Procedure heavy?

[doctorlarry]

To all the veterans on the forum:

How many procedures do you perform per year? I ask because I'm looking at a practice where the pain physician did 2500-3000 procedures last year...this seems like a lot, and I wonder about the quality of care, ethics, etc. Maybe they just have an excellent support staff, etc. to pull this off...any thoughts about practices boasting large numbers...is this just to draw you in?

Realizing their are a multitude of other factors that are important including job satisfaction, etc.

Thanks for any replies.

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[Aether2000]

I do somewhere around 1800 a year, and that includes SCS and IT pump trials and implants, and US guided non-spinal injections. If you do the math, 365 days a year minus 104 days for weekends and minus additional 35 days off holidays and 6 weeks vacation, that leaves 226 working days a year. For 3000 injections per year, that averages around 14 procedures a day, every working day. This is possible if all are short cases...say 15 minutes. Ya can't do 14 SCS implants a day, so this number limits you to smaller procedures. Our injection procedure times are relatively short- brevital anesthesia, when used, speeds our cases along...takes me 40 secs to drop in an IV and tape it in place, 2 min to position the patient and apply monitors, most procedures require 2-10 minutes, and recovery with brevital occurs in the procedure suite, usually within 3 min after the end of the procedure the patient is awake and lucid. Some procedures are much shorter such as contrast demonstrated caudal ESI. Some are much longer including bilateral cervical RF or SCS work. But can you do 14 patients a day and appropriately evaluate the patients? Possibly, but it depends on the speed of your documentation, and that goes back to the functionality of your EMR.

 

[facets]

That is a lot. I did about 100 a month for years and made a perfectly acceptable living. They may have midlevels seeing new patients and just using the docs to do procedures. I have seen many practices do this, but I personally don't like the model.

 

[Sandpaper]

Averaged almost 2500 procedures a year my first two years out. It was way too much, but I learned a lot in the process. Now, I average about 35/week. A good living and still have my sanity.

 

[SSdoc33]

1800-2000

 

[Jcm800]

1800-2000

me too...but i feel like i could do a little more if needed, but after 50 procedures a week, its get to be a bit of a blurr, and i dont feel like patients are getting an individualized plan, just kind getting run through. I do office procedures and try to split my day 1/2 procedures, 1/2 all the other stuff. I dont count trigger points as procedures...

on average 7-10 per day, 5 days a week 46 weeks a year, roughly...

i dont like doing procedures on patietns that the plan was determined by someone else, mid-level or MD. in some cases it might work, but you have to be VERY like minded. My partner and i are very similar, but we still differ in what procedure we would do at times. sometimes it may just be the level or the approach, and in reality it may not make a difference, but we still differ, and i still feel my way was right, of course...so its something to consider.

 

[Jcm800]

lets move this to physicians forum?

 

[lonelobo]

Make sure the number you are getting is separate procedures

I have seen this before but sometimes they were counting multiple levels in procedures and breaking out CPT codes

ie:
Procedure-two level facet injections

1st level-64493
2nd-64494

sometimes the billers count as two different procedures in the same encounter

 

[doctorlarry]

Thanks to everyone for your valuable feedback. I will have many questions for this practice...

 

[Tenesma]

in my opinion to generate 2500 procedure per year, you need to see about 6-7,000 E/M per year - (unless you are doing a lot of series of 3s of everything....)

so in my mind, this practice is UNBELIEVABLY efficient and is getting fed a TON of procedures from local spine surgeons...

or more likely, something fishy is going on...

I am at about 1800-2000/yr but included in that number are also non-spinal injections (field stimulators, peripheral nerve injections/denervations, etc.)

IF i did series of 3 injections (my local competing pain docs do a series of 3 ESIs, then a series of 3 facets, then a series of 3 SI joints, and if no improvement they do TPI every 2 weeks with BOTOX every 3-4 months)... i think i could push up my volume to the 3500 mark/year --- but i would not sleep well at night...

 

[lobelsteve]

in my opinion to generate 2500 procedure per year, you need to see about 6-7,000 E/M per year - (unless you are doing a lot of series of 3s of everything....)

so in my mind, this practice is UNBELIEVABLY efficient and is getting fed a TON of procedures from local spine surgeons...

or more likely, something fishy is going on...

I am at about 1800-2000/yr but included in that number are also non-spinal injections (field stimulators, peripheral nerve injections/denervations, etc.)

IF i did series of 3 injections (my local competing pain docs do a series of 3 ESIs, then a series of 3 facets, then a series of 3 SI joints, and if no improvement they do TPI every 2 weeks with BOTOX every 3-4 months)... i think i could push up my volume to the 3500 mark/year --- but i would not sleep well at night...

I'm 100% concordant.

 

[Sandpaper]

in my opinion to generate 2500 procedure per year, you need to see about 6-7,000 E/M per year - (unless you are doing a lot of series of 3s of everything....)

so in my mind, this practice is UNBELIEVABLY efficient and is getting fed a TON of procedures from local spine surgeons...

or more likely, something fishy is going on...

I am at about 1800-2000/yr but included in that number are also non-spinal injections (field stimulators, peripheral nerve injections/denervations, etc.)

IF i did series of 3 injections (my local competing pain docs do a series of 3 ESIs, then a series of 3 facets, then a series of 3 SI joints, and if no improvement they do TPI every 2 weeks with BOTOX every 3-4 months)... i think i could push up my volume to the 3500 mark/year --- but i would not sleep well at night...

2500 is not a big number. Like I said before, that was my average for the first two years out. I would see about 20 patients a day and of those, maybe 15-18 would be getting injections under fluoroscopy. I averaged at least 70 procedures a week. Throw in a couple of weeks of vacations and holidays and 2500/year is very doable. That particular practice set up emphasized same day procedures with in office fluoroscopy. No ASC for us. Patients were pre-approved prior to making it onto the schedule, so we had an army of people who badgered insurers all day long. An army of nurses and MAs helped to move the day along as well.

It was a very large practice that had complete monopoly in the area with excellent referrals from spine surgeons and primary care docs. I was on the low end of things. Some of the partners were doing upwards of 100 procedures a week. So yes, even 3000 procedures/year was no sweat. And no, we were not doing a series of 3s of everything. Let just say that the take home pay of the top dogs were in the seven figures.

In short, the OP should do due diligence, but don't write off practices that seem on the high scale of thing.

