Thank you everyone for joining us. This is perfect timing for this talk. There's a Prozac at all the doors and Happy hour is right after this. So you're gonna need it My name is Mehul Desai. I'm In private practice in Washington DC. So most likely next year. I'll be looking for donations to survive but All joking aside. I think this is a really important time in our specialty, especially for those of us who are Practicing the spine and pain world I think if we can get folks to be as engaged as possible in this part of what we do I think it's really critical because there's so many challenges already that have been Put forth and more challenges to come. So the more all of us can be active in Advocacy and helping with legislative policy the better off we're going to be as a specialty I've got a great group of folks up here with me I'm gonna let each of them introduce themselves. So dr. McCormick, maybe you can go first Yeah, Zach McCormick. I'm at the University of Utah faculty there and team in our course and You know Do my best to sort of suppress some of the depression and we are gonna end on a high note Yeah with some updates on on you know coding and possible reimbursement in the future But I think I'll just also emphasize that we do want to make this interactive So obviously in a talk that includes a lot on coverage and in a policy it could be dry obviously So I would just you know open up the floor Honestly, I don't think we need to make it like a didactic if people want to just jump up and ask questions and we can sort of Problem-solve some of this together a lot of this comes down to practice management. Yes, there are updates That you'll see here and you know, these are really meant for you to literally, you know Pull these slides and implement them into templates or you know for your use to make life easier in your day-to-day practice But I think we all probably can share practice pearls on how to address These inevitable new challenges that come down the road every year When you know Medicare or third-party payers kind of impose new rules. So yeah, dr. Kali I'm Hemanth Kali. I'm one of the physiatrists in upstate New York, Rochester and I practice in a private practice setting and actively involved in advocacy and policy through multiple societies NANS ASPN and Some of the local state societies like our New York New York State interventional pain physicians Yeah, and I think to echo, you know, I have a tendency to lead with the negative but to echo what dr McCormick said I think there is cause for optimism I'm actually the NPW rep the multi-specialty pain work group rep for AAP MNR And so there's a lot of activity ongoing behind the scenes That most of us never really see or recognize that helps us protect and fight for access The multi-specialty pain work group. How many people are familiar with that? Just can raise hands to see. Yeah, so that's Like four people raise their hands and three of them are up here So we need to do a better job of publicizing what NPW is so there's about 26 give-or-take societies that are involved with Sort of that form them NPW the multi-specialty pain work group and they tend to take issues that come along that are related to coverage or policy or advocacy and they come together to generate a singular voice in a singular letter that then all the member societies can sign off on or decline if they choose to So I think that's that can be very a very powerful tool to help us and and I think that the folks up here I think you I think you're part of probably the advocacy side of things at SIS. Is that true? Actually, no, I do more standard stuff, but I feel like you know, very familiar with the work going on at SIS and NAS in the policy world I'll just mention if you guys are familiar with the the epidural safe use initiative The Rathmell the first author of people you do epidurals. Hopefully, you know what that is No That was probably the I think that was probably the first time that the NPW was convened and it was at the direction of The FDA where there was all this fear about epidurals causing paralysis and you know major harm So the NPW at that point I think was 14 societies. It may be more than that Yeah, it's I think it's around 22 to 26 A PM&R is in the NPW, SIS, NAS, ASRA, ASA I Think also NANS. Yeah, but but I would just echo Dr. Desai that you know If we have you know, we have 15 or so societies getting together with a common message That is incredibly powerful. I think we can probably do a better job with publicizing Sure in pulling this group together. Yeah, and I think dr Kali and I are involved with the legislative and advocacy group at NANS as well So and I think the neurosurgeons ANS CNS is also part of that So there's there's a whole host of groups that are a part of that. So I think it's important So again, I do think it's important to make this as interactive as possible. Please feel free to interrupt come on up ask questions We want to make this as sort of a more of a conversation because we're all in this together, right? so ultimately we need to sort of work together to find solutions as best