What would you like to see in a Pain specific US course??

[specepic]

I am a course director for a US (Ultrasound) course in 2013 that we are currently selecting content for. I would appreciate some feedback/input regarding topics/techniques.etc that would be of interest to potential participants.

Topics under consideration:
SIJ
Cerv facets
ESI (caudal, others?)
Stellate
TFESI
Limb sympathetic blocks (periarterial)
LFCN
TPI
GON
SS nerve
ilioing/liohypog NB
Piriformis
TAP


I know some folks on here are "anti-US", so replies regarding how you think US is lame will be considered off-topic ( a-hem SL)

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[Ducttape]

i do SGB and periph nerve blocks with US.

(i dont think SIJ should be included, as no insurances cover it, but thats my opinion.)

now i feel fairly comfortable with US, but i would consider a course that looked at:

Lat fem cut N
ilioinguinal/iliohypogastric
TAP (yes, its mostly for anesthesia, but...)
SGB
suprascapular
GON
caudal (but not the other spine interventions)

 

[Tenesma]

do you mean US as in Ultrasound or US as in United States???

where is this course gonna be?

 

[onechance]

For me the most helpful is intercostal nerve block under ultrasound.

 

[bedrock]

I wouldn't bother doing SIJ, TFESI, cervical facets. People are much less interested in doing those under ultrasound if they cant charge the US guidance fee, which you can't for those procedures.

Caudal ESI would be the only common spine intervention worth doing under ultrasound, that you can do with similar success as fluoro, the other spine procedures seen so much more clearly seen with fluoro, and performed much quicker with fluoro..

The one thing I would add to your list is hip injections-

Otherwise, I do think there is value to learning US guidance for those other procedures you listed---

Limb sympathetic blocks (periarterial)
LFCN
TPI
GON
SS nerve
ilioing/liohypog NB
Piriformis
TAP

 

[specepic]

I wouldn't bother doing SIJ, TFESI, cervical facets. People are much less interested in doing those under ultrasound if they cant charge the US guidance fee, which you can't for those procedures.

Caudal ESI would be the only common spine intervention worth doing under ultrasound, that you can do with similar success as fluoro, the other spine procedures seen so much more clearly seen with fluoro, and performed much quicker with fluoro..

The one thing I would add to your list is hip injections-

Otherwise, I do think there is value to learning US guidance for those other procedures you listed---

Limb sympathetic blocks (periarterial)
LFCN
TPI
GON
SS nerve
ilioing/liohypog NB
Piriformis
TAP

You make a good point that hip (shoulder?) may not classically be within the "pain" world, yet it is a common injection(s) and a useful tool for lumbar vs. hip source of gluteal/leg pain, diff dx., etc. I do a lot of guided shoulder and hip injections as part of figuring out, is this MSK or spine/radic? I will see if we can include this in the course. This will be a AAPMR course in 2013 (stand alone, not part of Annual Assembly), month and location TBD, I am advocating for FL in spring. I am also going to look into partnering with ISIS in that there is already a AAPMR/ISIS relationship. I appreciate everyone's feedback. We will be putting a lot of time/effort into making sure this is a top notch course.

 

[PinchandBurn]

You make a good point that hip (shoulder?) may not classically be within the "pain" world, yet it is a common injection(s) and a useful tool for lumbar vs. hip source of gluteal/leg pain, diff dx., etc. I do a lot of guided shoulder and hip injections as part of figuring out, is this MSK or spine/radic? I will see if we can include this in the course. This will be a AAPMR course in 2013 (stand alone, not part of Annual Assembly), month and location TBD, I am advocating for FL in spring. I am also going to look into partnering with ISIS in that there is already a AAPMR/ISIS relationship. I appreciate everyone's feedback. We will be putting a lot of time/effort into making sure this is a top notch course.

add Hip, Shoulder, knee injections to bedrock's list. I agree with him, only spine injection would be caudal. Everything else would just take too long and cant be billed for.

