]

I give them oral Valium and then IV fentanyl during the procedure if they need it. Without the IV verses the hospital does not consider it “conscious sedation” so you could try that

 

[Scottie_Dog]

In fellowship we used oral valium and IV fentanyl for some patients if they needed it. Private practice is a different story, almost everyone in my area (large city in midwest) offers MAC for lumbar/cervical RFA. I don't use it for all RFA but i do offer it. Most patients can get by with an oral anxiolytic. I have a tendency to lean towards Xanex, not sure why. There is a pretty hefty amount of literature out there that shows anxiolytics can reduce vasovagal reactions. I don't typically give patients anything PO for basic spine procedures, certainly not MBB, but I don't have any issues offering PO/IV sedation for RFA. Maybe that makes me incompetent

 

[lobelsteve]

In fellowship we used oral valium and IV fentanyl for some patients if they needed it. Private practice is a different story, almost everyone in my area (large city in midwest) offers MAC for lumbar/cervical RFA. I don't use it for all RFA but i do offer it. Most patients can get by with an oral anxiolytic. I have a tendency to lean towards Xanex, not sure why. There is a pretty hefty amount of literature out there that shows anxiolytics can reduce vasovagal reactions. I don't typically give patients anything PO for basic spine procedures, certainly not MBB, but I don't have any issues offering PO/IV sedation for RFA. Maybe that makes me incompetent

When you show up to explain why you are doing something, you feel guilty and/or defensive. Never had a vasovagal in procedure suite (2007-)
Sedation for RF 4x in last 15 years, And one on Friday in OR because nearby pain doc sent me a POTS patient specifically for this as he went out in their office. So it becomes anesthesia's job to watch him. Of course same doc moved out of state as soon as he made consult.....

 

[callmeanesthesia]

I have to wonder if there are differences in population or patient selection. I consider myself pretty reasonable but I have vasovagals every so often. Mostly younger and/or high anxiety people. Passive leg raise for a minute usually fixes it. I’ll give them a peppermint if they’re still feeling nauseated after that.

And I have some patients who are coming off the table as soon as I touch them with a 27g, but they do get great relief with the RF once they make it through. Also some who are psychologically normal, but just don’t numb up with lidocaine - 2-3 mL of 2% and double-checking needle tip positions, and they can still feel it burning.

 

[RoloTomassi]

I have to wonder if there are differences in population or patient selection. I consider myself pretty reasonable but I have vasovagals every so often. Mostly younger and/or high anxiety people. Passive leg raise for a minute usually fixes it. I’ll give them a peppermint if they’re still feeling nauseated after that.

And I have some patients who are coming off the table as soon as I touch them with a 27g, but they do get great relief with the RF once they make it through. Also some who are psychologically normal, but just don’t numb up with lidocaine - 2-3 mL of 2% and double-checking needle tip positions, and they can still feel it burning.

Same with all the above

 

[TIVAndy]

I have vasovagal pts about once a year. i just give some slap to the cheek a few times

 

[lobelsteve]

I have vasovagal pts about once a year. i just give some slap to the cheek a few times

Which cheek?

 

[Ducttape]

well, i think when they are prone, there are only 2 that are accessible, right?

 

[bedrock]

When you show up to explain why you are doing something, you feel guilty and/or defensive. Never had a vasovagal in procedure suite (2007-)
Sedation for RF 4x in last 15 years,

Bull$hit. You made that no vagal claim in 15 years ago before on SDN, and I stop don’t buy it at all or you misdiagnose vagals every year since 2007. No matter the technique some patients will vagal during pain procedures with local only.

I’ve seen at least ten vagals with patients on PO Xanax in the past 15 years, none of them vagaled when I repeated their procedures with IV sedation.

Though with patients on Xanax, I see far less vagals than patients getting local only.

(And I use the smallest needle possible and numb as I go)

 

[lobelsteve]

Bull$hit. You made that no vagal claim in 15 years ago before on SDN, and I stop don’t buy it at all or you misdiagnose vagals every year since 2007. No matter the technique some patients will vagal during pain procedures with local only.

I’ve seen at least ten vagals with patients on PO Xanax in the past 15 years, none of them vagaled when I repeated their procedures with IV sedation.

Though with patients on Xanax, I see far less vagals than patients getting local only.

(And I use the smallest needle possible and numb as I go)

Trained in 2004-05.
1 in office for knee injection sent for VV by Orhto in office to train the fellow on VV. He probably checks here and can verify.
1 patient went out after I injected marcaine into vertebral artery at C3 on right side. Not a VV. Thread posted by me on this misadventure years ago. My patient population does not lend it to VV. I am 53 and on any given day not more than 4-5 patients younger than I am. And if you met me, you would understand that the ambience in the procedure suite is more a stand up act than a surgery. When needed I control the situation. That is my gift. I am merely adequate at throwing needles in the spine. But anyhow:

 

[TIVAndy]

Which cheek?

left cheek - more accessible to me as i stand on the left

 

[SSdoc33]

Trained in 2004-05.
1 in office for knee injection sent for VV by Orhto in office to train the fellow on VV. He probably checks here and can verify.
1 patient went out after I injected marcaine into vertebral artery at C3 on right side. Not a VV. Thread posted by me on this misadventure years ago. My patient population does not lend it to VV. I am 53 and on any given day not more than 4-5 patients younger than I am. And if you met me, you would understand that the ambience in the procedure suite is more a stand up act than a surgery. When needed I control the situation. That is my gift. I am merely adequate at throwing needles in the spine. But anyhow:

some of it is how good you are in the needle.

most of it is the physiology of the patient. doesnt matter how good your jokes are, if the HR goes from 70 to 30 once you do a skin wheal, even george carlin isnt going to help.

