block jocks

[Aether2000]

If you are coding as a second level for a bilateral epidural transforaminal injection, then we are talking about Medicare fraud. You cannot code the contralateral side as an additional level according to Medicare rules. You can code the second side as a -50 modifier but Medicare does not pay for modifiers in our region. In a hospital or ASC, the transforaminal rate is $108
As for interlaminar ESI, the Medicare payment rate is $84 in a hospital or ASC.
Remember, these are based on conversion rate of over 39.89 whereas some regions have rates much lower than this.
The 200% rates over Medicare are quite optimistic and in our region are completely unrealistic. Our carriers do not "negotiate". They offer a pre-set price and if the physician will not accept those fees, they find another pain physician who will. There is little physicians can do to "negotiate" a fee schedule unless they have some leverage. Their mere existence is not a sufficient reason for insurers to negotiate. Some pain physicians are employees of large ortho groups or hospitals that do have negotiating power, but I have seen these groups agree to sacrifice the reimbursement rates of the pain docs or anesthesiologists in order to pad their own fees.

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[f_w]

The $330 is based on doing it as an in-office procedure. You can only bill an additional level, if it is an additional level (and it might get discounted at that). The other side is indeed a -50 modifier which you might or might not get paid for.

 

[Tenesma]

algosdoc... wow... it sounds like your area is very penetrated by managed care... you are right, thought, that negotiating with managed care is pointless.... they will outmuscle you.

 

[tempperson]

When you refer a patient to a cardiologist, do you expect the patient to follow with the cardiologist for the rest of his life regarding HTN management??? i don't think so... another example: Interventional cardiologists diagnose the problem and put in the stent and then the patient goes back to the PCP or the cardiologist for further work-up or maintenance...

i think we can agree that there are those pain physicians who want to be the all-encompassing physician providing hand-holding, chronic narcotic management and interventions, and there are those pain physicians who want to practice only the interventional aspect of pain medicine....

one way doesn't trump the other...

I actually feel results would differ in a comprehensive pain program that integrated psych, PT/OT, pharmacology vs a program that only focused on procedures then referred for other issues. One thing that we established is pain is complex and is likely a component requiring thinking in terms of all these treatments. The other thing is chronic pain patients are suffering and anxious, and many do not follow through with psychiatric or PT referrals even when you stress their importance. Having services on site helps with compliance. Wouldn't it be great for someone who is already frustrated to be able to have their pain physician be the team leader and oversee all therapies undertaken. A PCP often won't delve into some of the other issues as many have limited understanding of the psychological aspects nor do they necessarily understand how to order PT/OT which would depend upon whether it is pain that is radicular, facet, factitious, muscular, etc etc.
Over time, hopefully evidence based studies will show better results at comprehensive pain centers vs procedural focused practices. Follow-up to referred services is often a problem, and the lack of relationship building by not having one go-to guy adds to this.

and it doesn't imply a lack of resources or education... trust me... setting up a chronic narcotic program doesn't take much education... in fact, in some pain practices it is entirely run by RNs with a supervising NP who writes the scripts...

Again, I think a singular practice focused on any one aspect of pain is inferior to a comprehensive one, esp one in which the physician doesn't even see the patient. By comprehensive practice, I don't mean a pill pushing practice run by RNs in addition to procedures.

Finally, about the cardiologist and PCP analogy: I think pain is fundamentally different than coronary artery disease. CAD is a very specific pathophysiologic event that requires intervention that is easy to understand. There is no psychiatric, neurologic, or any other aspect involved. Having PCP follow these pts is appropriate, since monitoring HTN, lipids, angina, etc is well within the scope of IM. Pain is more complex and there is less exposure to it in IM or FP residencies.

 

[blokjok]

 

[blokjok]

Hi.Nice discussion. I missed some parts. I have been really busy. Today we did 43 blocks, mostly ESI’s. Seems like everybody wants to be painfree for X-mas. We are finally sharing some knowledge. I like when Algos talks about coding. He definitely knows what he is talking about. Analgesic is still incoherent. Zyprexa might help.

 

[analgesic]

Hi.Nice discussion. I missed some parts. I have been really busy. Today we did 43 blocks, mostly ESI’s. Seems like everybody wants to be painfree for X-mas. We are finally sharing some knowledge. I like when Algos talks about coding. He definitely knows what he is talking about. Analgesic is still incoherent. Zyprexa might help.

Blokjok,

Why for X-mas only? Did it ever dawn on you that your patients want to be pain free for life? All bashing aside, I sincerely hope you redefine your style of practice toward being more comprehensive. I am sure you are making more than enough to be able to do so. As for sharing knowledge, I think it is prudent to note that there have been several oppurtunities in which you have failed contribute.