 

[lonelobo]

" I would see about 20 patients a day and of those, maybe 15-18 would be getting injections under fluoroscopy"

wow 75-80% were actually candidates for injections?

 

[Tenesma]

in my opinion that isn't really a pain practice --- more of an interventional radiology practice....

because if you are doing 15-18 procedures per day, and assuming that about 30-40% get relief, that leaves you with about 10 follow-ups on a regular basis to address their chronic pain needs.... so over-time, at that rate of procedures, you would quickly end up with about 35 follow-ups per day within about 9-12 months...

so your practice set-up, in my mind, was a block-shop without much attention to chronic needs....

which is perfectly fine, and i have no problem with that....

also, i get a lot of referrals from spine docs for injections --- and most of them DON'T need injections right off the bat....

 

[facets]

Agree 100% Tenesma, that is IMHO a block shop, not comprhensive pain management

 

[Sandpaper]

I find it amusing that people who know nothing about me or how my practice runs would make snarky comments about whether something is a "block shop". And so what if it was? What if I told you that we employed several psychologists and have our own PT facilities? What if I tell you that our psychologists do hypnosis and biofeedback in addition to the other aspects of pain counseling? What if I tell you that our PTs are faculties at the nearest physical therapy school and are experts at manual therapy?

In short, don't humor me with your judgments, since clearly everyone here knows how to best run a practice.

My expertise is injections, not to hold hand and sing Kumbaya with my patients. That's the psychologist's job.

In regards to medication management, we do very little of it. Most of the time the primary care docs take care of it. If the patient is difficult, then yes I do step in. Thereafter, the patient follow up with our PA. And so it goes.

15-18 injections may seem like a lot, but it's easily doable depending on the setup. As I mentioned before, yours truly was on the low end of things. Most of the partners averaged 20 or more injections a day.

There seems to be a hint of dismissal of the legitimacy of this. And frankly, I don't give a damn what any anonymous person thinks about it in this forum. But my posting is to give the OP another view point so that he doesn't automatically rule out what may possibly be a good opportunity.

 

[lobelsteve]

I find it amusing that people who know nothing about me or how my practice runs would make snarky comments about whether something is a "block shop". And so what if it was? What if I told you that we employed several psychologists and have our own PT facilities? What if I tell you that our psychologists do hypnosis and biofeedback in addition to the other aspects of pain counseling? What if I tell you that our PTs are faculties at the nearest physical therapy school and are experts at manual therapy?

In short, don't humor me with your judgments, since clearly everyone here knows how to best run a practice.

My expertise is injections, not to hold hand and sing Kumbaya with my patients. That's the psychologist's job.

In regards to medication management, we do very little of it. Most of the time the primary care docs take care of it. If the patient is difficult, then yes I do step in. Thereafter, the patient follow up with our PA. And so it goes.

15-18 injections may seem like a lot, but it's easily doable depending on the setup. As I mentioned before, yours truly was on the low end of things. Most of the partners averaged 20 or more injections a day.

There seems to be a hint of dismissal of the legitimacy of this. And frankly, I don't give a damn what any anonymous person thinks about it in this forum. But my posting is to give the OP another view point so that he doesn't automatically rule out what may possibly be a good opportunity.

I actually see you more as a defensive douchebag, trying to rationalize your needle monkeying and not doing anything other than someone elses bidding for your own profit.

Real pain doctors evaluate the patient and determine what is appropriate, not just plunging needles into them and heading to the next procedure suite. Psychologists to hold hands, kumbaya?

Yes, you are what is wrong with pain medicine. No better than the $50 for visit FP with road signs saying they are pain management.

If they don't come back, they must get better.

 

[Sandpaper]

Actually, your unprovoked and incendiary ad hominem attack does more to discredit your character than illuminate anything about me. I will go out on a limb here and say that your character attack is unsightly and sets poor example for what constitute a civil discussion.

Further, your suggestion of what or who constitute a "real" pain doctor is perfectly subjective, and if that keeps you feeling good about yourself, well, kudos to you. Would you like a cookie?

But more to the point, the problem with pain medicine is that we have people like yourself who think that others owe you something just because they practice differently than you do. That somehow things must be shady just because it's different. I apologize to your patients if it is you who "plunge the needle". Perhaps I should show you how real pain physicians do injections.

In the end, I really don't give a fig what you think. My patients, my referrals, and my staff are perfectly happy with the work that I do.

Don't hate, edumacate.

 

[axm397]

That particular practice set up emphasized same day procedures with in office fluoroscopy. No ASC for us. Patients were pre-approved prior to making it onto the schedule, so we had an army of people who badgered insurers all day long. An army of nurses and MAs helped to move the day along as well.

How did you bill for the same day consult and the procedure?

 

[lobelsteve]

Actually, your unprovoked and incendiary ad hominem attack does more to discredit your character than illuminate anything about me. I will go out on a limb here and say that your character attack is unsightly and sets poor example for what constitute a civil discussion.

Further, your suggestion of what or who constitute a "real" pain doctor is perfectly subjective, and if that keeps you feeling good about yourself, well, kudos to you. Would you like a cookie?

But more to the point, the problem with pain medicine is that we have people like yourself who think that others owe you something just because they practice differently than you do. That somehow things must be shady just because it's different. I apologize to your patients if it is you who "plunge the needle". Perhaps I should show you how real pain physicians do injections.

In the end, I really don't give a fig what you think. My patients, my referrals, and my staff are perfectly happy with the work that I do.

Don't hate, edumacate.

Witty diatribe does not negate your feral ways. Customers and not patients. Real pain docs do their own evals. You know I'm hiding behind my username.

 

[stim4u]

Sandpaper:

I agree with you. 15-20 procedures a day, with 4-5 new patients and a start time of 6:45 am to about 5:30 is legitimate and common amount my pain buddies and myself.

The MD's on this forum appear to be similar in opinion and work ethic. They are probably not solo owners, incentivized, motivated, or something else(ie. radiation phobic). The ultra hard working pain MD's tend to be labeled on this forum as 'needle jockeys', which is completely idiotic. I probably write more neuropathic medications, tramadol, PT, traction, CBT, etc. than any MD in my region. As long as you are following the literature and some national guideline in your pain practice, god bless and good luck......

