Procedure heavy?

[Sandpaper]

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...

It has to do with practice set up. Four exam rooms and 1 fluoro room per physisican. Each doctor have three nurses and one fluoro tech. Nurses take the patient back to the exam rooms, get vitals, punch in their pain ratings, etc. The doctor goes in and eval the patient, and if they are returning from a prior injection, then the eval pretty much focuses on whether it helped or not.

If injection is needed, nurse takes the pt back to the fluoro suite for an IV, sedation, prep and draped the patient, and all necessary needles and meds laid out while the doctor goes to the next exam room. The doctor does the injection and patient is wheeled back to exam room for monitoring and then discharged with driver. Repeat times 15. Or as the case of some of the senior guys, repeat times 22.

The time consuming part is not the injection, but the actual evaluation of the patient. Here's how it's broken down in terms of time with a returning patient - 8 minutes face time with patient, 2-5 minutes for the actual needle jockeying, 2 minutes to dictate note and procedure. RFs are booked into 30 minutes slots. Stim trials are booked in 30 minutes or 1 hr slots depending on the doc.

It's a quick pace, clearly not for everyone, but extremely efficient and effective.

As for E/M with the procedures. We've been audited, no problem. Who knows, that may change in the future.

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[painchas]

Never do I bill E/M on same day as injection. Dont use 25 modifier here. Double diagnostics before RFA needing 50% + relief prior to burn. Not much for me in the way of stim for PHN too much chest wall grabbing. Thoughts??

 

[stim4u]

Never do I bill E/M on same day as injection. Dont use 25 modifier here. Double diagnostics before RFA needing 50% + relief prior to burn. Not much for me in the way of stim for PHN too much chest wall grabbing. Thoughts??

I rarely ever bill mod 25 with a procedure and med refill, unless there is a clearl new diagnostic issue. However, I have seen many colleagues billing f/u's in their surgical centers in addition to the injection. Technically the medication evaluation it is for chronic pain (338.4) and not necessary for the underlying c/l radic, facet arthrosis, or whatever pathology is be 'needle jockeyed'. Any other opinions out there?

By the way, I appreciate all the diverse opinions on the forum. Ultimately it keeps my practice more efficient and legit.

 

[Finally M3]

I'm still astounded at the 75% of EM patients being candidates for injections number.

I'm happy if 10% of my E&M patients are candidates (but then again, I cheerfully admit I'm very conservative).

 

[Aether2000]

We also do not use a 25 modifier...that is a code that begs for CMS scrutiny and/or fraud charges.

 

[Tenesma]

Sandpaper - i get the efficiencies... and your practice sounds like an IR practice.... which is fine... everybody can run their practice their way...

i see between 25-35 follow-ups and 5-8 new patients a day currently and that generates about 10 procedures a day.... and none of those procedures are performed concurrent with an E/M. for a total of 40-44 encounters a day... so my ratio is close to 25%....

i would love to be at 75%.... but for me that ratio allows me to offer conservative treatments first...

 

[PMR 4 MSK]

Summary of the thread so far:

If you have a very busy and/or highly efficient practice and see lots of patients and do lots of injections, you are a block jock and not worthy of the title "Pain Management" but should label yourself an "Injectionologist."

If you take more time to see patients, evaluate the whole person, recommend and prescribe meds, PT, psych and do some injections, your practice sucks.

If you make a lot of money in Pain Management, you are unscrupulous. If you are not making a lot of money you should do more injections.

Anyone who sees more patients than I do is not taking enough time to fully evaluate the patients. Anyone who sees less than I do is wasting their time.

Have I got it right so far?

 

[lobelsteve]

Summary of the thread so far:

If you have a very busy and/or highly efficient practice and see lots of patients and do lots of injections, you are a block jock and not worthy of the title "Pain Management" but should label yourself an "Injectionologist."

If you take more time to see patients, evaluate the whole person, recommend and prescribe meds, PT, psych and do some injections, your practice sucks.

