My name is Nick Godby, and Dr. Toomer and I are going to be discussing spasticity from a private practice standpoint with attention toward practice management. Dr. Godby has no relevant financial disclosures. I am a speaker for a number of pharmaceutical and device companies. Our objectives are to discuss creating effective documentation systems relevant to spasticity treatment, to review methods for regulating clinic appointments to optimize spasticity control and also to avoid potential for intrathecal baclofen withdrawal, to discuss the various options for obtaining pharmaceuticals utilized in spasticity treatment, and to review billing and coding for spasticity procedures. Patient education is an important part of spasticity management, and providing written documentation to patients is very useful in a spasticity practice. Forms should always be written in a clear manner with patient-friendly language. Consent forms should be utilized for all procedures involved in spasticity management, and potential side effects and black box warnings should be included on all consent forms. Patients should be given information outlining symptoms that warrant evaluation, and patients should know how to contact their physicians. Efficiency is important, particularly in private practice. User-friendly, templated forms can increase efficiency. These should include the technique used, the drug used, including lot numbers and expiration date, the dose, the guidance technique, and the muscles or nerves targeted. Ongoing treatment is necessary in spasticity management. Maintaining the timing of treatments is important for optimizing control of spasticity and is essential for preventing serious complications in an intrathecal baclofen patient. A delay of a pump refill could cause an abrupt discontinuation of intrathecal baclofen delivery, and baclofen withdrawal is a potentially life-threatening situation. Physicians who treat spasticity should develop an organizational system within the clinic so that missed appointments are identified immediately and rescheduled promptly. Of course, the patient and caregivers have an important role in maintaining compliance. Patients should be given appointment cards for their next appointment, injection, or pump refill at the time of the current appointment. Patients should never leave the physician's office without knowing when they will return. They should receive reminder calls, texts, or emails for upcoming appointments. Patients and caregivers should be educated early and often on the importance of maintaining appointments. In the case of intrathecal baclofen patients, symptoms of withdrawal and overdose should be included in this education. When specifically referring to intrathecal baclofen patients, the importance of pump refill appointments is paramount. If the patient is still undergoing titration to reach optimal benefit of the therapy, the alarm date will change as the dose is changed. The spasticity physician or clinic staff must remain vigilant about updating refill appointments in accordance with the alarm date. When scheduling appointments, it is important to schedule baclofen pump refill appointments a few days to a week ahead of the alarm date. By giving yourself a few days of time between appointment and alarm date, you make it possible to reschedule when a patient misses an appointment so that you can avoid symptoms of withdrawal. The timing of the pump refill appointment relative to the alarm date will vary depending on the dose of the intrathecal baclofen and the patient's level of compliance and available support system. Whether dealing with toxin injection or intrathecal baclofen therapy, maintaining ongoing treatment is critical in obtaining good results. Make it the practice of the office to contact the patient on the day of the missed appointment to get them rescheduled promptly. It can be helpful to have one point person in your office as the member of the team who schedules or reschedules spasticity procedure appointments. This can prevent other staff from making appointments after the due dates for injections or refills and prevent front desk personnel from inadvertently canceling an appointment. A more educated staff member can also ensure that all medications needed for a given procedure are available. When managing a spasticity practice, obtaining the treatment medication is critical. Depending on the practice logistics and the patient funding source, the drug may be obtained from either the hospital pharmacy or a specialty pharmacy. Alternatively, drugs may be obtained by the clinic directly from the pharmaceutical company. In this case, the practice would purchase the medication and then file for reimbursement with the funding source, which is otherwise known as buy and bill. The circumstances of how the drug is obtained will vary depending on many factors, and physicians should be familiar with the correct protocols for obtaining and billing the medication depending on the individual practice circumstances. It is critical to have educated staff members who can correctly order the needed pharmaceutical and correctly bill for that same drug to ensure payment. These medications are very costly, and errors in this system can result in wasted drug or delayed or inadequate reimbursement of the drug. It is often the case that prior authorization for both the procedure and the drug is required through a patient's insurance provider prior to administering treatment. It is critical that the staff member seeking this authorization be educated on providing the correct diagnosis, drug, and procedure codes to prevent a delay in treatment. It is very important that drug is ordered in advance of the planned treatment. It may be cost-effective for an