neurosurgeons doing pain medicine injections

[epidural man]

Holy crap!

I did anesthesia today in a surgicenter for two neurosurgeons who did a bunch of spinal injections.

I was blown away. One of the guys did two level bilateral transforaminal epidural steroid injections, all with an AP projection, no lateral projection - and 4 blobograms. He also did a lumbar sympathetic nerve block for leg pain (no contrast was used), and a bunch of facet injections with needle placements all over the place.

It is no wonder that insurance companies get annoyed that our pain "injections" don't work.

Also concerning, is they wanted basically general anesthesia - and these guys were stabbing that needle all over the place with no idea where the needle tip actually was.

The whole day was brutal to watch.

I couldn't believe it.

They were very fast though.

---

Members don't see this ad.

 

[geauxg8rs]

Holy crap!

I did anesthesia today in a surgicenter for two neurosurgeons who did a bunch of spinal injections.

I was blown away. One of the guys did two level bilateral transforaminal epidural steroid injections, all with an AP projection, no lateral projection - and 4 blobograms. He also did a lumbar sympathetic nerve block for leg pain (no contrast was used), and a bunch of facet injections with needle placements all over the place.

It is no wonder that insurance companies get annoyed that our pain "injections" don't work.

Also concerning, is they wanted basically general anesthesia - and these guys were stabbing that needle all over the place with no idea where the needle tip actually was.

The whole day was brutal to watch.

I couldn't believe it.

They were very fast though.

Surprisingly enough phase two being multilevel fusion when the injections don’t work

 

[Agast]

I’m not saying one should do this, but if there are a lot of Medicare patients getting sham injections with inadequate imaging views to support an actual procedure done, one could theoretically blow the whistle and make 10% of the money recouped

 

[PikminOC]

Holy crap!

I did anesthesia today in a surgicenter for two neurosurgeons who did a bunch of spinal injections.

I was blown away. One of the guys did two level bilateral transforaminal epidural steroid injections, all with an AP projection, no lateral projection - and 4 blobograms. He also did a lumbar sympathetic nerve block for leg pain (no contrast was used), and a bunch of facet injections with needle placements all over the place.

It is no wonder that insurance companies get annoyed that our pain "injections" don't work.

Also concerning, is they wanted basically general anesthesia - and these guys were stabbing that needle all over the place with no idea where the needle tip actually was.

The whole day was brutal to watch.

I couldn't believe it.

They were very fast though.

Yes fast $$$$

 

[pastafan]

That's one of the drawbacks of anesthesiology. Depending on the surgeon, you sometimes feel like an accomplice to a crime.

 

[Ronin1]

Yeah we’ve got a ortho guy in town that lines up 60 plus a few times a week in the office. Things like 3 sets of facets with 180 depo each time along with the ABN for coverage and then they see me….

 

[gaspasser127]

Can’t do anesthesia for epidurals on Medicare patients as of January of this past year.

If they’re doing it regularly and without any clear cut justification in the medical record that’s reportable to Medicare

 

[Agast]

Can’t do anesthesia for epidurals on Medicare patients as of January of this past year.

If they’re doing it regularly and without any clear cut justification in the medical record that’s reportable to Medicare

You can do it, you just can’t get paid for the sedation

 

[MitchLevi]

Two of our spine surgeons regularly do ESI. Depo 80mg + 2cc bupi 0.25%.

One is actually pretty dang good at them, the other isn't terrible but he ain't sticking me under any circumstance.

Both are far better than the other pain guy in our group who also only uses Depo 80mg.

 

[runfastnow]

Did an SIS course and an ortho spine guy from Estonia who just finished his training came over to do learn lumbar stuff since they didn't have anyone in his region who did them. Seemed genuinely interested in doing a good job.

Can't say I've ever seen a surgeon in the US do them.

 

[RoloTomassi]

I can think of at least 5 spine surgeons around me who do them. Most are terrible

 

[epidural man]

I should also point out that TFESIs we’re on very big people and he used 3..5 inch needle with no lateral. I’m sure he went by feel though….they have such good hands ya know.

 

[epidural man]

That's one of the drawbacks of anesthesiology. Depending on the surgeon, you sometimes feel like an accomplice to a crime.

100%. I really had a miserable day.

Plus, surgicenters in general are super shady. None of the equipment worked. They only care about speed.

 

[epidural man]

I’m not saying one should do this, but if there are a lot of Medicare patients getting sham injections with inadequate imaging views to support an actual procedure done, one could theoretically blow the whistle and make 10% of the money recouped

Yeah. I think that would be hard - the single shot saved images is so crappy I bet the surgeon could talk his way around it. Although I have wondered if I should do something…say something…

These poor patients are getting horrible treatment.