 

[PMR 4 MSK]

Is this course for beginners or advanced?
Diagnostic or interventional?

Why bother with SIJI under US, you can't get paid for it. Same with facets, and likely soon, ESI. Hell within 2 years, I expect US to be bundled with everything.

 

[sblau001]

I would definitely include SIJ. I don't know why so many people here are saying you can't get paid for it. You most definitely can. You just can't bill it as a typical SI joint. It is supposed to be billed as a TP injection. I do these all the time. Surprisingly, in my elderly patient population, I've had better success with US for these than with fluro. It's also really easy to learn to do. I agree with all the other posters here that standard joint injections would be very helpful, specifically both shoulder and hip. I would also include lat and med epicondylitis injections and carpal tunnel injections. Even though facets aren't covered yet, things may change in the future. There have been a handful of patients I have done this for who were in their 90's and were in such crippling pain, they couldn't lie prone on the procedure table. I was able to do US lumbar facets with the patients in a seated position, which worked well enough for them to be able to have a 'proper' fluro-injection a week later. SS is another one that comes in very handy and is fairly easy to teach. Intercostal is another great one, especially if taught right with explanations for preventing and diagnosing PTX, Thoracic TPI's is then intuitive.

Personally, I think it's imperative to learn US basics before jumping to procedures, especially advanced procedures like many of the ones mentioned here. As a resident, I took several diagnostic US courses, then would practice on myself during lunch breaks and in clinic on patients. I probably read more articles on US technique than any other MSK subject. Only after I felt comfortable really being able to differentiate between all anatomic structures did I start injecting. I went to one advanced procedure course, and there were only a handful of us there who actually had any experience with US. We were all fine and picked up the new techniques fairly quickly. It definitely seemed to me though that the others were pretty lost. I highly doubt any of them incorporated any of the procedures taught into their practices. My point is that I highly recommend a preliminary US basics course.

 

[bedrock]

I would definitely include SIJ. I don't know why so many people here are saying you can't get paid for it. You most definitely can. You just can't bill it as a typical SI joint. It is supposed to be billed as a TP injection. I do these all the time. Surprisingly, in my elderly patient population, I've had better success with US for these than with fluro. It's also really easy to learn to do. I agree with all the other posters here that standard joint injections would be very helpful, specifically both shoulder and hip. I would also include lat and med epicondylitis injections and carpal tunnel injections. Even though facets aren't covered yet, things may change in the future. There have been a handful of patients I have done this for who were in their 90's and were in such crippling pain, they couldn't lie prone on the procedure table. I was able to do US lumbar facets with the patients in a seated position, which worked well enough for them to be able to have a 'proper' fluro-injection a week later. SS is another one that comes in very handy and is fairly easy to teach. Intercostal is another great one, especially if taught right with explanations for preventing and diagnosing PTX, Thoracic TPI's is then intuitive.

Personally, I think it's imperative to learn US basics before jumping to procedures, especially advanced procedures like many of the ones mentioned here. As a resident, I took several diagnostic US courses, then would practice on myself during lunch breaks and in clinic on patients. I probably read more articles on US technique than any other MSK subject. Only after I felt comfortable really being able to differentiate between all anatomic structures did I start injecting. I went to one advanced procedure course, and there were only a handful of us there who actually had any experience with US. We were all fine and picked up the new techniques fairly quickly. It definitely seemed to me though that the others were pretty lost. I highly doubt any of them incorporated any of the procedures taught into their practices. My point is that I highly recommend a preliminary US basics course.

I agree with everything you said....but
billing a SIJ injection as a TPI + US guidance isn't accurate, borders on fraud, and that kind of behavior is why in 1-2 years US will be bundled into everything and no one will be able to bill for US guidance.