 

[SSdoc33]

2500 is not a big number. Like I said before, that was my average for the first two years out. I would see about 20 patients a day and of those, maybe 15-18 would be getting injections under fluoroscopy. I averaged at least 70 procedures a week. Throw in a couple of weeks of vacations and holidays and 2500/year is very doable. That particular practice set up emphasized same day procedures with in office fluoroscopy. No ASC for us. Patients were pre-approved prior to making it onto the schedule, so we had an army of people who badgered insurers all day long. An army of nurses and MAs helped to move the day along as well.

It was a very large practice that had complete monopoly in the area with excellent referrals from spine surgeons and primary care docs. I was on the low end of things. Some of the partners were doing upwards of 100 procedures a week. So yes, even 3000 procedures/year was no sweat. And no, we were not doing a series of 3s of everything. Let just say that the take home pay of the top dogs were in the seven figures.

In short, the OP should do due diligence, but don't write off practices that seem on the high scale of thing.

sandpaper, you are speaking out of both sides of your mouth, here.

how can you claim this above scenario is not a "block shop"? thats sort of the definition of one. i dont see how you can adequately perform 70 injections/week and also do a legitimate eval, f/u, and treatment plan. its not a question of how hard you work, its a question of practice set-up and style. this IS the practice across down that makes most of us vomit in our own mouths.

and that is fine. it is what it is. if the "top dogs" are bringing in 1 mil from injections, then something is a bit fishy, no? you yourself stated that your expertise is with the needle. again, thats fine, but dont try to play the perfect pain doc here so you can look yourself in the mirror.

we all think that the way we practice is "better" than others, or more just. definite defense mechanism. maybe time to really think about this a bit.

don't like people second guessing you, stim and sandpaper? thats understandable. but there's too much trash in our field to see a description like this and not get even a little bit angry

 

[facets]

To use an analogy with our surgical associates, what would you think of a surgeon who operated on 80% of his consults stating "they were referred for a cholecytectomy." A true consultant evaluates each patient him or herself, does not do blocks on request or have a midlevel making treatment decisions and carefully creates a complete treatment plan for each individual patient considering their complete history. Sorry, this cannot be done in 15 minutes and doing so makes us look like less than a true specialty to fellow physicians and more like money grubbing machines. This is killing the field. As they say in surgery, a good surgeon knows how to operate, a great one knows when not to.

 

[Sandpaper]

It is amusing that lobelsteve has called on his posse to continue to question the legitimacy of my practice. I never made it an issue; I'm simply advising the OP not to overlook a good practice. On the other hand, some seem to have a chip on your shoulder about what I do. There will be no apologies forthcoming from me because some of you lack imagination or practice management skills. That's your problem. The defensive posturing is not from me, but from you people who are the high-falutin' keepers of the flame. It's cringe-inducing to read these mystical, self-righteous rants about what makes for a "good" pain physician.

And why is it fishy if the top earners in the practice make a million bucks? They are in the office at 7 am, see 25 patients and do injections on 20. Why is that an impossible feat? If the hand surgeons send us patients with florid CRPS, would it matter that I get a bone densitometry and spend an hour in the room to "eval" the situation? Or would it be more sensible to examine the patient, make a quick assessment, and into the fluoro suite for a stellate? I can't help it if you people are slow.

Name calling and perjoratives will neither advance your cause nor make me think of you as a superior physician. So you write opioids, whoopee. So you add an adjuvant. Wow. Amazing. In the meanwhile that little old lady with humongoid facets and the large disc herniation is still waiting for you to stick the needle in her. It is patently absurd to think that some painful situation will magically resolve after PT or some other non-invasive treatment. The non-invasive modalities have already been maxed out before they see us. The PAs and ARNPs only see the patient after they've been seen, evaluated, and stabilized by the physicians in the practice. I can't help it if your practice set up suck.

To stim4u, I appreciate the kind words cuz it's starting to feel like high school all over again with all these cliques and their *tsk* *tsk*. Our practice utilizes Press Ganey to measure outcome, in addition to an electronic version of the Brief Pain Inventory that we have modified. Our database is extensive and our outcome is impressive. We use the data to justify to the insurers that what we do help patients. In addition, one of our partner is an ISIS instructor, so we have pretty much all the bases covered.

So in short, the results speak for itself. Good night and good luck.

 

[lonelobo]

Sandpaper

Nobody called in a posse.
and you are right nobody here knows you or your practice.

I think most are just commenting that your numbers fall outside
the norm of how the majority of pain physicians practice.

I interviewed in the past with busy clinics like yours and it was rather
enlightening.

ESI's on ladies with Fibromyalgia-with the justification by doc of-" Well nothing else worked so we might as well try it"

I think you must see a very different population if you inject 80% who walk into to your clinic for evaluation.

Speaking from my own experience , I practiced at a large Orthopaedic Clinic
of 30 docs and I was only pain Doc. I would say 50 % of referrals for injections were inappropriate for injection therapy and this from guys with musculoskeletal training and multiple education sessions on interventional pain.

So unless you rely on knowledgable spine specialists for the majority of your
referrals-

wow 80%-that is high

 

[Jcm800]

i would i have to agree that those numbers are not so high, given the right population. i have busy PCPs and some descent surgeons that basically send me patients for injections. I still do an initial consult, because i dont feel comfortable seeing all new comers, giving them a thorough eval and an injection in 20 minutes...but that being said, a few times a week, maybe once a day, a new patient gets an injection as its a no brainer and they are miserable and insurance is not a barrier.

most of my consults come from PCPs that send them to therapy first, try them on reasonable meds (sometimes) and basically have exhausted conservative methods. I say that i inject maybe 65-75% of new comers. my rate of in-appropriate consults has dropped quite a bit with some eductation. my numbers are less then this, because i dont see 25 patietns EVERY DAY...thats a lot of people.
most of my patients are tee-ed up for an injection, i just need to determine which one and where...which can take some time...often most of that 20 minute block. Many of the referels i get FOR an injection usaully need a DIFFERENT injection than the one requested, but an injection still, which is why i went to the consultation ONLY on the first visit (given the occassional exception)

i dont like to work 12 hour days anymore, but if i wanted to, i dont think those numbers are so crazy...i insist on the consult first, and it has led to a better run practice for me, and i feel like i have done a thorough eval... but when need be, i will do the procedure on the same day. given that, i dont think i have enough patietns to work that hard even if i wanted...

i mean if your practice is a bunch of acute discs with obvious HNP and radicular pain, how much time does it really take for the eval...5-7 minutes, especially with good support staff? you can inject those people on the same day and be comfortable with the plan.