 

[oneforfighting]

All I can think about is the poor patients. Going in with all the hope in the world. What a waste of time and resources.

 

[Asclepius186]

Do you think they realize they’re doing a terrible job? Not sure which is worse…

 

[GoBeers]

Yeah. I think that would be hard - the single shot saved images is so crappy I bet the surgeon could talk his way around it. Although I have wondered if I should do something…say something…

These poor patients are getting horrible treatment.

So shady. of course it inevitably doesn't work so they subsequently send to pain management (aka pain meds) and wipe their hands clean

 

[lobelsteve]

Do you think they realize they’re doing a terrible job? Not sure which is worse…

Don't know and don't care.

 

[RoloTomassi]

So shady. of course it inevitably doesn't work so they subsequently send to pain management (aka pain meds) and wipe their hands clean

More like, injections didn't work so now surgery is indicated

 

[GoBeers]

More like, injections didn't work so now surgery is indicated

More like, surgery ultimately wont work and now send to pain management

 

[clubdeac]

You should definitely report this to Medicare

 

[DrMDAware]

Yeah we’ve got a ortho guy in town that lines up 60 plus a few times a week in the office. Things like 3 sets of facets with 180 depo each time along with the ABN for coverage and then they see me….

What do you mean you can’t give me steroid for the diagnostic block? The other doctor did!

 

[lobelsteve]

I have a jackhole NS by me who tries to dump. 18 y/o boy on Adderal and axial low back pain. Discordant MRI. He rxs 60 Percocet and tries to send for an ESI. I called him out to his partner and practice manager.

 

[epidural man]

You should definitely report this to Medicare

Question: fraud is reportable true- but is incompetence? Or poor technique? I mean, he certainly tried to do TFESI. If he can’t recognize he wasn’t even close to the foramen, can one claim fraud?

 

[lobelsteve]

Question: fraud is reportable true- but is incompetence? Or poor technique? I mean, he certainly tried to do TFESI. If he can’t recognize he wasn’t even close to the foramen, can one claim fraud?

Yes. Ever do a cholecystectomy and not take out the gallbladder?

 

[Doctodd]

I don’t think a lateral is a requirement. I’ve felt the needle slip perfectly into the foramen and had a perfect transforaminal epidurogram, and I didn’t bother with a lateral.

 

[MitchLevi]

I don’t think a lateral is a requirement. I’ve felt the needle slip perfectly into the foramen and had a perfect transforaminal epidurogram, and I didn’t bother with a lateral.

I never do them. Unnecessary.

Additional radiation, and over the course of an entire career that's a LOT of radiation.

Those pictures and the second MBB add up.

 

[clubdeac]

I never do them. Unnecessary.

Additional radiation, and over the course of an entire career that's a LOT of radiation.

Those pictures and the second MBB add up.

I believe the new medicare guidelines require 2 views for all epidurals. They can audit you and take their money back as of 1/22. You should check out the new medicare guidelines for epidurals

 

[clubdeac]

Question: fraud is reportable true- but is incompetence? Or poor technique? I mean, he certainly tried to do TFESI. If he can’t recognize he wasn’t even close to the foramen, can one claim fraud?

I'd say if they're consistently getting blobograms that are clearly not epidural then yes I'd report. We had an NP out here billing hundreds of lumbar mbb's and facet injections w/o fluoro. She got audited and shut down.

 

[lobelsteve]

I never do them. Unnecessary.

Additional radiation, and over the course of an entire career that's a LOT of radiation.

Those pictures and the second MBB add up.

1 view is no view.

 

[MitchLevi]

1 view is no view.

Who said I do one view? I do AP and oblique.

 

[SSdoc33]

Who said I do one view? I do AP and oblique.

I do the same and with the same rationale

 

[spondy14]

I'd say if they're consistently getting blobograms that are clearly not epidural then yes I'd report. We had an NP out here billing hundreds of lumbar mbb's and facet injections w/o fluoro. She got audited and shut down.

I believe the new medicare guidelines require 2 views for all epidurals. They can audit you and take their money back as of 1/22. You should check out the new medicare guidelines for epidurals

I can't seem to find this requirement in the Medicare Guidelines, can someone provide the link?

 

[MD87]

I can't seem to find this requirement in the Medicare Guidelines, can someone provide the link?