 

[sblau001]

Bedrock, Thanks for the response. I had a lengthy discussion with my billing dept in the past regarding this, and was told that this was the correct way to bill this. I will speak to them again tomorrow to see if anything has changed. I know that the billing codes clearly state that if fluoro is not used, it should be billed as a trigger point. 2012 CPT manual states: "if CT or fluoroscopic imaging is not performed, use 20552." So this is definitely not fraud, just billing as told, as silly as it sounds. (Intuitively it would make more sense to bill it as a large joint injection.) My question is can US be billed as well? While it is clear that 27096 can no longer be billed together with fluoro or US guidance, can 76942 be billed with 20552? What doesn't make sense is that if someone does an US guided ligament injection, this can definitely be billed together, But SI joint wouldn't be covered?! Hey, I'm not trying to commit fraud; I just want to pay off my freakin equipment here!

 

[Ducttape]

you cannot bill US guidance for trigger points.

i.e. 20552 cannot be combined with 76942.

 

[sblau001]

Ducttape, can you verify this or is this your personal opinion? I can think of other times where TPI's can benefit from the use of US guidance. Best of luck to the physician who attempts TPIs along the scapular border or intercostal musculature in a very thin patient without guidance. Not only can US help prevent ptx, you can actually use M-mode right after the procedure to verify that no ptx occurred. As far as I recall, I have never seen any documentation stating that 76942 may not be billed with 20552. (Of course I will check again with my billing dept.)

 

[bedrock]

you cannot bill US guidance for trigger points.

i.e. 20552 cannot be combined with 76942.

I dunno, Powermd does this all the time to my understanding.

I've spoken to several US docs who do this regularly . Whether its necessary most of time is another discussion, but I believe it's legal at the moment.
I do think that US guidance is reasonable in the situations sblau011 listed.

However you can't bill fluoro with a trigger point injection.

 

[bedrock]

Bedrock, Thanks for the response. I had a lengthy discussion with my billing dept in the past regarding this, and was told that this was the correct way to bill this. I will speak to them again tomorrow to see if anything has changed. I know that the billing codes clearly state that if fluoro is not used, it should be billed as a trigger point. 2012 CPT manual states: “if CT or fluoroscopic imaging is not performed, use 20552.” So this is definitely not fraud, just billing as told, as silly as it sounds. (Intuitively it would make more sense to bill it as a large joint injection.) My question is can US be billed as well? While it is clear that 27096 can no longer be billed together with fluoro or US guidance, can 76942 be billed with 20552? What doesn't make sense is that if someone does an US guided ligament injection, this can definitely be billed together, But SI joint wouldn't be covered?! Hey, I'm not trying to commit fraud; I just want to pay off my freakin equipment here!

Certainly a gray area. Injection of the SIJ ligaments while you're there, does a lot more to legitimize the TPI+ US code.... of course you could just use the code for injection of ligaments + US in that situation, which is more accurate anyway. And if you inject the SIJ just use the SIJ code.

I find that many patients respond much better to one injection over the other and you many not need the SIJ or the ligament injection

 

[PinchandBurn]

Now I'm confused....

For sure, I thought you could only bill for SI joint injectins ONLY if fluro used. Additionally it is bundled.

Although I havent been doing it this way, I thought I read on here if you bill using "Large Joint/Bursa" then you can bill the ultrasound code. I thought this was legit?

 

[sblau001]

Spoke to billing dept today. SI joint should be billed as 20552 if not being performed with CT or fluoro guidance. US-guidance may be billed together with 20552 if medically indicated.

 

[PMR 4 MSK]

Spoke to billing dept today. SI joint should be billed as 20552 if not being performed with CT or fluoro guidance. US-guidance may be billed together with 20552 if medically indicated.

Step 1 - do it on a patient with Medicare.
Step 2 - send a bill with the 2 CPT codes together to CMS
Step 3 - See if you get paid. If you do, it's allowed.

 

[sblau001]

PMR 4 MSK, yes, I have been getting paid by Medicare.