Maybe Sandpaper is a terrible human who is a scourge on society, but i doubt it. He probably just works hard. The fact he is on this board, and interested in helping youngsters looking for jobs with advice probably says something. If he was so bad, dont you think he would be too busy spending all of this money then to be posting on this messageboard...

It is amusing that lobelsteve has called on his posse to continue to question the legitimacy of my practice. I never made it an issue; I'm simply advising the OP not to overlook a good practice. On the other hand, some seem to have a chip on your shoulder about what I do. There will be no apologies forthcoming from me because some of you lack imagination or practice management skills. That's your problem. The defensive posturing is not from me, but from you people who are the high-falutin' keepers of the flame. It's cringe-inducing to read these mystical, self-righteous rants about what makes for a "good" pain physician.

And why is it fishy if the top earners in the practice make a million bucks? They are in the office at 7 am, see 25 patients and do injections on 20. Why is that an impossible feat? If the hand surgeons send us patients with florid CRPS, would it matter that I get a bone densitometry and spend an hour in the room to "eval" the situation? Or would it be more sensible to examine the patient, make a quick assessment, and into the fluoro suite for a stellate? I can't help it if you people are slow.

Name calling and perjoratives will neither advance your cause nor make me think of you as a superior physician. So you write opioids, whoopee. So you add an adjuvant. Wow. Amazing. In the meanwhile that little old lady with humongoid facets and the large disc herniation is still waiting for you to stick the needle in her. It is patently absurd to think that some painful situation will magically resolve after PT or some other non-invasive treatment. The non-invasive modalities have already been maxed out before they see us. The PAs and ARNPs only see the patient after they've been seen, evaluated, and stabilized by the physicians in the practice. I can't help it if your practice set up suck.

To stim4u, I appreciate the kind words cuz it's starting to feel like high school all over again with all these cliques and their *tsk* *tsk*. Our practice utilizes Press Ganey to measure outcome, in addition to an electronic version of the Brief Pain Inventory that we have modified. Our database is extensive and our outcome is impressive. We use the data to justify to the insurers that what we do help patients. In addition, one of our partner is an ISIS instructor, so we have pretty much all the bases covered.

So in short, the results speak for itself. Good night and good luck.

 

[Doctodd]

Mr Sandpaper.....i think we have better things to do, like you, than to judge you. But if you have only been in the private world for ~3-4 years, dont you think your tone is a bit odd?....kinda snobby? Maybe im wrong cuz i didnt bother to read everything you typed. Now if you tell me you are a Democrat, then all bets are off.

 

[facets]

And why is it fishy if the top earners in the practice make a million bucks? They are in the office at 7 am, see 25 patients and do injections on 20. Why is that an impossible feat?

You are so out of touch with reality. Primary care physicians work at least this much and are lucky to get 150 K. The average worker much less. This attitude of entitlement makes us hated by our fellow physicians and patients. Pull your head out of your own practice and look and see what is going on the world today, access for patients being cut off, reimbursement been cut or eliminated, people losing their homes. Then very self-rightously tell us you are entitled to 1 million a year because you work so hard, crybaby

I can't help it if your practice set up suck.
Very mature



[/QUOTE]

 

[axm397]

My billing question got lost in the conversation - sandpaper, how are you billing for a same day consult and procedure? Are you using a 25 modifier each time? Do you see a patient for consultation in the office then take them directly to the procedure suite or do you see all consults in a certain number of hours then do procedures on them later that day?

You said that patients are pre-approved for procedures prior to visit - how do you know what procedure they are going to need? based on imaging? based on referring doc request? Are you working with a protocol based on imaging and location of pain? i.e. axial back pain -> facets/MBB x 2 --> RFA if effective --> etc. etc.

Also, in terms of your set up - do all patients that come to you have MRI imaging, off blood thinners, have failed conservative management x 6 weeks (as some insurance companies require), and have a driver? Do you sedate your patients for procedures?

You mentioned PT - do the patients go to PT first then injection or injection then PT? Do you have more active methods of PT like McKenzie? (manual is kind of passive for most spine issues)

Are you doing multilevel procedures or multi-type procedures (i.e. ESI AND facet or Facets and SI, etc.) same day? How frequently do the patients come back for follow ups and/or repeat procedures?

 

[Kwijibo]

I think that the readers of this forum can use this as an opportunity to look at their own practices and say how can I be more efficient? How can I maximize my practice? How can I work less, have the same or better results and make more?

It sounds like Sandpaper's pracitce has done a good job at marketing themselves in the community and that is the first step. You cannot get more injections without the right volume coming in. Then it is educating the community on what you do- getting the physicians/chiro's/PT's/etc sending you patients that are ready for injections- basically have the patients fail conservative before getting to you. Get good results and have and maintain good relationships with your patients and referring physicians and soon you will have a self perpetuating machine.

Any practice that can do that many injections is doing that many because they are giving good care and getting people better. If you don't people will find out and stop sending you patients. It's that simple.

Finding out how others practice is a way to make your own better. For those in private practice, we run a medical business, and what your patients get from their experience in your office is a product. Have an open mind and learn from others in the same field.

All that being said, I perform between 85-110 injections per week, every week. 5-6 days a week 9-10 hour work days. Practicing in one of the most competitive markets in US. Mostly office procedures(95%)/surgi-center/minimal hospital 2 midlevel practitioners. All new patients seen by MD. No 'series of 3'. Not narcotic heavy practice, although we do write.

 

[Jcm800]

Any practice that can do that many injections is doing that many because they are giving good care and getting people better. If you don't people will find out and stop sending you patients. It's that simple. (quote)


i disagree. many physicians a terrrible job, but the patients keep coming, despite the results. THis is based on RELATIONSHIPS with other physicians, medical centers, etc. Often in my opinion, there are things behind the scenes that determine referral pattern despite results. I see this a lot. there are many reasons to send to a physician despite the care being provided. And in my jaded opinion, it is typically the rule not the excpetion... much sketchiness i have seen with the BIG practices, with horrible results, yet still a line out the door...