Documentation Requirements, #5

Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)

Use this page to view details for the Local Coverage Article for Billing and Coding: Epidural Steroid Injections for Pain Management.

www.cms.gov

 

[Ducttape]

from MD87 lnk:

1. Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.

it is not explicitly stated in the most recent epidural guideline.

 

[Agast]

I'd say if they're consistently getting blobograms that are clearly not epidural then yes I'd report. We had an NP out here billing hundreds of lumbar mbb's and facet injections w/o fluoro. She got audited and shut down.

Yes, what I meant was if the one picture you have looks like crap, the burden is on you to prove that you didn’t scam Medicare. If patients get 0% improvement and you have one crap image where you are clearly in the wrong location, you will probably fail the audit.

When patients tell me they felt no relief but I can show that everything is correctly placed, that proves I didn’t do a sham procedure.

 

[drrosenrosen]

There's a guy here locally who does his own pain shots... very poorly. Good news is that he's also a hack surgeon. I've never come across a satisfied former patient of his.

 

[SSdoc33]

There's a guy here locally who does his own pain shots... very poorly. Good news is that he's also a hack surgeon. I've never come across a satisfied former patient of his.

why would you, though?

 

[Analgesia108]

NS here does SI joint injections on every back pain patient as his 'protocol' ..... of course, he also does SIJ fusions to 'fix'

 

[geauxg8rs]

There's a guy here locally who does his own pain shots... very poorly. Good news is that he's also a hack surgeon. I've never come across a satisfied former patient of his.

And yet he prolly told the patient that they would be in a wheelchair if they did not have a multi level fusion for their axial back pain. Since they are not in said WC, they come in saying their back surgery was a success, but they hurt more now than pre surgery.

 

[MD87]

from MD87 lnk:


it is not explicitly stated in the most recent epidural guideline.

Very confusing to me. Both of these say different things, and they are both effective 12/2021. I don't know what to believe.

Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)

Use this page to view details for the Local Coverage Article for Billing and Coding: Epidural Steroid Injections for Pain Management.

www.cms.gov

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

 

[Ducttape]

one is the guidelines towards performing the injection, the other is guidelines for how to "correctly" document for the injection itself.

the first line of Article - Billing and Coding:

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36920, Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.

 

[drrosenrosen]

And yet he prolly told the patient that they would be in a wheelchair if they did not have a multi level fusion for their axial back pain. Since they are not in said WC, they come in saying their back surgery was a success, but they hurt more now than pre surgery.

My worst example of this was a woman who had a C3-T4 posterior fusion for a medium sized C5-6 disc herniation. That guy was out of state, but I called the medical board to report it. Poor lady remains in excruciating pain, but was eternally grateful to the doctor who "saved me from being a quadriplegic"

 

[Gauss]

There's a guy here locally who does his own pain shots... very poorly. Good news is that he's also a hack surgeon. I've never come across a satisfied former patient of his.

I've seen 2 variations on this theme: 1 is a good ortho spine surgeon but does his own spinal injections, poorly, so when they fail he can operate. The other is an awful neurosurgeon, barely made it out of training, that can't operate so has been attempting injections - literally has a textbook open in OR procedure suite trying to figure it out on the fly.

 

[Ferrismonk]

More like, surgery ultimately wont work and now send to pain management

More likely surgery didn't work so needs revision, then that didn't work so needs hardware removal, then that didn't work so stim trial which worked on paper but the patient disagrees, then stim implant which doesn't work, THEN send to pain management.

 

[hyperalgesia]

In my area, spinal injections are routinely done by NSs. It's a competitive area with an overabundance of NSs and atrocious payment environment. I can't comment on the quality of the injections because I haven't seen images or witnessed the cases. The NS argument would probably be that referring to a Pain Specialist would likely result in opioid dependence and overuse of interventions and there's probably some truth to that.

TLDR; It's better to practice in an area that is underserved.

 

[nopain1234]

Two of our spine surgeons regularly do ESI. Depo 80mg + 2cc bupi 0.25%.

One is actually pretty dang good at them, the other isn't terrible but he ain't sticking me under any circumstance.

Both are far better than the other pain guy in our group who also only uses Depo 80mg.

What’s wrong with 80mg depo?

 

[MitchLevi]

What’s wrong with 80mg depo?

You prob shouldn't use 80mg Depo in a TFESI unless you've done Dexamethasone a few times first.

 

[nopain1234]

You prob shouldn't use 80mg Depo in a TFESI unless you've done Dexamethasone a few times first.

Oh I thought you were referencing LESI not TFESI

 

[specepic]

I see low quality inj's as well with nearby CRNA groups that have the CRNAs and PAs do inj's. Blob-o-gram city