triaging advice for spine clinic

Started by AndyDufrane
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AndyDufrane

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so I started working one day a week at a local ortho sports med oriented practice,I am the designated spine guy, problem is I am getting alot of nonsense type patients, ideally am wanting to see patients to generate fluor guided injections and EMGs, and any advice I should give to the office scheduling folks about what types of patients that I should see on my schedule, the ortho practice is young and progressive, so they have told me you can tailor your schedule however you like. thanks in advance.
 
Nonsense=my primary care provider just filled out my last oxycodone rx because of positive THC, w/ + ETOH abuse, wanted to see what you have offer for 10+year back pain that goes into both legs, up spine, into both arms, and nothing has changed with pain in last 1 year, has exam that is not focal for anything and alot of pain behavior in exam room
 
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lobelsteve said:
Hilarious. Did you do a fellowship in pain? Because thats what you are doing. Might want to post in pain forum. How about tell all patients that you do not rx at all before they schedule.
Click to expand...
no I did not do a pain fellowship, I did a spine fellowship and the sports ortho practice I have started to work at specifically don't want a pain clinic in their ortho clinic either, basically there to take the 40% of spine patients they were turning away before, so i am trying to guide their triage people and schedulers to weed out chronic pain med seekers who will defeat the purpose of me trying to help out in the ortho clinic as they will eat up all my time
 
Only solution is to not have a DEA reg. All referrals must be told prior to scheduling that you do not prescribe any medicine. They are there for PT recommendations and injections only. Maybe you could go back and do an IR training program.
 
  1. In order for me to see you, you must be referred by a physician (NOT a chiropractor).

  2. If a doctor is currently writing prescriptions for opioids, narcotics, or controlled substances, we may ask you to get a letter documenting that they will no longer be writing such prescriptions.

  3. If you have been a patient at another pain management clinic, I may require a letter from your treating physician explaining the circumstances that lead to your termination from care.

  4. Please bring a copy of your medical records, including MRI and CT reports, operative reports, as well as a list of your current medications, to the office, so we can review it. Please DO NOT assume your physician has sent such records, but rather, bring them with you.

  5. I do not just write for medication. If that is all you want, I may not be the right doctor for you.
    1. My approach includes physical therapy and interventions (things like epidural steroid injections in the neck or the back, facet injections in the neck or the back, etc).

    2. Please understand that, if you are unwilling to undergo such procedures when they are recommended, I may not be able to continue treating you.
  6. No opioids, narcotics, or controlled substances will be prescribed on the first visit. Please make sure your referring doctor has written enough medication for you.

  7. No other doctor can write for your opioids, narcotics, or controlled substances.
    1. That includes your primary care physician, the emergency room doctor, your dentist, or another doctor who is going to operate or do a procedure.

    2. If they do, and you don’t call the office to ask my permission, I will not be able to write for any more opioids, narcotics, or controlled substances
  8. No opioids, narcotics, or controlled substances will be prescribed unless I have a copy of a recent (within the past two years) MRI or CT of the area where you are having your pain.

  9. There are certain drugs I do not write prescriptions for: Methadone, Soma, Roxycodone, Oxycontin, Fentanyl, Opana, Dilaudid, Ativan, Valium, or Xanax.

  10. There are drugs that, while I am willing to prescribe them, I do not write more than
    1. Norco/hydrocodone, 10mg 3-4 pills/day (105 pills/month) – if taken as the only narcotic.

    2. Norco/hydrocodone, 2 pills/day (60 pills/month) – if taken in combination with a long-acting narcotic.

    3. Percocet/oxycodone, 10mg 3-4 pills/day (105 pills/month) – if taken as the only narcotic

    4. Percocet/oxycodone, 2 pills/day (60 pills/month) – if taken in combination with a long-acting narcotic.

    5. MS Contin 15mg, 2 pills per day.
  11. If you have been prescribed Suboxone, I assume it was for a history of abuse. I will require a letter from your addiction specialist documenting that re-starting you on opioids, narcotics, or controlled substances is reasonable and safe.

  12. Fibromyalgia/chronic pain is a condition best treated with exercise and non-narcotic medication. I will be happy to take you on as a new patient if, in addition to generalized pain, you also have localized neck, low back, extremity, or knee pain (documented on MRI or CT).

  13. If you are on blood thinners (Warfarin (Coumadin), Clopidogrel (Plavix), Ticlodipine (Ticlid), Rivaroxaban (Xarelto), Apixiban (Eliquis), Prasugrel (Effient), Dabigatran (Pradaxa), Ticagrelor (Brilinta)), you will need to get a letter from the prescribing physician clearing you to come off the medication for potential procedures.

  14. If you or your friends or relatives are rude, ugly, disrespectful, yell, raise your voice, curse, or threaten my staff, I will have to stop writing for opioids, narcotics, or controlled substances.