 

[blokjok]

Pain free for life? Could you explain us how you can make someone pain free for life?

 

[analgesic]

Pain free for life? Could you explain us how you can make someone pain free for life?

Blokjok,

Try and take the time to read this and my other posts and maybe we can begin an intelligent discussion. As most of the members on this forum are aware, every patient doesn't seek maintenance they seek resolution!
Of course I am not being overwhelmingly optimistic and this is case specific. I repeat this is case specific! I am by no way stating that every case presentation has the potential to be pain free for life. However, I do feel that this should remain our goal when appropriate not just for special occasions.

Let's address pain dynamics from the longitudinal level of the lesion perspective. The nidus is either peripheral, cord based/myelopathic, or suprasegmental i.e thalamic/cortical. Now let's say a person has a thalamic pain syndrome i.e "Dejerrene's Roussau" or a case of spinal wind up from a previous trauma. They present with RUE hyperalgesia/allodynia in the absence of any other PE findings. I think we could all agree that it would make no sense to perform recurrent blocks on such an individual. To resolve this individuals pain takes a firm understanding of sensory integration and perceptual based cognitive mechanisms. Therefore, if I limit myself to blocks and ESI's I am pretty SOL with such a patient who was referred to me because I am a specialist.

Let's take a discogenic scenario. What caused the NP herniation/annular deformation in the first place. I have talked about my top down approach previously and will do so again here. The spinocerebellum and vestibulocerebellum set the myogenic tone/gamma-motor neuron spindle sensitivity of the deep erector spinae via vestibulo spinal descending projections. Now every person with a disc lesion does not have a cerebellar lesion. However, if you do not check to see if a patient is demonstrating truncal ataxia before you put them under flouro, you may miss the etiology behind there postural paresis which is crucial. How many pain fellows on this forum have ever been shown how to test for such a PE finding? Cerebellar lesions can be functional referring to a lack of central potentiation or they can be ablative secondary to trauma or ischaemia. The former is far more common and often missed. That being said, weak muscles displace their load to the myotendinous junction which causes an increase GTO firing. This phenomena further precipitates ligamentous laxity and more discogenic strain, torsion, and ultimately herniation and sequestration. Once again I ask, if you ablate with RFA have you addressed the problem correctly?

Last but not least how about a fibromyalgia patient. What on earth can being a blok jok offer such a patient? I would really appreciate it if you could reply as to your approach to the FM patient and why your approach is appropriate. That is if you approach the FM patient at all. Not to bash but so many pain fellows automatically refer to psychiatry.

 

[Spine Specialist]

Blokjok,

Try and take the time to read this and my other posts and maybe we can begin an intelligent discussion. As most of the members on this forum are aware, every patient doesn't seek maintenance they seek resolution!
Of course I am not being overwhelmingly optimistic and this is case specific. I repeat this is case specific! I am by no way stating that every case presentation has the potential to be pain free for life. However, I do feel that this should remain our goal when appropriate not just for special occasions.

Let's address pain dynamics from the longitudinal level of the lesion perspective. The nidus is either peripheral, cord based/myelopathic, or suprasegmental i.e thalamic/cortical. Now let's say a person has a thalamic pain syndrome i.e "Dejerrene's Roussau" or a case of spinal wind up from a previous trauma. They present with RUE hyperalgesia/allodynia in the absence of any other PE findings. I think we could all agree that it would make no sense to perform recurrent blocks on such an individual. To resolve this individuals pain takes a firm understanding of sensory integration and perceptual based cognitive mechanisms. Therefore, if I limit myself to blocks and ESI's I am pretty SOL with such a patient who was referred to me because I am a specialist.

Let's take a discogenic scenario. What caused the NP herniation/annular deformation in the first place. I have talked about my top down approach previously and will do so again here. The spinocerebellum and vestibulocerebellum set the myogenic tone/gamma-motor neuron spindle sensitivity of the deep erector spinae via vestibulo spinal descending projections. Now every person with a disc lesion does not have a cerebellar lesion. However, if you do not check to see if a patient is demonstrating truncal ataxia before you put them under flouro, you may miss the etiology behind there postural paresis which is crucial. How many pain fellows on this forum have ever been shown how to test for such a PE finding? Cerebellar lesions can be functional referring to a lack of central potentiation or they can be ablative secondary to trauma or ischaemia. The former is far more common and often missed. That being said, weak muscles displace their load to the myotendinous junction which causes an increase GTO firing. This phenomena further precipitates ligamentous laxity and more discogenic strain, torsion, and ultimately herniation and sequestration. Once again I ask, if you ablate with RFA have you addressed the problem correctly?