as we can so Starting off so CMS proposed the 2023 physician fee schedule that this happens every year. There's every year. There's sort of this panic that occurs so this is a payment schedule for physicians ASC's and HOPD's and they Recommended a reduction of four point four percent in the conversion factor Even though last year's makeup was only three percent during the last year This basically creates a cumulative effective cut of ten point four percent for physician fees And if you add in nine percent inflation that can be theoretically an effective cut of twenty percent so you're talking about all sort of Procedural codes going down by four point four percent And then the added cost of doing business, which is not being accounted for and hasn't been accounted for in quite some time So while four point four percent in isolation doesn't sound Catastrophic when you start looking at you know, how many people have struggled in the last six months to hire staff? How many people have struggled in the last six months to find iso view or omni pay contrast How many people currently can't find lidocaine? right So so there's there's a host of challenges going on So now what you have is if you had a practice the McKisson's the other sort of Organizations that are part of GPO's group purchasing organizations They basically have decided that let's say I have four patient four docs in my practice I get a hundred vials of contrast a month They've rationed that if you start a new practice you get zero vials of contrast Right, if you are a large organization, you may get 250 So what's happening is the bigger organizations are hoarding all the contrast and the smaller folks can't get any contrast It's one example of adding cost to the way we have to do business, right? So there's a bunch of guidelines that came out about contrast use that I think SIS did a great job with putting out In terms of how to you know, what procedures you should you can maybe sort of forego using ICV contrast for but again The goal of this this slide is not to suggest that this is a catastrophe But it's also to contextualize any cuts that occur so that we can sort of Evaluate them more critically as opposed to just a singular number So if you look at this This is sort of just gives you an idea of like the fact that these these are physician fees are not keeping up with Inflation, right? So the conversion factor has been reduced and it will reduce payments from thirty four point thirty four dollars and sixty one cents to thirty three Dollars and eight cents. It's a dollar fifty three reduction, but when you start adding Inflation which is sort of kind of shown on the on this graph here You start to see the gap that's now starting to occur pretty dramatically and I got these some of these slides are from ASIPS website. So just keep that in mind. This is based on their interpretation of what's likely to happen Yeah, this is sort of cumulative changes so you can see here that practice costs continue to go up rent Like so fixed costs like rent but also variable costs like equipment drugs Staff those those costs continue to rise, right? They're not static. They're not staying stable We live in I live in Washington DC. We don't actually have any ma's in our practice We only have what we call patient care coordinators These are typically people who are graduated college want to go to medical school PA school nursing school And we cannot find people to work people don't want jobs They're they want to stay at home with their parents and be Instagram influencers Or tik-tok influencers or fitness influencers Which maybe I could use some more fitness, but that's a different story But also physician costs are going up and you know at the end of the day folks coming out of residency coming out of fellowship are expecting certain salaries and so these we have to kind of keep these in mind and not look at a Singular number cut as is in isolation pass this off to you So I'll touch on SI joint RFA or rather sick a lot of branch RFA, but just for a moment Yes, you know some bad news. I'm gonna put a little bit of positive spin on this So yes physician fees are you know, not keeping up with inflation and even being cut slightly. That's not good There's nothing good about that Hospital fees so, you know the the facility fees for hospital-based procedures Are probably going up slightly so they're probably being better supported and that probably makes a lot of folks angry especially if you're in an office-based setting or ASC and you're not doing procedures in a hospital or Even if you are well, you would say what how does that how is that any good for me? The physician fees are going down. I will say that What you might consider if you are doing hospital-based procedures Or you were employed by a hospital is if you show your administrators or those that you lean on for support Whether it's you know staff or you know Capital investments equipment, whatever you can say. Look you guys are doing better every year Marginally, but better every year and we're actually not so Just something to keep in mind that it's