  15. The staff may potentially drug test you every visit.
    1. If you test positive for marijuana, I will not be able to write for opioids, narcotics, or controlled substances.

    2. If you test positive for any other illegal substances (like cocaine, ecstasy, methamphetamine, etc), I will not be able to write for opioids, narcotics, or controlled substances until you complete a drug treatment program.
  16. The staff may call you without warning, and ask you to bring the pills I prescribe into the office. If you can’t bring them in within a couple of hours, I won’t be able to write for any more opioids, narcotics, or controlled substances.

Please understand that these are my practices. They will not be negotiated. If you are willing to work with me, and try alternative medications, I am happy to address your pain with all the available options methods, and techniques.
 
ampaphb said:
  1. In order for me to see you, you must be referred by a physician (NOT a chiropractor).

  2. If a doctor is currently writing prescriptions for opioids, narcotics, or controlled substances, we may ask you to get a letter documenting that they will no longer be writing such prescriptions.

  3. If you have been a patient at another pain management clinic, I may require a letter from your treating physician explaining the circumstances that lead to your termination from care.

  4. Please bring a copy of your medical records, including MRI and CT reports, operative reports, as well as a list of your current medications, to the office, so we can review it. Please DO NOT assume your physician has sent such records, but rather, bring them with you.

  5. I do not just write for medication. If that is all you want, I may not be the right doctor for you.
    1. My approach includes physical therapy and interventions (things like epidural steroid injections in the neck or the back, facet injections in the neck or the back, etc).

    2. Please understand that, if you are unwilling to undergo such procedures when they are recommended, I may not be able to continue treating you.
  6. No opioids, narcotics, or controlled substances will be prescribed on the first visit. Please make sure your referring doctor has written enough medication for you.

  7. No other doctor can write for your opioids, narcotics, or controlled substances.
    1. That includes your primary care physician, the emergency room doctor, your dentist, or another doctor who is going to operate or do a procedure.

    2. If they do, and you don’t call the office to ask my permission, I will not be able to write for any more opioids, narcotics, or controlled substances
  8. No opioids, narcotics, or controlled substances will be prescribed unless I have a copy of a recent (within the past two years) MRI or CT of the area where you are having your pain.

  9. There are certain drugs I do not write prescriptions for: Methadone, Soma, Roxycodone, Oxycontin, Fentanyl, Opana, Dilaudid, Ativan, Valium, or Xanax.

  10. There are drugs that, while I am willing to prescribe them, I do not write more than
    1. Norco/hydrocodone, 10mg 3-4 pills/day (105 pills/month) – if taken as the only narcotic.

    2. Norco/hydrocodone, 2 pills/day (60 pills/month) – if taken in combination with a long-acting narcotic.

    3. Percocet/oxycodone, 10mg 3-4 pills/day (105 pills/month) – if taken as the only narcotic

    4. Percocet/oxycodone, 2 pills/day (60 pills/month) – if taken in combination with a long-acting narcotic.

    5. MS Contin 15mg, 2 pills per day.
  11. If you have been prescribed Suboxone, I assume it was for a history of abuse. I will require a letter from your addiction specialist documenting that re-starting you on opioids, narcotics, or controlled substances is reasonable and safe.

  12. Fibromyalgia/chronic pain is a condition best treated with exercise and non-narcotic medication. I will be happy to take you on as a new patient if, in addition to generalized pain, you also have localized neck, low back, extremity, or knee pain (documented on MRI or CT).

  13. If you are on blood thinners (Warfarin (Coumadin), Clopidogrel (Plavix), Ticlodipine (Ticlid), Rivaroxaban (Xarelto), Apixiban (Eliquis), Prasugrel (Effient), Dabigatran (Pradaxa), Ticagrelor (Brilinta)), you will need to get a letter from the prescribing physician clearing you to come off the medication for potential procedures.

  14. If you or your friends or relatives are rude, ugly, disrespectful, yell, raise your voice, curse, or threaten my staff, I will have to stop writing for opioids, narcotics, or controlled substances.

  15. The staff may potentially drug test you every visit.
    1. If you test positive for marijuana, I will not be able to write for opioids, narcotics, or controlled substances.

    2. If you test positive for any other illegal substances (like cocaine, ecstasy, methamphetamine, etc), I will not be able to write for opioids, narcotics, or controlled substances until you complete a drug treatment program.
  16. The staff may call you without warning, and ask you to bring the pills I prescribe into the office. If you can’t bring them in within a couple of hours, I won’t be able to write for any more opioids, narcotics, or controlled substances.
Please understand that these are my practices. They will not be negotiated. If you are willing to work with me, and try alternative medications, I am happy to address your pain with all the available options methods, and techniques.
Click to expand...