Im not saying that is the case with either of the two high volume practices in this thread. I am soying that its NOT THAT SIMPLE..."If you don't people will find out and stop sending you patients. It's that simple."

 

[SSdoc33]

It is amusing that lobelsteve has called on his posse to continue to question the legitimacy of my practice. I never made it an issue; I'm simply advising the OP not to overlook a good practice. On the other hand, some seem to have a chip on your shoulder about what I do. There will be no apologies forthcoming from me because some of you lack imagination or practice management skills. That's your problem. The defensive posturing is not from me, but from you people who are the high-falutin' keepers of the flame. It's cringe-inducing to read these mystical, self-righteous rants about what makes for a "good" pain physician.

And why is it fishy if the top earners in the practice make a million bucks? They are in the office at 7 am, see 25 patients and do injections on 20. Why is that an impossible feat? If the hand surgeons send us patients with florid CRPS, would it matter that I get a bone densitometry and spend an hour in the room to "eval" the situation? Or would it be more sensible to examine the patient, make a quick assessment, and into the fluoro suite for a stellate? I can't help it if you people are slow.

Name calling and perjoratives will neither advance your cause nor make me think of you as a superior physician. So you write opioids, whoopee. So you add an adjuvant. Wow. Amazing. In the meanwhile that little old lady with humongoid facets and the large disc herniation is still waiting for you to stick the needle in her. It is patently absurd to think that some painful situation will magically resolve after PT or some other non-invasive treatment. The non-invasive modalities have already been maxed out before they see us. The PAs and ARNPs only see the patient after they've been seen, evaluated, and stabilized by the physicians in the practice. I can't help it if your practice set up suck.

To stim4u, I appreciate the kind words cuz it's starting to feel like high school all over again with all these cliques and their *tsk* *tsk*. Our practice utilizes Press Ganey to measure outcome, in addition to an electronic version of the Brief Pain Inventory that we have modified. Our database is extensive and our outcome is impressive. We use the data to justify to the insurers that what we do help patients. In addition, one of our partner is an ISIS instructor, so we have pretty much all the bases covered.

So in short, the results speak for itself. Good night and good luck.

looks like we touched a nerve here (no pun intended). if you REALLY believe that you are not selling your soul for the almighty dollar, why be so defensive? your responses are actually quite telling.

agreed that how busy you are has very little relation to the quality of care you provide

and im pretty sure lobelsteve doesnt have a posse. he strikes me as more of the biker-gang type.

 

[painchas]

EMR, motivated staff employed by me in the office with own flouro. When I enter the room for procedure back is prepped shot is set up tray is open. 5-7 minutes for 2 level TF (if not vascular). RF 3 joints 25 minutes ( do an awful lot), Cervical epidural 5 minutes all out of one flouro room and yes I do vist between injections for last minute questions. We start early and work late daily. No association with surgeons as employers. Many specific requests for specific levels etc from neuro. I can easily do 20 injections by 1 pm. I dont stop for lunch push on with a sandwich in between. Clinic starts at 1:30 NP and f/u. PA sees stable med management with me popping in every third month. Stim trials different story takes longer. Oh and charts are finished with the EMR by the time I leave for the day. We code in the room thanks to my RN who has got it figured out. I do go behind her to check.
Regards

 

[lobelsteve]

Any practice that can do that many injections is doing that many because they are giving good care and getting people better. If you don't people will find out and stop sending you patients. It's that simple. (quote)


i disagree. many physicians a terrrible job, but the patients keep coming, despite the results. THis is based on RELATIONSHIPS with other physicians, medical centers, etc. Often in my opinion, there are things behind the scenes that determine referral pattern despite results. I see this a lot. there are many reasons to send to a physician despite the care being provided. And in my jaded opinion, it is typically the rule not the excpetion... much sketchiness i have seen with the BIG practices, with horrible results, yet still a line out the door...

Im not saying that is the case with either of the two high volume practices in this thread. I am soying that its NOT THAT SIMPLE..."If you don't people will find out and stop sending you patients. It's that simple."

Completely agree. Where is Ben Crue when you need him?
More injections do not effect outcome. Injecting 80+ percent cannot possibly be anywhere close to appropriate. In training, most folks get the mantra of: "They are here to have an injection, figure out which one to start with."

Most patients do not need any injections, they need lifestyle changes, coping skills, and therapeutic exercise. I perform injections as a means to get them through the first three. Anyone who comes back to see me after SIJ injection has failed to do exercises, has anterior fiber SIJ disease, or doesn't have SIJ pain. Anyone who comes to see me for ESI for DDD with axial pain is not going to get an ESI.

I think it would be easy to convince myself and my patients that everyone needs an injection after every follow-up. I would drive a few Ferraris and get rid of my Kia and Subaru.
(even if the Subaru is faster than an Enzo)

I couldn't live with myself unless I was crooked or stupid enough to believe everyone needed a shot for everything.

 

[Jcm800]

Completely agree. Where is Ben Crue when you need him?
More injections do not effect outcome. Injecting 80+ percent cannot possibly be anywhere close to appropriate. In training, most folks get the mantra of: "They are here to have an injection, figure out which one to start with."

Most patients do not need any injections, they need lifestyle changes, coping skills, and therapeutic exercise. I perform injections as a means to get them through the first three. Anyone who comes back to see me after SIJ injection has failed to do exercises, has anterior fiber SIJ disease, or doesn't have SIJ pain. Anyone who comes to see me for ESI for DDD with axial pain is not going to get an ESI.

I think it would be easy to convince myself and my patients that everyone needs an injection after every follow-up. I would drive a few Ferraris and get rid of my Kia and Subaru.
(even if the Subaru is faster than an Enzo)

I couldn't live with myself unless I was crooked or stupid enough to believe everyone needed a shot for everything.[/QUOTE]

again not everyone needs a shot, the point is, if they have done all the things necessary before a procedure is indicated, then you will have more appropriate patients for procedures. I used to say just send em to me and let me do it all...then i had to send everyone to PT, and start them on NSAIDS, and tell them to loose weight, and blah blah. I did all that, put in my notes, and calls to the PCPS, and guess what, they saw it wasnt rocket science, and now they do all of that BEFORE they get to me...so lots of time, the majority of these patients are there for procedures, then its up to me to decide WHICH ONE, and IF they need one...

no one NEEDS one, but you know what i mean. it doesnt take a pain fellowship to determine that a patient with 5 days of a classic radic could benefit from NSAIDS, bed rest, stretching and PT. Before i got there, those patients with 5 days of a acute radic were sent to the NEUROSURGEON for evaluation, who then sent them to me, then i had to send them to PT etc...

so i have to say, my PCPS (the good ones) actually do a pretty good job BEFORE i see the patient. sometimes its the HIP and not the BACK, but they try, and most of these patients are good patients, not on narcs and not drug seekers.

