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Each b/l rfa patient is $2000. Consult, mbb, mbb f/u, mbb, mbb f/u, rfa, 6w f/u.
You can’t really do unilateral planned staged in private practice. You won’t be able to do another RF for a year which you probably want to keep in your back pocket as there are many patients that have pain come back around 10-11 months. Also, you have $50-100 in disposables depending how you sharpen your pencil and calculate the time required to clean the probes per case. So staged doesn’t make any extra money.
I was going to say - I think I've seen more unilateral (left then right or vice versa) than bilateral RFA's at this very busy PPThis is one of the few times I would disagree with bob regarding practice management.
I think you are correct to use this bilateral RFA scheduling for federal insurance (Medicare, Medicaid, Tricare).
But commercial insurance and WC pays well enough that unilateral RFA is more profitable than bilateral. And commercial insurance/WC tend to be more lenient regarding total RFA treatments per year, compared with government insurance.
can you post a video of your RFA one day? 🙏I’m just spit balling so please forgive me for running all over this thread.
But imagine this hypothetical practice:
4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos
Take Friday’s off.
Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.
I’m just spit balling so please forgive me for running all over this thread.
But imagine this hypothetical practice:
4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos
Take Friday’s off.
Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.
But your calculations assume each of those is done daily right? So 12 f/u and 4 new pt visits plus 8 MBBs and 4 RFAs per day? Certainly doable and the MBB f/u visits are quick, but most of us don’t move at your pace. Also especially if the MBBs are “100% effective” then plenty of those follow-up conversations will be bogged down with “the RFA didn’t help. Now what?”I’m just spit balling so please forgive me for running all over this thread.
But imagine this hypothetical practice:
4 new patients per day - dx facetogenic pain
4 medial branch block #1 - all done with local only but premedcated with 10mg oral diazepam and 10mg oral ketorolac. 100% effective 100% of the time for the duration of the local (or Valium/toradol)
4 mbb 1 f/u
4 mbb #2 done in the same fashion as #1
4 mbb 2 f/u
4 b/l rfa
4 6m rfa f/u - potentially schedule repeat RFA’s
Sprinkle in DME and kyphos
Take Friday’s off.
Only need one assistant, can do your own billing and prior auth as you are just chilling a lot of the day.
Need 1000 sq ft office.
Gross over $2M.
But probably impossible to get 16 new facetogenic pain patients per week and reject everything else. And not entirely ethical with the 100% mbb success rate.
Mbb 1/2 f/u via telemed. So that is 8 less bodies through the office.
But your calculations assume each of those is done daily right? So 12 f/u and 4 new pt visits plus 8 MBBs and 4 RFAs per day? Certainly doable and the MBB f/u visits are quick, but most of us don’t move at your pace. Also especially if the MBBs are “100% effective” then plenty of those follow-up conversations will be bogged down with “the RFA didn’t help. Now what?”
fwiw I agree with you on bilateral RFA being much more time and resource efficient. Procedure suite time is usually only about 5 minutes more for bilateral vs unilateral RF. Speaking of which, we should have a workflow thread where we each discuss the sequence of actions for common procedures. I’ve made many small adjustments over time to shave a few seconds here or there off and would love to share and learn from everyone else.
Doxy.me texts them a link. I usually just use the Healow chat included with ECW.
Doxy is a free tele website anyone can use. Healow is the platform that is part of e clinical works if you have that emrThank you but can you expand on that a bit? I’m not familiar with any of the three things you mentioned.
I couldn’t agree more. I once offloaded all these visits to my PA and felt down because I wasn’t reminded of the successful outcomes. It’s nice to chat in between the 1st and 2nd MBB and provide some more nuggets of education. And then after the RFA, as well. If they get relief then it’s an opportunity for them to leave a review or tell a friend. Basically a social visit with a macro.Correct, don’t delegate the easy work. I have my medial branch block follow ups as telemed and use macros to do the notes while we are talking. It is refreshing to get to talk to your successful patients as well.
If your schedule isn’t full then yes, you maximize billing by doing one side at a time. And if you are in an employed setup where cost of supplies don’t affect you, and you have staff to do all the prep work for you and walk in to the room and the patient is prepped and draped with the probes connected and laid out, and the c-arm in position.Wouldn't you maximize billing by doing unilateral RFA per day? Do right then left on another day?