Blahahaha
 
lobelsteve said:
Only solution is to not have a DEA reg. All referrals must be told prior to scheduling that you do not prescribe any medicine. They are there for PT recommendations and injections only. Maybe you could go back and do an IR training program.
Click to expand...

this is clearly not the ONLY solution. if you dont want to prescribe opioids, then dont. you can still have a DEA number, but not be "loose with the pen" shall we say. we all deal with this BS all the time. inappropriate patients, etc. no great way to weed them ALL out, but either you personally or someone in your practice needs to read some charts before scheduling these yahoos.
 
also, being the "spine guy" in an ortho practice is not necessarily a bad place to be. is there a spine surgeon in the practice? if so, you can dig out a nice little niche with injections, and a non-operative practice. if there is no spine surgeon, and you have to farm out the surgeries, it might be more difficult to avoid these "problem" patients
 
Who handles the post fusion pain? And 8 weeks later they are no better? An you did a series of 3, then MBB/RF and SIJ, then fusion. Do you then turf to a pain clinic? And what do you think those guys will do? Send them right back to you to continue the regimen the surgeon started and dumped on you. And we pain guys will tell the patients all the things to say to you. Don't fall into the trap. Do you see where this can go?
 
SSdoc33 said:
also, being the "spine guy" in an ortho practice is not necessarily a bad place to be. is there a spine surgeon in the practice? if so, you can dig out a nice little niche with injections, and a non-operative practice. if there is no spine surgeon, and you have to farm out the surgeries, it might be more difficult to avoid these "problem" patients
Click to expand...
yes , the office next door does have a spine surgeon who is referring injections to me, but he wants a SNRB "fast tracked" without me even evaluating the patient in office, but the office manager in our office told me insurances won't authorize injections unless they have had some other stuff done like PT or oral meds, plus this surgeon wants all his patients to have sedation w/ propofol, which I think is over the top, to have propofol for a TFESI, my usual practice is no sedation unless I think the patient seems anxious, then if they do then I am ok w/ oral anxiolytic like Xanax 0.5 mg 60 minutes pre-procedure,
 
AndyDufrane said:
yes , the office next door does have a spine surgeon who is referring injections to me, but he wants a SNRB "fast tracked" without me even evaluating the patient in office, but the office manager in our office told me insurances won't authorize injections unless they have had some other stuff done like PT or oral meds, plus this surgeon wants all his patients to have sedation w/ propofol, which I think is over the top, to have propofol for a TFESI, my usual practice is no sedation unless I think the patient seems anxious, then if they do then I am ok w/ oral anxiolytic like Xanax 0.5 mg 60 minutes pre-procedure,
Click to expand...


frankly, andy, it seems like you are a bit over your head.

you have to get the auth for any procedure (if auth is needed) before they come in. your office staff should be dong that. you can bill an E/M the day of the injection in most cases, so you dont necessarily have to see the patient in clinic on a separate day before the shot, though some injectionists prefer it that way. there is no such thing as a SNRB, although i think what you mean is a "spinal nerve block". check the ISIS nomenclature. This is different than a TFESI. propofol for a TFESI is ludicrous, and the referring surgeon is either old and doesn't know better, or seriously misinformed. in the vast majority of cases, oral anxiolytics shouldnt be necessary either. If this is the surgeon that you hitched your wagon to..... you might want to find a new horse......
 
SSdoc33 said:
there is no such thing as a SNRB, although i think what you mean is a "spinal nerve block". check the ISIS nomenclature. This is different than a TFESI. propofol for a TFESI is ludicrous, and the referring surgeon is either old and doesn't know better, or seriously misinformed. in the vast majority of cases, oral anxiolytics shouldnt be necessary either. If this is the surgeon that you hitched your wagon to..... you might want to find a new horse......
Click to expand...

I thought SNRB = Selective Nerve Root Block is the same as TFESI?
 
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Louisville04 said:
I thought SNRB = Selective Nerve Root Block is the same as TFESI?
Click to expand...

meh. not really. i may be a bit pedantic, but there is no selectivity with a TFESI, as 0.25mL fluid travels up and down a few levels. you can do a SNB, which is a spinal nerve block, but that is really not selective. TFESI implies steroid, where nerve blocks may or may not contain steroid
 
SSdoc33 said:
meh. not really. i may be a bit pedantic, but there is no selectivity with a TFESI, as 0.25mL fluid travels up and down a few levels. you can do a SNB, which is a spinal nerve block, but that is really not selective. TFESI implies steroid, where nerve blocks may or may not contain steroid
Click to expand...

Going off topic why even bother doing TFESI if they are no more efficacious than a parasagittal ILESI?
 