The chronic pain patient with 5 back surgeries on methadone and oxycodone for "breakthrough pain", thats a different story. I rarely see those anymore, thankfully...

 

[Tenesma]

Sandpaper and others:

Every practice is different and has different referral patterns.

Can many injections be done per day? Yes
Can more injections be done if you are slick and have an efficient practice? Absolutely

Interventional Radiology does tons of injections (even though so far most of them aren't all that slick)...

It also depends on how you market yourself and the size of your market.

In order for me to do 20 injections per day I would have to see about 14 new patients per day, based on my current ratios...

could i see 14 new patients per day? no... my community is not large enough to generate that kind of flow.

i wouldn't have an issue with doing 15 procedures a day if we are going to be honest about pain management and the realities of doing 15 procedures per day...

none of our procedures provide long-term management (other than v-plasty or SCS) and therefore procedure patients will fall into 3 groups
1) group A gets better --- may or may not return to your practice, but fair chance that they may require injections in the future
2) group B gets no relief --- may need further diagnostic evaluations/procedures
3) group C gets no relief from any interventions - but will require long-term management, guidance and re-evaluations

so what do you do w/ the post-procedure follow-ups?

i have all of my procedure patients follow-up with me for re-direction (unless they get fantastic pain relief, in which case they can just call in and my RN makes some notes into our EMR)

so if i do 10 procedures per day, that would mean about 7-8 follow-ups per day just from procedures, plus the 5 new patients per day and then the 10-15 follow-ups per day for new issues, lack of improvements, medication re-evaluation... it ends up being about 38 patients a day (incl procedures)

so if you are doing 15 procedures per day that would translate to a daily average of 57 encounters (incl procedures per day)....

that would be the case if you practice pain medicine the way I practice it...

i can understand if you a have different practice philosophy

but for the most part, the pain guys in my region who practice with your approach of a high % of procedures/patient visits per day, are all detested because we all get their poor outcomes (which is a huge amount) and for the most part most of those patients are over-injected and adrenally suppressed.

clearly, everybody would love to enjoy a practice such as yours... and maybe we are all a bit jealous, because i'd rather be in the fluoro suite versus teasing out whether the hip pain is truly radicular versus an undetected sacral insufficiency fracture versus a femoral acetabular impingement in a depressed, fibromyalgic 45 year old chronic lyme patient.

 

[Sandpaper]

Gentlemen,

The echo chamber that is this pain forum has fostered a certain cozy and comfortable attitude about how pain medicine should be. One erroneous belief is that it is impossible to have a productive yet ethical practice. But as demonstrated by other posters like painchas, stim4u, and Kwijibo, such a practice is very much possible. Being dismissive of our ideas and then patronize us with your tiresome lectures about moral standards do not change the facts on the ground.

The reasons that "only"15 out of 18 of my patients get injections are 1) they have made meaningful improvement from previous injections, 2) they have conditions that are not amenable for interventional treatments such as central pain or fibromyalgia, or 3) your typical drug seekers. Otherwise it would be 18 for 18.

One of the main reason it works is that our referrals are educated by our marketing team about what services we offer patients and thus our referral base is huge. (Yes, we have a marketing team, and you should too.) General surgeons send us their post hernia repair pain. Hand surgeons send us CRPS. Spine surgeons, your bread a butter spine pain, which make up the bulk of the practice. Heme/onc send the cancer patients for pumps and stim. Lastly the primary docs send all sorts. Because of this volume we can not have the usual type of practice with bookings for ASC for procedures weeks down the road. We would be swamped in no time.

We have an awesome hybrid EMR. It takes but seconds to pull up the MRI reports, previously dictated notes and procedure pics. Patients are booked in 15 minutes slots, with 4 new pts a day booked into 30 minutes slots. I am out the door by 5 with all notes dictated and all encounters billed. 99212/99213 plus a CPT code of choice. Many are old patients who don't want surgery or meds, and are happy with twice a year injections. Never had an adrenal suppression issue. ESIs are 40mg of Depo at most. So the question is, if a returning patient pt got 50% improvement with your first TFESI, would you repeat a second? Hell yeah. How long should it take you to assess that and do your injection? Hopefully not all day.

The flip side of all this teeth gnashing is that pain physicians are a great disservice to their patients if they shy away from injections. For example, if one gives up after an unhelpful transforaminal and don't pursue another approach via the interlaminar or caudal or whatever else, now all of a sudden the patient just became a surgical candidate or a chronic opioid taker. If I have a spine problem, I'd rather have someone inject me til they find the pain generator than be stuck taking drugs, or worse, be operated on.

In conclusion, if you are an elderly woman with postherpetic neuralgia not responsive to or unable to tolerate neuropathic meds, assorted compounded creams and patches, please see the holier-than-thou in this forum for lifestyle modifications and herbal remedies. If you really want to get better, please see stim4u, painchas, Kwijibo (what the hell kinda name is this?) for ESIs and possible stim. Thank you.

(axm497, I will PM you about the questions you asked.)

 

[Tenesma]

fair enough - it sounds like you have set up a primarily interventional practice - nothing wrong with that.

every practice comes in different flavors - for example, i don't prescribe opiates but rather guide the PCPs in opioid mgmt (for which i have taken my share of heat on this forum).

however, i remain curious as to what you do or tell patients who are not surgical candidates (or SCS/pump candidates), in whom your injections have not been effective either diagnostically or therapeutically - and what do you tell your referring docs regarding those patients?

for example, pt w/ post-lami syndrome w/ failed SCS and poor response to a variety of injetions via a variety of approaches, has been through PT 4 times and is looking for guidance
1) do you tell them there is nothing that can be done and to pursue cognitive therapy?
2) do you guide them through pharmacologically for med mgmt?
3) do you refer them to a pain doc for med mgmt?

curious

 

[painchas]

Chronic narcotics for some degree of somatic pain reluctantly by me. Membrane stabilizer, neurontin my favorite for the doughnut hole of medicare and the I dont want to gain weight female crowd. C2s monthly in the office. May throw in some Cymbalta and or Mobic (note generic again). We dont leave out our favorite psych. guy for coping and feedback activity. We will say at this point if not already addressed that chronic pain is somewhat like HTN or DM. ....Cant get rid of it just have to manage it the best way we have...as above.
Regards

 

[Sandpaper]

DeInspiRespite of our best efforts, sometimes pts don't improve. *That is life and I prepare the patient for that unpleasant truth by impressing upon them the chronicity of the problem. *To a person the pt appreciates the fact that I have tried everything to help them. *There is no shame in that. *Patients are not dumped back to the referral sources. *I personally manage the meds. Again, that's why I'm usually only 15 for 18 in injections.