unfortunately physicians are getting cuts hospitals are doing a little bit better so you could use that to your advantage if you you know, if you choose to but moving on so secretly act joint interventions This is bad news If you were here in the lot, I caught the end of the last session that dr Desai was in and had helped put together and where I think you said we're basically we're not gonna be able to do these anymore And and that is maybe true I really hope not but the the gist of this slide is that a lot of Medicare contractors So the third parties that administer, you know policy for regionally for Medicare Are are putting out basically non coverage policies for a sacred Iliac or sacred lateral branch RFA So just you know out of curiosity how many folks do currently perform SI RFA a lot yeah, I do too and frankly, I think most of you probably perform it because you find it helps your patients and I do too and It's it's a little so Many societies and PW included and I know dr. Kali is gonna weigh on this to SIS NAS I believe a P and R all been a part of this to put together letters at a society level To try to you know, rebut some of what's going on here Dr. Desai put together this slide in hopes that I think everybody who's listening here and maybe people that aren't but access these slides later Use these links and write a letter. So obviously it matters for our societies, you know at a high level That represent all of us a P and R NAS, etc To put together society level letters, but as an individual physician it makes a difference the more they hear the greater the chances that we can hopefully sway this or Or at least maybe defer some of these non coverage decisions It's you know, I'll just brief side note It's a little ironic or it's a little strange that there are two different sham controlled Randomized control trials that support si RFA, which is more than there are in any Spinal segment, right? So we have the Lord study for C-spine. We have the MIT trials which were terrible. That was the only RCT for lumbar facet denervation, but strangely we have actually, you know, reasonable data for SI, RFA and this is what happens. This is what we have to fight with. And the funny thing is there's a... The third RCT is about to come out. So there's a third RCT that's got three month data that was presented at ASAP and then 12 month data that will be presented at ASRA in a couple of weeks. And that the three month paper will be submitted to journal like any minute now. So it's eminent. And the other point I want to make about this slide is that these are just draft LCDs. So we still have an opportunity. So folks, if anyone has an interest, feel free to ping me. I'm happy to send you like a sample letter that you can customize for yourself and send out. So we want to make it as easy as possible. You can just sort of put your letterhead on at minimum. You can change it as much as you want at maximum, but we have all that information. So we're happy to share it. So there's still an opportunity to make this change. So I think that's the important part to take away here. Very much so and if you look at the deadlines on the comment periods, I mean they're coming right up. So that's a wonderful offer from Dr. Desai, but a template of letters is really just as good. Just the numbers matter. So definitely encourage everyone to do that. So I think this raises a bigger question. We hope that we can continue to do SI-RFA. What are we left with if that's taken off the table? Mahul's gonna talk about some of the fusion, SI fusion procedures, codes, and updates on that. I personally am gonna find it pretty sad if everyone who was getting SI-RFA and was doing relatively well now doesn't have an option other than fusion, presuming that they're there because they've failed physical therapy, mechanical interventions, potentially a belt, SI steroid injections, and that's why they've arrived at SI-RFA. So we will see. You know, some of us, I think none of us have answers to, but I hope that everyone isn't ending up with SI fusion as a result of this. So I will... I'm actually gonna pass it back to Dr. Desai for a little bit on some changes related to sedation, procedural sedation. Thank you. Yeah, so this next group of slides, I think this is one that if I had an option, I would just take photos of this and make sure you've got this in your practice. These aren't per se... This is our respite for a moment here from anything particularly negative. This is just FYIs. We should all know about this so that we can document these things appropriately. So you should always defer to individual payer policy. Most of these things that we're presenting today are primarily related to Medicare right now, although some third-party payers like United are also making a lot of changes for sedation policies. So keep in mind that procedures that really never require sedation from a Medicare perspective are things like epidural steroid injections, trigger point injections, medial branch blocks, interarticular facet injections, any sort of joint injection, hip, knee, elbow, any of that