What kinda $ do you get ??

[apma77]

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can anybody post up what kinda insurance and medicare reimbursements are for the typical pain procedures? LESI, neurolytic blocks etc

 

[aebilling1]

California rates approx:

CPT 62280-62282 (injection/infusion of neurolytic substance with or without other therapeutic substances; subarachnoid--cervical, thoracic, lumbar, sacral

Approx $130-$150 per level, if performed in a surgery center, which gets the $$ for the facility. If not performed in a facility, the rates are approx $300-$400 per level.

Also, depending on the situation, you may be able to get a few bucks for fluoroscopic guidance, etc.

*****
CPT 62290-62291 (injection procedure for diskography, lumbar, cervical, thoracic)

Approx $150-$175 per level. If not performed in a facility, the rates are approx $$350-$400 per level.
******

CPT 64470-64476 (injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve, single level)

Approx $80-$100 for the first level and approx $40-$60 for each additional level---approx $330-360 for first level done in a non-facility and $120-$140 for each add'l level.
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CPT 64479-64484 (injection, anesthetic agent and/or seteroid, transforaminal epidural, cervical, thoracic, lumbar, sacral, each level

Approx $100-$120 for the first level and $60-80 for each additional level if done in a facility setting. For non-facility: approx $380 for first level and $170-180 for each add'l level

 

[Unemployed]

is that a lot?

 

[aebilling1]

I've heard physiatrists grumble that $250-$350 reimbursement for ,say, a two level injection isn't worth the "sphincter" value (ie the stress and responsibility of performing injections on the spine, especially of older patients who may tank right there on the table). However...A well organized physiatrist, with a good steady volume of patients, can book a day at a surg center for injections and do maybe 10 patients/day....that's $3000 or so in reimbursement for one day....you decide!

 

[Kwijibo]

then that means he should not be performing blocks. He obviously does not have the training or experience, and hopefully some day, people like that won't be.

 

[Doctodd]

id like to know what the facility fees are.

T

 

[Tenesma]

aebilling... 10 pts at a surgery center that you don't own in one day... that doesn't pay the bills... when you are doing 15-25 procedures/day in your clinic then you start seeing the positive cash flow... most procedures shouldn't really take longer than 5 minutes, except for the more advanced stuff and the rfls... which should be done under 20-25 minutes..

 

[aebilling1]

Good information. My experience here in CA is with physiatrists who normally book 1/2 hour per patient (for epidurals, blocks, discograms, etc.) at the surgery center. My guess is that the surgery center has something to do with the time slots and scheduling. I'm not sure on those details...just collecting the bucks!

 

[C Fiber]

Good God!!
That is very fast RF time. How many levels are you doing? We usually do L2 though S1 (5 levels). We burn 90 seconds twice with a 90-120 deg turn in between burns. I thought I was pretty fast doing this in 30-35 minutes with 40 sec Flouro time. Oh, I do check lateral views, test sensory and motor, and I am only restricted to 2 RFK needles per patient because of the cost$$. We only use blunt RFK needles. Maybe the angiocath introducers are slowing me down.

What are you guys in private practice doing? Mann I need to catch up !!! 🙁

 

[Tenesma]

why do 5 levels? are your diagnostic MBB 5 levels as well?
you could be actually faster if you RF all at the same time (depends on which machine you have)

 

[C Fiber]

We found that patients usually have both PE and MRI findings of multiple facet arthropathy. Yes, our diagnostic blocks are 5 levels too. One of our attending, a pretty famous guy(author of an atlas/textbook), sometimes will go right ahead to RF without diagnostic blocks!!! A man with balls!!! Even if there are only 2-3 levels hurting, considering the innervation of each facet, you end up having to block a level above and a level below anyways....i.e. 4-5 levels. And no, we don't have a machine that burns 3 levels at a time. 🙁

 

[Aether2000]

Of course the danger in such approach is that it may be considered fraud by denervating normal joints and billing for it. Also it is certainly not consistent with any published guidelines on medial branch neurotomy, and is teaching techniques that are contrary to medicare and many major insurance requirements of positive medial branch diagnostic blocks to precede any z-joint denervation. I would be extremely apprehensive of this type of cowboy approach....