Last but not least how about a fibromyalgia patient. What on earth can being a blok jok offer such a patient? I would really appreciate it if you could reply as to your approach to the FM patient and why your approach is appropriate. That is if you approach the FM patient at all. Not to bash but so many pain fellows automatically refer to psychiatry.

 

[Disciple]

forgive me my lack of understanding.... but why should pain physicians become primary care physicians. From my point of view, a pain physician should be a consultant specialist who makes recommendations and provides treatment options that the PCP/referrer is unable to do....

When you refer a patient to a cardiologist, do you expect the patient to follow with the cardiologist for the rest of his life regarding HTN management??? i don't think so... another example: Interventional cardiologists diagnose the problem and put in the stent and then the patient goes back to the PCP or the cardiologist for further work-up or maintenance...

I would disagree in this analogy in that an interventional Cardiologist, though performing primarily interventions, will have the knowledge base and medical skills in Cardiology and IM.

Is it likely that those who practice in a "needle jockey" type of manner have the skills to make an accurate diagnosis through a good history, MSK/neuro exam, correctly review their own films, manage complex medication regimens, write proper PT and spinal orthotic scripts (sorry, eval and treat doesn't fly)?

In my limited experience,

No.

At least you mentioned that an interventional cardiologist makes a diagnosis.

I've seen many a needle jockey perform "shot-gun" epidurals for axial low back pain according to the Dx written on the referral slip.

 

[ht]

Block jock:
I am a fellowhsip trained spine physician at an academic spine center. First, I have to acknowledge that by reading your email that I cannot tell how good a clinician you are. However, if you do 40 injections per day, you are probably referring to many patients for injections. I see about 7 clinics of patients to fill up 1 day of injections, and I also get referrals from noninterventional colleagues and surgeons.

Secondly, over half the patients I see with acute/subacute pain have gotten improper injections from other "block jocks" who did their series of 3 injections which did not help and then send them back to their primary care physicians. Since their primary care physicians do not know what to do, they then send them our way.

I agree with all the other physicians. If you wish to treat patients with spinal disorders, and you are already making close to $2,000,000. Reinvest some of the money to set up a comprehensive rehabilitation program so you can help your patients better. Your local academic center with the comprehensive rehabilitation program can do injections just as well as you can. If you are not going to treat your patients to the best of your ability, you should forward all your referrals to your local academic center.

 

[paindefender]

Block jock:
I am a fellowhsip trained spine physician at an academic spine center. First, I have to acknowledge that by reading your email that I cannot tell how good a clinician you are. However, if you do 40 injections per day, you are probably referring to many patients for injections. I see about 7 clinics of patients to fill up 1 day of injections, and I also get referrals from noninterventional colleagues and surgeons.

Secondly, over half the patients I see with acute/subacute pain have gotten improper injections from other "block jocks" who did their series of 3 injections which did not help and then send them back to their primary care physicians. Since their primary care physicians do not know what to do, they then send them our way.

I agree with all the other physicians. If you wish to treat patients with spinal disorders, and you are already making close to $2,000,000. Reinvest some of the money to set up a comprehensive rehabilitation program so you can help your patients better. Your local academic center with the comprehensive rehabilitation program can do injections just as well as you can. If you are not going to treat your patients to the best of your ability, you should forward all your referrals to your local academic center.

You cannot compare apples with oranges. An academic setting is different than private practice.

 

[blokjok]

Hi
Lots of new posts!! Just came back from Rome. I went to buy a Ferrari 360 Modena. A true fusion of cachet and power.

Analgesic, my therapists eval and treat for all muscle imbalances, postural abnormalities and gait disfunctions. They are superbly trained and quite motivated to do so. No need for me to check that stuff, I focus on doing blocks.

Hank you need to find something more glamorous than posting anonymously in a public forum. Andy is not going to like it.

 

[ht]

Blockjok
You are correct. I have three papers to submit, 2 studies to resubmit, and two with which I need to analyze the data. Have a happy holiday.

 

[DigableCat]

This has to be a troll. Why else would someone post disregard for long term or comprehensive patient care and be a braggart about their monetary gains and treasures? People like trying to get a rise out of people for some reason.

I'm through with trying to reason. Makes no difference. To each his own.

 

[jsaul]

you are ONLY now figuring out that this guy is a troll???!!!

he is at home laughing at everyone who is seriously responding to his thread...

 

[Louisville04]

you are ONLY now figuring out that this guy is a troll???!!!