If you make a lot of money in Pain Management, you are unscrupulous. If you are not making a lot of money you should do more injections.

Anyone who sees more patients than I do is not taking enough time to fully evaluate the patients. Anyone who sees less than I do is wasting their time.

Have I got it right so far?

10 procedures per week = lazy
20 procedures per week = lazy/conservative
30 procedures per week = conservative
40 procedures per week = middle of the road
50 procedures per week = busy/aggressive
60 procedures per week = overworked/injectionist/interventionalist
70+ procedures per week = needle monkey

10 follow-ups per day = lazy
20 follow ups per day = conservative/caring
30 follow ups per day = humming with good help
40 follow-ups per day = zipping, not knowing your patients
50 follow-ups per day = flying, blind signing Rx's and trusting staff (at least 3 others)
60 follow-ups per day- dealer.
100 follow-ups per day- kingpin.

 

[painchas]

Great summation of the issues in the last 2 posts. I laughed when I saw the stratification. Thanks,

 

[Jcm800]

Sandpaper - i get the efficiencies... and your practice sounds like an IR practice.... which is fine... everybody can run their practice their way...

i see between 25-35 follow-ups and 5-8 new patients a day currently and that generates about 10 procedures a day.... and none of those procedures are performed concurrent with an E/M. for a total of 40-44 encounters a day... so my ratio is close to 25%....

i would love to be at 75%.... but for me that ratio allows me to offer conservative treatments first...

i am amazed at how you can see 44 patients in a day, and do 10 procedures in there...

i would be there til midnight...and still not be done.

 

[Tenesma]

the 44 patients include the 10 procedures... 10 procedures in 2-2.5 hours, 34 visits over 5.5 hours (i have an NP who helps w/ my load as well for a few hours)... so it is doable..

 

[stim4u]

Summary of the thread so far:

If you have a very busy and/or highly efficient practice and see lots of patients and do lots of injections, you are a block jock and not worthy of the title "Pain Management" but should label yourself an "Injectionologist."

If you take more time to see patients, evaluate the whole person, recommend and prescribe meds, PT, psych and do some injections, your practice sucks.

If you make a lot of money in Pain Management, you are unscrupulous. If you are not making a lot of money you should do more injections.

Anyone who sees more patients than I do is not taking enough time to fully evaluate the patients. Anyone who sees less than I do is wasting their time.

Have I got it right so far?

Sound just about right.

 

[Sandpaper]

Summary of the thread so far:

If you have a very busy and/or highly efficient practice and see lots of patients and do lots of injections, you are a block jock and not worthy of the title "Pain Management" but should label yourself an "Injectionologist."

If you take more time to see patients, evaluate the whole person, recommend and prescribe meds, PT, psych and do some injections, your practice sucks.

If you make a lot of money in Pain Management, you are unscrupulous. If you are not making a lot of money you should do more injections.

Anyone who sees more patients than I do is not taking enough time to fully evaluate the patients. Anyone who sees less than I do is wasting their time.

Have I got it right so far?

Yup. Great summary.

Life sucks and then you die and none of it matters.

Carpe diem! Where's my needle?

 

[lonelobo]

Yup. Great summary.

Life sucks and then you die and none of it matters.

Carpe diem! Where's my needle?

Unfortunately the Sucking may come sooner than later-
when your injection reimbursement start getting clipped by another 50%

 

[drrinoo]

Interesting example of crowdsourcing

Ultimately, the volume of procedures an interventional pan physician performs depends on how he/she frames the safety/outcome of the procedure and the physician's own charisma/charm (a surrogate for patient trust). Remember that patients still go to chiropractors for repeated treatments--chiropractors deal with this internal conflict daily; to be a successful chiropractor militates against cynicism.

I am interested in understanding what words or strategies (excluding intravenous sedation) some of you use to convince a patient to stay the course (to find the pain generator and that 'relief' is just around the corner (the next step in the 'spinal algorithm')).