stuff, SI joint injections, or genicular nerve blocks, even though I would suggest that genicular nerve blocks can hurt a little bit. But generally speaking, you're really gonna have to be very cautious about billing for sedation for any of these because if you don't have an appropriate medical documentation for need, it could trigger a review and also potentially an audit, which no one wants if they can avoid. Procedures where sedation is considered appropriate from the part of the payers, radiofrequency ablation, sympathetic nerve blocks, celiac plexus, parapertebral, hypogastric plexus blocks, and then spinal cord stimulator trials and obviously implants, intrathecal drug delivery trials and implants. And I would suggest that in this is probably peripheral nerve stimulation as well. So keep that in mind. Again, documentation is everything. When you do document for the first 10 minutes of sedation, it's 99152, make sure you're documenting that properly and documenting who's doing the sedation and what their credentials are. And then for every 15 minutes after, but only after at least eight minutes have been carried out. So you have to document a minimum of 18 minutes, basically a procedure time, because otherwise that could also trigger a review and possible audit. So that second code for the additional time is 99153. So keep that in mind as well. All right, so in your sedation record or in your documentation in the chart, make sure you include the total sedation time, the name and the qualifications of the person who's delivering the sedation and the fact that the patient was able to maintain their own airway. So for example, moderate sedation was carried out under my supervision by name and qualifications, specifically what sedation was given. In this case, Versed and Fentanyl were administered, intra-service time was X number of minutes from this time to this time and the patient maintained their airway and tolerated the procedure well. You wanna make sure you're documenting all that in order to get paid for sedation. It's easy to hit that 99152 number, but we have to make sure that we're documenting these things to get payment. The other thing is oftentimes, I live in a high anxiety zone, Washington D.C., it's like every election, there's like tears no matter who wins. And so patients will often come to us and say, well, I'm anxious, I need sedation. That's actually, while anxiety itself is considered a medical necessity for sedation, it must be something that's actually a diagnosis. And we can't say you have anxiety disorder for needle phobia but it actually has to be listed as a diagnosis and have a psychiatric evaluation or psychological evaluation that's related to that to justify using anxiety as the reason for doing sedation. So it's not enough to just say the patient's anxious or to document that in your chart, but you have to document that as a diagnosis and have some sort of workup with regards to it. With that, I'll pass it over to Dr. Kalia, right? Yeah, so I'll be totally honest. That last bit on sedation was completely new to me and I think probably, I imagine, most people in this room. So I would, I'm probably gonna make some changes in my own practice as a result of that and definitely just encourage folks to, this stuff isn't trivial. So we're gonna get to facets, but I'll just mention that there's been, OIG is doing nationwide audits right now and I don't know if, probably no one wants to raise their hand. It's not like you did anything wrong, but if you've gotten audited by the OIG related to facet interventions, and I'll share that I was, and it ended up fine for me. So they pulled one chart and exhaustively made me go line through line through what Dr. Kalia's actually gonna show us and prove in the chart that I checked every single box. And luckily I had and so they didn't tell me they needed a hundred more charts or whatever would happen and it worked out. But the point of that is that like, we don't wanna just ignore this stuff. Like the audits really do happen and you don't wanna be on the wrong side of that. So it's totally worth just investing a little time in how you're running your practice and educating your staff, your schedulers, your nurses, et cetera, on these changes. So epidural injections, so I'll just kind of hit the high points here. And honestly, this slide really shows it. So I see a lot of folks have their phones up, go for it. I mean, I would just honestly take a picture or pull the slides later and just make sure you have this kind of built into your language and that you're accounting for all these factors. But very briefly, so the major indication of epidural obviously is radicular pain, whether with neurogenic claudication, whether it's a fixed radic. If you're associating this with degenerative disc disease or spondylosis, that's gonna be a problem for you down the line if it's a Medicare patient you didn't get prior off, but then you get audited later. So that's huge and you don't wanna be in that situation. Pain for at least four weeks, but also failed conservative care for four weeks. And then