If this guy is a troll, how can he reach the gas pedal of the ferrari?

 

[analgesic]

If this guy is a troll, how can he reach the gas pedal of the ferrari?

Louisville04,

He is probably sitting on a telephone book steering the wheel while the midget he hired works the pedals.

 

[blokjok]

Louisville04,

He is probably sitting on a telephone book steering the wheel while the midget he hired works the pedals.

I percieve envy again.

 

[Doctodd]

Im laughing my ass off too at some of his posts, but im sure glad this thread is here to give me a chuckle and to read everyone's point of view. Im jealous of the Ferrari, but if blokjok was worth his salt, he would have bought the new Enzo track car for a year of his salary. The Modena is so "yesterday" already. Or is that your beater car or a gift for one of your staff?

I think id like something in the middle of what algos and blokjok describe, and to sleep (continue to sleep) well at night.

T

 

[aspiring_painMD]

I love this discussion, we should keep it for all time. Its total comedy in this 'block jok' character who is egging all of us on. But on the same note, there are lots of very very good discussion on pain and the need to be comprehensive and not to be a 'block jok' type of guy.

Unfortunately, the sad reality is that there are probably lots of real life 'block joks' who don't really care about their patients long term well-being and have to hire others to push the gas pedal of their company sports car, being the trolls that they are.

 

[blokjok]

Im laughing my ass off too at some of his posts, but im sure glad this thread is here to give me a chuckle and to read everyone's point of view. Im jealous of the Ferrari, but if blokjok was worth his salt, he would have bought the new Enzo track car for a year of his salary. The Modena is so "yesterday" already. Or is that your beater car or a gift for one of your staff?

I think id like something in the middle of what algos and blokjok describe, and to sleep (continue to sleep) well at night.

T

Todd
The pleasures of the Enzo come at very high price tag. The Modena I got costs 1/3 of a new Enzo and provides enough cachet to pick up the most amazing babes. I have to admit that the life of a pain doc is so much fun.

 

[Spine Specialist]

Todd
The pleasures of the Enzo come at very high price tag. The Modena I got costs 1/3 of a new Enzo and provides enough cachet to pick up the most amazing babes. I have to admit that the life of a pain doc is so much fun.

^^^^Hmmmm...is this your new car Dr.jok?

 

[blokjok]

My Modena is yellow.

 

[DigableCat]

This thread has jumped the shark.

 

[blokjok]

D C, Let us discuss Ferraris, you might find the PM&R threads more interesting.

 

[DOctorJay]

I personally would have picked the F430, how many miles on the modena?

 

[blokjok]

I personally would have picked the F430, how many miles on the modena?

12000. Yeah the F430 is a beauty. Too expensive for a blokjok. You can find a nice Modena 360 in the low 100's.

 

[DOctorJay]

just saw a beautiful white 911 GT3 at the mall (I guess that's redundant). anyway nice to see some people who enjoy fine automobiles around here.

 

[blokjok]

The 911 GT3 is beatiful but doesn't have the cachet of the Ferrari Modena. Yeah I got the Spyder.
BTW some guy called DrMOM doesn't like my posts and claims that he is going to kick me out of SDN. Might have to discuss cars in some other forum.

 

[Supreme Love]

On another note, i dont like doing pumps and stims. I can relearn how to do them if it is absolutley necessary in the future. But i dont enjoy doing them, so id much prefer doing perc discs and RF.

I envy the financial success the OP is having though. If he is enjoying it and helping people at the same time, then kudos. I hope to build as successful a practice too, and helping people is what makes me sleep at night. I dont think the tone of the OP was to gloat or brag. And i meant no harm or sarcasm with my "evidence based medicine" post earlier.

So maybe the OP wants to share some secrets?

T

Why do you dislike the pump business? It can't be the lack of reimbursement, so what gives?

 

[Doctodd]

I just prefer disk procedures. I like that niche. I also dont like standing up in one position for extended periods of time because of my low back pain. Doing an esi in a couple of minutes prevents that. Otherwise i just dont enjoy the technical aspect of it. Maybe when i start doing more.....i prefer stims vs pumps, but things change.....i may change my mind.

T

 

[Tenesma]

actually pumps are money losers right now...and if you have an active block shop stims can lose you money as well...

 

[Jared Leger]

If you are billing correctly and have daily oversight of your pump refill billing and collections, pumps can be a "winner" on the reimbursement side.