Very much like painchas, I throw in neurontin (Lyrica if there's a coupon laying around) NSAIDs, anti-depressant and a long acting opioid, most likely methadone. *Once stablized on a regimen, the patient follows up monthly with a PA or ARNP. *They are also seen by one of our psychologist for biofeedback and relaxation and whatever else.

So again, if this is what a block shop is like, well then, I'm proud to call it home. *Keep in mind that I didn't set any of this up. *Straight out of fellowship and I walked into a well established practice. If I had listened to the BS from the ivory tower crowd I'd be miserable at some practice holding hands with some fat fibromyalgia patient and telling the guy with the L4 radic that he needs lifestyle changes and coping skills. *Brutha please... * * * * *

 

[SSdoc33]

Gentlemen,

The echo chamber that is this pain forum has fostered a certain cozy and comfortable attitude about how pain medicine should be. One erroneous belief is that it is impossible to have a productive yet ethical practice. But as demonstrated by other posters like painchas, stim4u, and Kwijibo, such a practice is very much possible. Being dismissive of our ideas and then patronize us with your tiresome lectures about moral standards do not change the facts on the ground.

The reasons that "only"15 out of 18 of my patients get injections are 1) they have made meaningful improvement from previous injections, 2) they have conditions that are not amenable for interventional treatments such as central pain or fibromyalgia, or 3) your typical drug seekers. Otherwise it would be 18 for 18.

One of the main reason it works is that our referrals are educated by our marketing team about what services we offer patients and thus our referral base is huge. (Yes, we have a marketing team, and you should too.) General surgeons send us their post hernia repair pain. Hand surgeons send us CRPS. Spine surgeons, your bread a butter spine pain, which make up the bulk of the practice. Heme/onc send the cancer patients for pumps and stim. Lastly the primary docs send all sorts. Because of this volume we can not have the usual type of practice with bookings for ASC for procedures weeks down the road. We would be swamped in no time.

We have an awesome hybrid EMR. It takes but seconds to pull up the MRI reports, previously dictated notes and procedure pics. Patients are booked in 15 minutes slots, with 4 new pts a day booked into 30 minutes slots. I am out the door by 5 with all notes dictated and all encounters billed. 99212/99213 plus a CPT code of choice. Many are old patients who don't want surgery or meds, and are happy with twice a year injections. Never had an adrenal suppression issue. ESIs are 40mg of Depo at most. So the question is, if a returning patient pt got 50% improvement with your first TFESI, would you repeat a second? Hell yeah. How long should it take you to assess that and do your injection? Hopefully not all day.

The flip side of all this teeth gnashing is that pain physicians are a great disservice to their patients if they shy away from injections. For example, if one gives up after an unhelpful transforaminal and don't pursue another approach via the interlaminar or caudal or whatever else, now all of a sudden the patient just became a surgical candidate or a chronic opioid taker. If I have a spine problem, I'd rather have someone inject me til they find the pain generator than be stuck taking drugs, or worse, be operated on.

In conclusion, if you are an elderly woman with postherpetic neuralgia not responsive to or unable to tolerate neuropathic meds, assorted compounded creams and patches, please see the holier-than-thou in this forum for lifestyle modifications and herbal remedies. If you really want to get better, please see stim4u, painchas, Kwijibo (what the hell kinda name is this?) for ESIs and possible stim. Thank you.

(axm497, I will PM you about the questions you asked.)

right. a block shop.

gotta call a spade a spade, no matter how you may want to justify it.

it sounds like you are advocating pain physicians to perform MORE injections, rather than fewer.

also, you seem to believe that every type of spine issue can be remedied with an injection. keep injecting until you find the pain generator? are you kidding me? no wonder you inject 15/18 or 18/18. just because you dont get relief from an injection doesnt mean you HAVE to take opioids or get a surgery. it is this lack of insight which leads me -- and many others im guessing -- to believe you are sticking a needle in everyone who meets your criteria (ie: they have a spine)

its great that your practice is busy, and that you can select the patients who will benefit most from injections. that is a situation in which many of us would like to be in. i would just hope you really are as good with your needle as you seem to believe that you are.

 

[stim4u]

right. a block shop.

gotta call a spade a spade, no matter how you may want to justify it.

it sounds like you are advocating pain physicians to perform MORE injections, rather than fewer.

also, you seem to believe that every type of spine issue can be remedied with an injection. keep injecting until you find the pain generator? are you kidding me? no wonder you inject 15/18 or 18/18. just because you dont get relief from an injection doesnt mean you HAVE to take opioids or get a surgery. it is this lack of insight which leads me -- and many others im guessing -- to believe you are sticking a needle in everyone who meets your criteria (ie: they have a spine)

its great that your practice is busy, and that you can select the patients who will benefit most from injections. that is a situation in which many of us would like to be in. i would just hope you really are as good with your needle as you seem to believe that you are.

Correct me if I am wrong. I am a sub specialty of a specialty (pain med with anesthesia board). The patients that I see have failed many therapies prior to consulting with me. Therefore, most of our patients will be candidates for spinal injections, stims, Rfa and so forth. Otherwise, they continue with pure opioid management/PT etc by the neurologist, PCP, and physiatrist down the street.

I have thousands of patients that obtain 1-3 years of relief with epidurals, RFA, perc discs, etc. I actually loose track of my patients until they show up again years later. If you are selecting correctly, and doing injections correctly , patients will get better. So, I am not sure why Tenesma tends to defame the benefit of pain medicine procedures. If you are not providing relief for long periods of time, then maybe reassess your technique.