if it's being repeated, it needs to have been documented the patient improved at least 50% improvement in their pain symptoms for at least three months. So if it's less than that, that's gonna again, create a problem for you on the back end. So anything that's being pre-authorized, third-party payer, you're gonna be doing a peer-to-peer. And that's a pain in the butt, but that's the worst that happens is maybe it gets denied, maybe it was a peer-to-peer, maybe you have to wait, et cetera. On the other side, if it's a Medicare patient, there is no pre-auth process. It's the audit that is the big problem if that comes down the road later where now clawback, et cetera, big headache for your practice. The other thing here is that you have to document pain scale or functional scale. So it's not enough to just say they improve by 50%. You have to actually show the numbers. So just one more unfortunate small thing that I would just build it into your templates so that's easy and just automatically collect that. So otherwise, there's some interesting steroid considerations. So one is that you can't use beta, excuse me, methylpenicillin anymore, Depomedrol. So it's not even, you just can't use it. You'll have a problem with the claim if you say you use methylpenicillin. The other are the dose limits. And I remember this from a couple of years ago, but we had occasionally folks were using, in our practice, we're using over 15 milligrams of dex in a bilateral procedure. Those claims will all get denied. So you gotta keep your dexamethasone under 15 milligrams or less, which honestly, when you look at the data, you don't need that much dex. In the Ahadian study from UCSD, and this is old now, but they looked at four versus eight versus 12 milligrams of dexamethasone, just randomized folks that received those dosages and there weren't any intergroup differences in pain improvement. So you don't need massive doses in a transferaminol for it to work, at least if you believe the Ahadian study. This is stuff that I think people are already doing, but you need CT or fluoro. If you're not using CT or fluoro guidance for an epidural injection, there's gotta be medical necessity. So whether they're pregnancy or some other reason that it's not possible. And then also, I hope folks are already doing this, but just make sure to save two views. So you need, everybody would probably have an AP view, their final view, but you gotta have a depth view. So for a transferaminol injection, I mean, save your lateral, save your AP. If you wanna save an oblique on top of that, fine, great. If it's an interlam, many people like the CLO view. It's a great view. Hopefully people are maybe using it. You can save your CLO and your AP. You can save a CLO lateral and an AP, but at minimum, other than the AP, save one more depth view. And then, Dr. Desai talked about sedation again. So there are gonna be problems. I mean, if you're using MAC for epidurals, like this is gonna create problems if there are audits down the line. I think that those are... No, let me touch on one more. Can't do an epidural along with a facet intervention on the same day. That's gonna be a problem. So you can't do multiple procedures. I know. Unless... Facet cyst? Facet cyst, yeah. That's okay. That's an exception. So yes, absolutely. So facet cyst is the one exception where you can do, for example, I think many of us will block that nerve or do an epidural so that it's less painful when you then rupture or access the facet cyst. Yes, you can do that. But with that one exception out, you can't decide you're gonna do an epidural and a lumbar RFA or you name it in the same day, same day of service. Other thing is there are some limits to be aware of. So bilateral transforaminals, that's okay. Unilateral two-level, that's okay. You can't do more than that. So you can't do bilateral two-level transforaminal. Like that's not gonna fly. And some of that may be old news. Maximum of four epidural injections per spinal region per year. And remember that cervical and thoracic are one spinal region, which, well, crazy, right? C2 down to T12, but yep, that's a spinal region. So you've got lumbosacral and you've got cervical thoracic, essentially, body regions. And then, oh yeah, go right ahead. Yeah. Is it per year? I thought it was for rolling 12 months. It's no longer per calendar year, I thought. I believe you're right about that. For rolling 12 months. Yeah, that's correct. 