SSdoc33 said:
frankly, andy, it seems like you are a bit over your head.

you have to get the auth for any procedure (if auth is needed) before they come in. your office staff should be dong that. you can bill an E/M the day of the injection in most cases, so you dont necessarily have to see the patient in clinic on a separate day before the shot, though some injectionists prefer it that way. there is no such thing as a SNRB, although i think what you mean is a "spinal nerve block". check the ISIS nomenclature. This is different than a TFESI. propofol for a TFESI is ludicrous, and the referring surgeon is either old and doesn't know better, or seriously misinformed. in the vast majority of cases, oral anxiolytics shouldnt be necessary either. If this is the surgeon that you hitched your wagon to..... you might want to find a new horse......
Click to expand...

the office staff are pretty good about getting the preauth, and yes I meant selective nerve root block is what the surgeon is requesting, even though I call it a TFESI, and yes, I have not been giving them any anxiolytic, I have never really used any sedation for patients except maybe once or twice Xanax for a really anxious patient, this referring surgeon is part owner of the ASC that I do the procedure at, and my office manager thinks using propofol may require setting up like an OR and might bump up the facility fee, but anyway, luckily I am not part of the surgeon's group, he just is referring for injections for now, but he may stop once he realizes I am not doing what he is requesting, which is OK I am part of sports med ortho group which is under another larger multispeciality group which has been providing a steady stream of patients.
 
AndyDufrane said:
the office staff are pretty good about getting the preauth, and yes I meant selective nerve root block is what the surgeon is requesting, even though I call it a TFESI, and yes, I have not been giving them any anxiolytic, I have never really used any sedation for patients except maybe once or twice Xanax for a really anxious patient, this referring surgeon is part owner of the ASC that I do the procedure at, and my office manager thinks using propofol may require setting up like an OR and might bump up the facility fee, but anyway, luckily I am not part of the surgeon's group, he just is referring for injections for now, but he may stop once he realizes I am not doing what he is requesting, which is OK I am part of sports med ortho group which is under another larger multispeciality group which has been providing a steady stream of patients.
Click to expand...

good, i think thats a step in the right direction, but there are red flags all over this
-adding conscious sedation solely for the increased ASC revenue (which he is a part owner) borders on malpractice
-"selective" nerve root block (better termed "spinal nerve block") really should not be used for diagnosis. It sounds like this yahoo wants you to do a diagnostic injection so that if it helps, then he will fuse. my guess is that he will probably fuse anyway.
-you should have the opportunity to get shares in the ASC -- provided you have enough volume
-you ideally need to have a good working relationship with a reasonable spine surgeon
-the sports med group and multispecialty group can generate referrals, but spine-specific referrals from good surgeons are really helpful.


i may be seem a bit jaded, but unfortunately, there are way too many charlatans out there. best of luck
 
Agree that this spine surgeon does not sound like an ideal referral source.

Also, I hope that Andy understand that you don't make jack on procedures performed in an ASC unless you own a big chunk of it (10% or more). You make more money seeing patients in clinic than you do while performing pain procedures in an ASC, unless you are a significant owner in the ASC.

Doing procedures with Xanax is fine if you consider your dose per patient. 0.5 mg is helpful for so many patients, as just a little bit really helps with many procedures.
I use 1.5 mg all the time for my wimpy young male or anxious obese patients.
 
SSdoc33 said:
good, i think thats a step in the right direction, but there are red flags all over this
-adding conscious sedation solely for the increased ASC revenue (which he is a part owner) borders on malpractice
-"selective" nerve root block (better termed "spinal nerve block") really should not be used for diagnosis. It sounds like this yahoo wants you to do a diagnostic injection so that if it helps, then he will fuse. my guess is that he will probably fuse anyway.
-you should have the opportunity to get shares in the ASC -- provided you have enough volume
-you ideally need to have a good working relationship with a reasonable spine surgeon
-the sports med group and multispecialty group can generate referrals, but spine-specific referrals from good surgeons are really helpful.


i may be seem a bit jaded, but unfortunately, there are way too many charlatans out there. best of luck
Click to expand...
great insight from everyone, appreciated, yes I have decided to do the procedures other than this spine surgeon's ASC, the sports med group I work at is talking about building a fluoro suite right in our office , so hopefully that will settle the matter, and yeah, I have gotten the vibe this spine surgeon might not be the ideal referral source, I am hoping my 50+ multispeciality group whose office I rent from will start sending me the spine stuff before sending to the spine surgeon, but thank you everyone for the great info, makes me feel better
 
SSdoc33 said:
true. ive been through this ad nauseum with the billing people. there is a ton of nuance and ambiguity in the language, but it can be done.
Click to expand...
Linda van Horn, Marvel Hammer, and David Vaughn all say otherwise. Since David is the one who will defend me, I take the word of the experts. I would encourage you to do the same.
 
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