 

[specepic]

Lots of dogma above, some of which wrong

You can inject an SIJ with US and get paid, but the current guidelines is to do it as 20552+76942, this is not fraud it is what CMS spec's

You can most certainly do TPI with US and bill for it. I think it is wise if this is reserved for medical necessity (obese, muscle over chest wall for safety, deep muscle like piriformis)

If you do not know, don't throw daggers like 'fraud' plz

 

[Ducttape]

http://www.medac.com/index.php/news...hesia-pain-management-a-critical-care-changesregarding TPI + US,


i asked billing (i work for hospital system) about 20552 with US code. has to do with local carrier, im told. im guessing its a local thing then.


sorry for the confusion.


ps for ICNB i code for ICNB, 64420 and 64421 (multiple), and code with US and have not had denials.

 

[TX PAIN DOC]

Lots of dogma above, some of which wrong

You can inject an SIJ with US and get paid, but the current guidelines is to do it as 20552+76942, this is not fraud it is what CMS spec's

You can most certainly do TPI with US and bill for it. I think it is wise if this is reserved for medical necessity (obese, muscle over chest wall for safety, deep muscle like piriformis)

If you do not know, don't throw daggers like 'fraud' plz

So in your dictation it should state you performed an US guided TPI near the SI joint and not that you performed an intra-articular injection in the SI (27096).

How does CMS see 27096 = 20552+76942 as being the same procedure?

 

[specepic]

So in your dictation it should state you performed an US guided TPI near the SI joint and not that you performed an intra-articular injection in the SI (27096).

How does CMS see 27096 = 20552+76942 as being the same procedure?

No I state I did a SIJ with US. Don't blame me that CMS makes no f_ing sense

 

[epidural man]

I am a course director for a US (Ultrasound) course in 2013 that we are currently selecting content for. I would appreciate some feedback/input regarding topics/techniques.etc that would be of interest to potential participants.

Topics under consideration:
SIJ
Cerv facets
ESI (caudal, others?)
Stellate
TFESI
Limb sympathetic blocks (periarterial)
LFCN
TPI
GON
SS nerve
ilioing/liohypog NB
Piriformis
TAP


I know some folks on here are "anti-US", so replies regarding how you think US is lame will be considered off-topic ( a-hem SL)

What is the SS nerve?

I would definitely add the GFN - we do a ton of those. I know groin pain isn't common in most pain clinics - but it is SOOO common in ours.

I agree - joints and bursas and peritendon views should be added to the list.

Also, I know others have said they see no place for peripheral nerve blocks (typically used in the peri-operative setting) in the chronic pain world, but I do - so I think these are useful in a chronic pain ultrasound course. I would suspect that many pain physicians who trained more than 10 years ago probably didn't learn peripheral nerve anatomy as it pertains to ultrasound views - so this would be useful.

And also....what gives? When I mentioned using ultrasound many months ago - I was almosted kicked off SDN for even thinking of such a thing. Where is the intense barrage of dissent against the very suggestion of using ultrasound for many pain procedures?

Actually, the heat I got may have come from the suggestion of using it for cervical SNRB's, which I still think is a good way to do them. Maybe add them to the list as well. (although truth be told, I usually just do them under CT and fluoro with digital subtraction.)

 

[Ducttape]

What is the SS nerve?


And also....what gives? When I mentioned using ultrasound many months ago - I was almosted kicked off SDN for even thinking of such a thing. Where is the intense barrage of dissent against the very suggestion of using ultrasound for many pain procedures?

Actually, the heat I got may have come from the suggestion of using it for cervical SNRB's, which I still think is a good way to do them. Maybe add them to the list as well. (although truth be told, I usually just do them under CT and fluoro with digital subtraction.)

SS = suprascapular nerve for shoulder pain.

you do cervical SNRB? thats one procedure i would not risk doing (and i do most of the "risky" procedures, like transaortic celiacs, anterior hypogastrics, etc.)