Also, not bc I care, but premedicating with Toradol makes the MBB invalid correct?
How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.I agree that Toradol would guarantee almost MBB are positive!
Couldn’t do it though. I can handle a patient who failed MBB. It is a much harder discussion if they pass MBB and then fail RFA.
Currently in my hands I only see about 2-3 RFA failures per year.
How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.
I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.
Cowboy honest question how do you deal with RFA failures?How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.
I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.
I find lower success rate in patients who are older AND obese.
You could be right. I’ll see what comes of it. Thanks.Older obese patients tend to be discogenic. Many of them likely need intracept over RFA.
Really important to do the MBB with contrast, readjust needle if contrast not spreading over MB, and don’t inject more than 0.4ml bup per MB.
I expect you’re having more false positive MBB than RFA failures in the elderly obese group.
Do you put much stock in the pain with flexion (discogenic) vs extension (facet)?
Not trying to trip you up or pigeonhole you into an answer just trying to see what I’m overlooking or accepting as dogma
How are you screening MBB success? Unless you are only doing 30 RFAs per year, your stats surpass the results of Dreyfuss’s study that involved strict, dual diagnostic block criteria.
I really hate the RFA failure f/u visits, too. Only consistently worse visit is the fibro phenotype or opioid issue.
As others describe above (not not doing Sprint to multifidi). Occasionally IA facet if I’m really convinced it’s facet despite RF failure. Usually updating MRI if not recent. Thinking intracept if covered.Cowboy honest question how do you deal with RFA failures?
I wish mine were 3-4 a year but sadly they’re not.
I find lower success rate in patients who are older AND obese.
agree with thisAs others describe above (not not doing Sprint to multifidi). Occasionally IA facet if I’m really convinced it’s facet despite RF failure. Usually updating MRI if not recent. Thinking intracept if covered.
Great pointsPhysical exam puts a thumb on the diagnosis scale, but is not the end all and often not overly specific.
Plenty of older patients have stenosis, not bad enough to cause claudication, but enough to make end range extension uncomfortable.
Some younger patients will have disc annular tears which can be uncomfortable in extension.
I always examine my patients but I also always keep those two exceptions to extension based pain in my mind.
given your volumes and what you have posted, it seems like you should be bringing in much more.I guess it must be the clinic visits. All the easy follow ups and new patients go to my mid-levels. I do lots of RFAs, mostly bilateral. Usually at least 4 per day. Relatively few lower-reimbursing procedures like peripheral joints.
technically, RFA sessions are based on the injections done at 1 sitting. at least 1 of the local insurers claim that each unilat RFA represent a session, so doing 2 unilat RFA is 2 separate sessions.... and you only get 4 sessions per spine region in a rolling 12 months...Wouldn't you maximize billing by doing unilateral RFA per day? Do right then left on another day?
Also, not bc I care, but premedicating with Toradol makes the MBB invalid correct?
premedicating with toradol shouldnt invalidate as you are not giving sedation. there is nothing in the LCD to this concern.
premedicating with toradol shouldnt invalidate as you are not giving sedation. there is nothing in the LCD to this concern.
Toradol the day of a MBB completely invalidates MBB results.
if you dont follow LCD, you may not be able to keep the money you took from Medicare.an LCD is not god. It’s just whatever the insurance bureaucrats decided to include. Certainly not infallible.
Toradol the day of a MBB completely invalidates MBB results. I don’t need an LCD to make a decision for me. My MD makes the decision.
We discussed RFA failures earlier in this thread. False positive MBB are the most common source of an RFA failures.
Bogduk and Dreyfuss would never allow Toradol the day of a MBB
I’d only let patients have pain meds the day of their MBB if they had been getting them on other days and know what their pain feels like with that on board. Toradol probably wouldn’t fall into that category since it’s not a chronic daily medicine.
Older obese patients tend to be discogenic. Many of them likely need intracept over RFA.
Really important to do the MBB with contrast, readjust needle if contrast not spreading over MB, and don’t inject more than 0.4ml bup per MB.
I expect you’re having more false positive MBB than RFA failures in the elderly obese group.