 

[Tenesma]

again.... it is upsetting to see people do things that are not based on science... to the best of our knowledge facet disease represents 15-20% of back pain patients, so to go ahead and RF without evidence of dysfunction is somewhat out of the mainstream. It isn't supported by the literature and to make things worse it makes us look like idiots...

 

[neuropathic]

.....to make things worse it makes us look like idiots...

I think RF multilevels without physical and radiologic evidence of multilevels disease is a very questionable way of practicing medicine. People who don't do medial branch blocks and go straight to RF are id...

 

[Tenesma]

as of right now there is no physical exam or radiologic evidence suggestive of facets as a generator of pain... the medial branch block is the only diagnostic tool we have...

 

[neuropathic]

as of right now there is no physical exam or radiologic evidence suggestive of facets as a generator of pain... the medial branch block is the only diagnostic tool we have...

Isn't correlation of facet manuevers, palpation, assess ROM with plain films or MRI evidence of facet arthropathy suggestive of facets as a pain generator?

I want to be a doctor, not a butcher.

 

[Aether2000]

Potential Z-joint pain generators:
1. Osteophytosis of the edges of the joints
2. Intra-articular cartilaginous degeneration
3. Synovial entrapment
4. Subchondral hematoma
5. Effusion of the joint
6. Subluxation of the joint
7. Capsular disruption
8. SAP fracture
9. Biomechanical transfer of both weight and center of gravity due to DDD
10. Ligamentum flavum impingement due to hypertrophy
11. Foraminal stenosis due to hypertrophy

Physical exam is too non-specific to pick up z-joint pathologies, MRI and CT do not have enough specificity either....

 

[C Fiber]

Points well taken. What would you do then, if a 75 yo female with bilateral low back pain, exam significant for facet loading maneuvers positive from L3/4, L4/5, & L5/S1 bilaterally and has MRI with multi level DDD, facet hypertrophy throughout?

I am not trying to be smart, but we do see this type of patients a lot. During residency, we used to try 1-2 level-blocks at a time, but patients complained that both sides still hurt post-op.

Now in fellowship, though we have attendings from various different fellowship programs(UTMB, Cleveland, Lubbock, NY, Chicago, etc) around the country, Somehow, they all eventually changed their way of practice to this Multi-level-blocks!!! Believe me, I've wondeedr about the same thing as you all mentioned above. But somehow, these patients do well compared to the ones I saw in residency who only had 1-2 levels done at a time. (I know, sorry, no published data to back it up.)

I was also told that the reason private pain docs only radiofrequency less than <3 leves at a time is because if you do more than 3, you will not get reimbursed. Is it true?

 

[Tenesma]

while it is possible that a patient may have multiple arthritic/damaged joints, why not be focused in your approach, otherwise you end up just doing one MASSIVE trigger point injection instead of a scientifically laid out diagnostic/therapeutic maneuver...

 

[Aether2000]

In my experience, it is not possible to isolate one affected segment from other affected segments during facet loading manuvers and the literature suggests these manuvers may be an inaccurate way of determining facet arthropathy. Therefore one may not be able to determine via facet loading that the patient has 3 or 4 level disease. The sequences being touted by ISIS are for 2 level blocks and in such situations, it may be useful to begin with such, then bring the patient back for a repeat block with expansion to 4 levels if there were only partial relief with the initial block. Then if there is only partial relief (50% or less), one would have to wonder whether the degree of relief that would be achieved via RF would be worth it. I agree that bilateral degenerative facet arthropathy is more common than unilateral with the exception of a scoliotic lumbar curve.