Ultimately, the difference of opinions will go on. My view is that higher volume practices will have high rates of injections. That is not good or bad. If you live in a rural area and have slower to moderate volumes, and your patients are seeing you earlier with their pain condition, you are less likely to inject and more likely to offer more conservative measures.

Why cant we all just get along....

 

[lonelobo]

"I have thousands of patients that obtain 1-3 years of relief with epidurals, RFA, perc discs, etc. I actually loose track of my patients until they show up again years later. If you are selecting correctly, and doing injections correctly , patients will get better."

So how many thousands did not get relief for 1-3 years?

 

[Tenesma]

i am not trying to defame my source of income...

but at the same time I also a realist and realize that injections are not long-term and not curative...

the data doesn't show that RFs provide 1-3 years of relief
the data doesn't show that epidurals provide 1-3 year of relief

now, i, too, have patients who do well for 12, 24, 36 months and then come back for repeat injection - but clearly, that isn't the norm..... for me or for the data.

i would gladly re-assess my technique - but I also realize the limitations of pain procedures... and if your technique reliably provides 1-3 years of relief, then you should publish how your technique improves on current knowledge....

sandpaper - it sounds like your 1st 2 years of practice are different from your current practice pattern... but i still have difficulty how you were able to provide 15-18 procedures out of 20 encounters per day.... if you had a PA/NP seeing all of your follow-ups, then that set up would make more sense to me

also issue w/ doing procedures on the same day of an E/M brings up the issue that E/M can only be billed for a SEPARATE and IDENTIFIABLE problem.... so if somebody sees you with leg pain and you do an ESI, you cannot bill for the E/M unless you are also assessing their headache or other ailment...

 

[facets]

also issue w/ doing procedures on the same day of an E/M brings up the issue that E/M can only be billed for a SEPARATE and IDENTIFIABLE problem.... so if somebody sees you with leg pain and you do an ESI, you cannot bill for the E/M unless you are also assessing their headache or other ailment...[/QUOTE]

Don't mean to hijak but I thought it had to be a seperate and identifiable service, eg the pt has not been seen in 2 years and has recurrence of sciatica so you evaluate an inject, not a seperate diagnosis?

 

[Tenesma]

"The submission of modifier -25 appended to an E&M code indicates that documentation is available in the patient's records for review upon request that will support the significant and separately identifiable nature of the E&M service.

All surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service. For those procedures and services a separate E&M service is not normally reimbursed. However, a separate E&M service may be considered for reimbursement if the patient's condition required services above and beyond the usual care associated with the procedure or service provided. To identify these circumstances, modifier -25 is attached to the E&M code.

Example of Proper Use of Modifier -25
An established patient is seen for a 2.0cm finger laceration. The patient also asks the physician to evaluate swelling of his right knee that is causing pain.
Correct Codes – 12001 and 99213-25

Example of Improper Use of Modifier -25
An established patient is seen for left knee pain. After evaluating the knee, the physician performs arthrocentesis.
Correct Code – 20610
It would not be appropriate to bill an E&M code because the focus of the visit was the knee pain which precipitated the arthrocentesis. "

this is my understanding and this is how Mehmert et al address the issue from a coding point of view....

so if you are doing an ESI for radicular pain and your E/M addresses radicular pain, then the understanding that the eval for radicular pain is inculded in the reimbursement for ESI for that day.... you'd have to identify a SEPARATE issue.

at least that is my understanding

 

[Doctodd]

it makes no sense to me that i would bill 20610 and get 45 bucks instead of just sticking with 99214 and getting 70ish

 

[stim4u]

"The submission of modifier -25 appended to an E&M code indicates that documentation is available in the patient’s records for review upon request that will support the significant and separately identifiable nature of the E&M service.

All surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service. For those procedures and services a separate E&M service is not normally reimbursed. However, a separate E&M service may be considered for reimbursement if the patient’s condition required services above and beyond the usual care associated with the procedure or service provided. To identify these circumstances, modifier -25 is attached to the E&M code.

Example of Proper Use of Modifier -25
An established patient is seen for a 2.0cm finger laceration. The patient also asks the physician to evaluate swelling of his right knee that is causing pain.
Correct Codes – 12001 and 99213-25

Example of Improper Use of Modifier -25
An established patient is seen for left knee pain. After evaluating the knee, the physician performs arthrocentesis.
Correct Code – 20610
It would not be appropriate to bill an E&M code because the focus of the visit was the knee pain which precipitated the arthrocentesis. "

this is my understanding and this is how Mehmert et al address the issue from a coding point of view....

so if you are doing an ESI for radicular pain and your E/M addresses radicular pain, then the understanding that the eval for radicular pain is inculded in the reimbursement for ESI for that day.... you'd have to identify a SEPARATE issue.

at least that is my understanding

Couple questions:

1. Can you bill mod 25 for a pain injection and medication refill for 'chronic pain' (338.4)? Does it change if you initiate a new medication for chronic pain?

2. Why is it unrealistic to accept 1-2 years of pain relief with epidurals, self-care and life style modification? This is common in my practice, and others. Also, whether these patient are benefiting from shots vs. pure time nobody knows fully. In the end, the outcomes are considered 'curative' and not simply 'palliative'. By minimizing the benefit of pain procedures you just feed WC companies, occupational MD's, neurologist, and all other pain 'haters'. When my productive years with my practice are up, I would love to perform studies with perc discs, IDET, and epidurals. I have done a moderate amount of research in the past and have turned down directorships in the past. My skill set is not special, most of the time I just make sure the shot was done correctly.

 

[lonelobo]

Couple questions:

2. Why is it unrealistic to accept 1-2 years of pain relief with epidurals, self-care and life style modification? This is common in my practice, and others. .

Don't think anyone says it is unrealistic, but just not the norm.

I think the self care and life style modification has a lot more to do with long term relief than a one-time injection.

 

[lonelobo]

Gentlemen,
In conclusion, if you are an elderly woman with postherpetic neuralgia not responsive to or unable to tolerate neuropathic meds, assorted compounded creams and patches, please see the holier-than-thou in this forum for lifestyle modifications and herbal remedies. If you really want to get better, please see stim4u, painchas, Kwijibo (what the hell kinda name is this?) for ESIs and possible stim. Thank you.

(.)

Please tell me about your success rate with ESI's and SCS for PHN