1 VV in 15 years is hard to believe

 

[bedrock]

some of it is how good you are in the needle.

most of it is the physiology of the patient. doesnt matter how good your jokes are, if the HR goes from 70 to 30 once you do a skin wheal, even george carlin isnt going to help.

1 VV in 15 years is hard to believe

Yep.

Steve is very good, but human physiology isn't different in Georgia compared to the rest of North America.

 

[lobelsteve]

Yep.

Steve is very good, but human physiology isn't different in Georgia compared to the rest of North America.

Not me, it is the Jimmy Buffett that keeps them going...

 

[pastafan]

Better lucky than good but good doesn’t hurt.

 

[NJPAIN]

Thanks for all of the responses. VERY helpful.
With regard to oral sedation, would like to know

1. What’s your drug of choice?
2. When do you administer? Prescribed to patient or stocked in procedure area?
3. Concerns about timing with regard to signing consent?
4. Anyone keeping PO sedation patients NPO.

 

[Ducttape]

xanax or valium. for the elderly, xanax is better.

do not have patient self-administer. patients may take their dose early, as in the week before. and then demand another prescription.

sign consent, make sure they have driver before they take the pill.

NPO is a good idea just in case they get nauseous for any other reason.

 

[Taus]

Thanks for all of the responses. VERY helpful.
With regard to oral sedation, would like to know

1. What’s your drug of choice?

Xanax or Ativan.

2. When do you administer? Prescribed to patient or stocked in procedure area?

Rx ahead of time to their pharmacy

3. Concerns about timing with regard to signing consent?

Ideally consent signed when scheduled

4. Anyone keeping PO sedation patients NPO.

No

 

[paindoc007]

Po versed

 

[jsaul]

there are 5 pain docs within 5-10 minutes from my office. All them do RFA with IV sedation. It is like the standard of care to do it like that around here.

 

[RoloTomassi]

Thanks for all of the responses. VERY helpful.
With regard to oral sedation, would like to know

1. What’s your drug of choice?

Xanax 0.5 1-2 tabs + T3/tramadol 1-2 tabs (because staff can call in)

2. When do you administer? Prescribed to patient or stocked in procedure area?

30-60 min before, pt takes. We do stock liquid versed and MKO if needed.

3. Concerns about timing with regard to signing consent?

No. Discussion and verbal documented during office visit.

4. Anyone keeping PO sedation patients NPO.

No

 

[lobelsteve]

there are 5 pain docs within 5-10 minutes from my office. All them do RFA with IV sedation. It is like the standard of care to do it like that around here.

No. It’s not. All bad actors.

 

[BoardingDoc]

there are 5 pain docs within 5-10 minutes from my office. All them do RFA with IV sedation. It is like the standard of care to do it like that around here.

I don't even understand the reason. Again, I know I'm a noob but I've never seen anyone complain about anything other than mild discomfort when I'm burning. Usually they don't report any pain from it at all. Local is a miracle drug.

This seems akin to sedating every lac repair I did in the ER. Do people want it? Probably. Is it appropriate to do so? Hell no.

 

[MitchLevi]

Saw a woman today who I had done an RFA and a CESI on around ‘18 or ‘19. No issues.

She moved to Atlanta and started seeing a different group who made her pay cash for IV sedation. Had a right L3-5 TFESI. She told them no sedation, and said she’d had shots without any issues with me (group she was sent to was a group I almost left my current practice to join). The NP in that group told her she had to get sedation, but it’s cash only.

Procedure was an awful experience. She drove all the way back to me and I saw her today. Scheduled an ILESI.

That doctor dictated bilateral L3-S1 TFESI with Kenalog 20mg every level.

 

[NJPAIN]

Po versed

Can you elaborate on dose and timing?

 

[lobelsteve]

Saw a woman today who I had done an RFA and a CESI on around ‘18 or ‘19. No issues.

She moved to Atlanta and started seeing a different group who made her pay cash for IV sedation. Had a right L3-5 TFESI. She told them no sedation, and said she’d had shots without any issues with me (group she was sent to was a group I almost left my current practice to join). The NP in that group told her she had to get sedation, but it’s cash only.

Procedure was an awful experience. She drove all the way back to me and I saw her today. Scheduled an ILESI.

That doctor dictated bilateral L3-S1 TFESI with Kenalog 20mg every level.

Id report that to the medical board. Menacing.

 

[MitchLevi]

Id report that to the medical board. Menacing.

This is all from her mouth, so who knows the reality of the situation. This practice is near you BTW.

 

[CleanUp]

No. It’s not. All bad actors.

Steve with all due respect 90% of my patients have no clue who Jimmy Buffett is. Your technique works for your patients. It won’t work for my neck of the woods or my patient population. And that’s ok. It’s an art