JL

 

[Tenesma]

jared please explain to me how pump refills are money makers?

you get reimbursed a pump refill amount plus the cost of the drug (you no longer are allowed to inflate beyond invoice the cost of the drug)...

so let's say you pay 1600 for the intrathecal morphine/bupi mix your charge will be pump refill reimbursement ($50) +1600 =1650... now subtract your overhead from that (which for me is about 30%) leaves you with 1155 reimbursement after you spent 1600 on the medication... so it is actually a money loser for me.

how do you do it differently?

 

[f_w]

Why would you charge overhead towards a pass-through expense such as reimbursable medications ?

 

[Tenesma]

well every clinic is setup differently, but here is a better example

you use a billing company that charges 8% of every collected charge... that leaves you w/ $1518 - which is still a money loser...

 

[Aether2000]

Consider using less expensive medicines. Compounded morphine costs us about $25 per 40ml syringe. Addition of clonidine, baclofen, or bupivicaine may not be cost effective dependent on the insurance. Also, check your Medicare policy as these are constantly changing. Some permit charges per unit and some require AWP reimbursement rates. Walk into the room and inject the medicine after your nurse accesses the pump...that increases reimbursement from $56 to 87 for the refill alone.

 

[Jared Leger]

The reimbursement is local carrier juristiction. Our local carrier pays a flat fee on the drugs. Therefore the lower our cost on the drug, the higher our margin. We use a pharmacy with very low cost drugs, with the same quality.

Commerical payors are about the same. When you combine this with the refill kit code, the analysis with reprogram, and refill and maintanence. They can usually be a winner, not huge, but a winner.

We have one very well trained MA that does the refills, with MD supervision of the re-program. I wouldn't advise the use of a MA, but this individual is more precise at pump access, bridge bolus, step bolus, etc. than most of our docs.


JL

 

[wonthurtabit1]

Blok Jok,

In terms of functional outcome measures our clinic uses the Modified Oswestry Disability scale. The ODI and the Roland-Morris Disability Index are the most commonly used instruments in the lumbar spine literature. Assessing functionality is also germane to pain medicine. Recall the 4 A's of chart documentation for pain medicine (per the DEA to avoid prosecution!) -- analgesia (VAS each visit, assess change post-intervention), activity (must document improved functionality, i.e. doing ADLs, work, recreation. you cannot just smoke dope and sit on the couch in my opinion), adverse effects and aberrant behavior.

We send our patients an intake form which includes a body pain diagram, VAS scales, the Zung depression scale, and the Oswestry. I also think this sends a critical message to the patients that we care about how the pain is affecting their lives -- in terms of function, mood, etc.

As a physiatrist, I think the secret of why our patients love us so much is that we ask the social history and functional questions!

 

[Tenesma]

wonthurtabit... their functional status and social history doesn't affect diagnosis and therefore is elucidated by my RN and incorporated into my note that I briefly skim over... maybe that is why my patients are always asking me to refer them to a physiatrist because they just don't love me...

whatever dude....

 

[stim4u]

As a start-up I would be interested in refilling IT pumps. My question is, whether it is possible to simply refill and reprogram the pumps and have the patients obtain the medicine directly. I have seen this with our patients with Baclofen pumps, who have their meds sent to the nursing facility/home directly (I believe Medtronic does this). Furthermore, is it safe to have such concentrations in the hands of our patients?

 

[lobelsteve]

wonthurtabit... their functional status and social history doesn't affect diagnosis and therefore is elucidated by my RN and incorporated into my note that I briefly skim over... maybe that is why my patients are always asking me to refer them to a physiatrist because they just don't love me...

whatever dude....

Let's hope you are kidding as far the SH and level of function.

 

[Tenesma]

lobelsteve... that posting was dripping w/ sarcasm

 

[lobelsteve]

lobelsteve... that posting was dripping w/ sarcasm

Excellent... (in a Monty Burns voice -Simpsons reference)

I get called an asshat a lot because this is the only thing we have to denote sarcasm.

 

[drusso]

While it's probably not good to antagonize, I think that many of the people of the board feel that you do not help in breaking the stereotype of the trigger happy needle jockey who will do any injection for the right price. And given your elaborate layout, I doubt not every patient could afford such luxurious attention.

You are fortunate in that for now you have a good referral source for patients. There may come a time however when reimbursements will decrease and insurance may no longer approve such billing practices(unless patients decide to pay out of pocket-which is their prerogative-many plastic surgery centers pamper their clients too. I'm sure Blue Cross and Blue Shield isn't footing the bill). When the scratching and clawing begins, where do you think you'll be if you only have a "one trick pony"?

Bring back @DigableCat!

 

[lonelobo]

Bring back @DigableCat!

I know Digable Cat he ain't coming back

 

[drusso]

I know Digable Cat he ain't coming back

We lost one to the other side...