employee to make one large order per month rather than multiple smaller orders throughout the month. To order drug in this fashion, it is helpful to keep an order sheet separate from the electronic medical record. It is important for the key staff members to be educated on proper storage procedures for the various pharmaceuticals. For example, certain toxins must be stored in refrigeration. Staff members must be aware that products are delivered in temperature-regulated packaging, but the product must be removed from this packaging promptly and stored properly. I will provide a brief overview of billing and coding for relevant procedures. Codes and reimbursement were accurate at the time of development of this presentation but may change year-to-year, region-to-region, and payer-to-payer. Be sure to do your own due diligence. These are the billing codes and the approximate reimbursement values for intrathecal procedures. If you interrogate the pump to obtain information, such as dosing and alarm date, but no changes are made, you would use the 62367 code. When a pump is interrogated and a dosing change is made, but the reservoir is not accessed and refilled with drug, you would use the 62368 code. When refilling the pump, you use the 62370 code, which includes interrogation and reprogramming involved with the refill. Thus, you do not also use an analysis and reprogramming code along with the refill code. Additionally, you will code for the drug itself and for any guidance method, if one is utilized, all of which is covered in subsequent slides. The pump refill can be performed by a physician assistant, nurse practitioner, or registered nurse, but in this case, the code is 62369 and has a slightly lower reimbursement value. CPT codes for toxin injections are provided. For a typical patient, I may perform 64644 for, say, a left upper limb and 64642 for a left lower limb, so the reimbursement would be additive. In addition, in any given encounter, the CPT code for guidance, to be discussed shortly, and the J code for the medication should be billed. CPT codes for neurolytic injections are presented here as well. As you know, there are various methods of guidance for injection. The codes and reimbursement for these guidance methods are presented here. As you can see, interestingly, the reimbursement for ultrasound guidance is significantly less than that for electrical stimulation or EMG. This chart outlines the list cost and reimbursement values for the intrathecal baclofen drug. As you can see in the chart, the list price is higher than the Medicare reimbursement, which would obviously have a negative financial impact on the medical facility. The reality is that no physicians or facilities are paying the actual list price for the drug. Physician practices and pharmacies typically sign a contract with the pharmaceutical company when purchasing intrathecal baclofen, and contract pricing is much lower than these listed prices. As a result, most facilities actually pay significantly less than the Medicare reimbursement for the drug, resulting in a small positive net for the facility. Currently, there are two pharmaceutical companies providing intrathecal baclofen. Additionally, compounded baclofen can be obtained from a pharmacy capable of compounding intrathecal drugs. Presented here are the J codes for the various botulinum toxins. As you can see, the cost and the reimbursement are very similar. For Medicare patients, which often represents the largest portion of a clinician's spasticity practice by payer mix, this means that toxin is generally relatively cost-neutral to a practice, assuming diligent record-keeping and close attention to prior authorization. It is prudent to review formularies and fee schedules for your major payers. There may be a preferred toxin on formulary that may result in less paperwork, fewer denials, or more favorable reimbursement, in addition to lower costs to the patient. Also, pay attention to insurance contracts. Be sure that your reimbursements are appropriate not just for the CPT codes for procedures, but also for the J codes. Close attention to documentation, billing, and coding is needed to avoid costly errors. Pre-approval should be verified and re-verified, and delays in reimbursement should be quickly noted and addressed. Again, do your due diligence. The reimbursement for EMG guidance doesn't change if you purchase $20 needles or $50 needles. Clinical efficacy is the top priority, but frugality benefits the private practitioner. Similarly, the reimbursement for EMG guidance is the same, whether using a full-sized EMG machine or a handheld device. If your practice doesn't otherwise include performing electrodiagnostics, choose wisely. Which of the following is true regarding the financial impact of toxin costs on a typical practice? 1. All toxin types can be marked up and represent a significant potential profit source for a practice. 2. A-type toxins are generally cost-neutral, while B-type toxins represent significant negative costs to a practice. 3. With diligent documentation and prior authorization, toxins are generally cost-neutral to a practice. 4. Government and private payers alike use specialty pharmacies exclusively as their toxin supplier. The answer is 3. Using CMS reimbursement as a reference, toxin reimbursement generally covers at least 96% of toxin costs. Certain payers may have toxins on formulary with slightly more favorable reimbursement. With close attention to office practices, toxins are generally cost-neutral. Government payers require buy-and-bill for toxin, while private payers may require buy-and-bill or may use specialty pharmacies.

spasticity treatment

private practice

billing and coding

patient education

clinic management