Open to suggestions. Current charge master has it about $1000 so some discount off that.
I’ve been doing one block in the same appointment as the initial consultation - palpation and ultrasound guided, lateral approach with a 27g needle (unless they are too big). Follow up in a few days to discuss results and ablation.
How are your results with Iovera. I keep being approached to doing it. I have cool RF that admittedly I am not in love with, and wanted to hear what your experience has been with it.
I bill for the block with the initial visit. Unfortunately Medicare won’t reimburse for ultrasound or fluoro with 64450 according to my coders, but at least I’m not wasting a fluoro procedure spot.
Surprisingly good (compared with genicular RF). Easier for me and on the patients. They have a new tip that makes it more like a u/s guided RFA. I'm concerned about duration, but so far it doesn't seem inferior to genicular RF in that respect either.
Yeah, they told me “as long as you have a good payor mix, you won’t lose money.” I didn’t pursue it further.
Haven’t gotten hit with that yet that I know of. I just recently started doing geniculars in clinic though.
I still need help /advice for doing this in clinic. Thense patients hate the procedure. I honestly rather do a scs stim without sedation than a genicluar without sedation . Any tips ?
Lidocaine. 25g needles for block, 20g for rfa.
For nerve block I took the advice of someone else on here and started approaching from lateral. I forget who that was but maybe they can chime in too. It’s much less painful. For small/medium knees I feel the condyles and mark, then verify with ultrasound, then go in blind with a 27g 1.5”, perpendicular to skin down to bone, inject 0.5 mL local, redirect proximal or distal and inject another 0.5 mL. For big patients where I can’t feel landmarks, I do it under fluoro with a 25g 3.5”. Mark in AP then trace straight down to the side of the knee (like you’d do for a GT bursa), stick the needles in parallel to the table to the target points.
So no sensory/motor testing?
I still motor test but I realize it doesn’t do much. I think mainly the safety comes from the position on lateral view and making sure the tips aren’t too far posterior. As far as sensory, patients seem to feel it radiating into the knee during ablation even with lots of local.
Never.
Yes, except insert knee replacement after HA injections, before genicular, for patients that are good surgical candidates. TKR corrects mechanical problems in addition to pain relief, in a way that only killing the pain nerves can't. For patients that still have some quality years left, I personally would rather have a well done TKR, than an ablation that allow me to walk on a knee that's destroyed, functioning poorly and breaking down mechanically more by the day.