12 month period. Yes, good point. That's an important clarification. Yep. That's a good question. I can tell you what I do know the answer to. So if you... This is actually on the next slide. This is all the same information. Uh, no. It's here. So if you do an initial epidural and they... that individual gets sort of inadequate relief, it's okay to do a second one after 14 days presuming that you're changing your approach or the medication. And so just for example, like practically speaking, if I were to do, you know, an individual with an L5-S1 kind of subarticular disc, right, and I were to do an L5-S1 or an S1 transforaminal and it didn't work that great, I might pivot to doing an interlaminar injection with a particulate steroid, paramecinolone, let's say. Um, and that would be okay. That would be acceptable. Um, but your second question, I actually... or the first one, really, um, I actually don't know the answer. If there's a sort of a reset that happens after a year. I think, unfortunately, there's not necessarily any guidance on that, meaning from the MAC level itself. It's sort of like this question that they've left unanswered so far. So I think it will just depend. I suspect there will be some ability to retry, but that's sort of like a... I don't know that we'll ever get full clarity on that. What I would say is that when there isn't clarity, if you can document in your note that, you know, your judgment is that this is an appropriate treatment and it's in the best interest of the patient and, you know, that's you saying that as a physician, I think that's the best you can do to justify your decision. Because again, you know, this is an issue... this isn't so much, um, you have a patient with Blue Cross and you're submitting for prior auth and you're either going to... it's going to be approved or you're going to be on the phone with the peer-to-peer. This is... you wrote a note and maybe it's five years later that Medicare comes and... or OIG comes and audits your charts and says, like, were you doing what was, you know, concordant with the LCDs and so on. So... My two cents would be specifically to that question. Move on. Don't open yourself to audits. If your patient has reported less than 50% improvement, either try a different strategy or try to find another pain generator. Yeah. Many people did the same. I don't have a good answer for that, but, you know, folks are using beta-methazone or they're using trimicinilone. Why? Is that the mineral? Well, they actually said, according to... There was different versions. So they put out a version that actually allowed for depo and then they had a final version that took depo out and they said there was a black box warning also on depo at the time. So I think there's a black box on both. I could be wrong about that, but fundamentally it doesn't make It doesn't actually make a lot of sense because if you were looking at it from a black box warning perspective, you would think the only thing they would really allow would be dex, right? But for some reason they picked on methylpropenicillone and it may be going back to what you described when there was that contaminant issue that happened a while ago that was I think more of a depo issue than it was the other ones. So they may have been some institutional memory because the first call... When that news broke, the first call I got was from the attending physician's office at Congress and I thought they were like wanting to comment on it, like one of the docs. The only question they had is you didn't inject any of the members of Congress with this, did you? I was like, I wish I had, no. That was from a company policy, but that wasn't the mainstream. Yeah, but it took on a life of its own, right, that news story. Dr. Nagpaul's got a question or comment. Well, going back to this question about... of epidural steroid injection management according to the new OSI. Yeah, Dr. Nagpal is absolutely correct. So if you are planning on continuing patients on epidural injections beyond a year, there are three specific things which you need to document on in your chart. One is the functional improvement. One is the medical necessity, why you think that patient is needing a continued epidural steroid injections after a year, and third is imaging. So imaging has to be repeated in that time frame to justify your clinical decision of continuing epidurals beyond one year. Every year, MRI. They don't specify what is needed. It's unintended consequences, right? So you make these decisions and... Do you have a question back there? You could do an S1 transforaminal, yeah, because you are changing your approach, yeah, or you could alter it to caudal or interlaminar, yeah, but that would be true. Question? Is it enough to change the dose of the same medicine or no? My understanding is no. You wouldn't be able to use the same approach, same medicine, at least for a Medicare patient. Now that doesn't carry for everyone, but just with what we're looking at here. The same approach to the medicine as well? Yes. You have to change one of the two things. Yeah. Something that you believe will help more than just repeating the same thing that you already did and didn't work well enough. And make sure that you are clearly documenting that clinical rationale in your documentation, because, you know, as Dr. McCormick said, you know, with Medicare patients, it's a straight Medicare or straight Medicare. You don't need any prior authorizations. You will directly move on and do the procedure until a RAC audit happens. So you don't want to be in a situation where, you know, five years down the road, a RAC audit happens, and then they pick you up on that specific legality of that. Yeah. Oh, you're saying you did an L5 S1 transbranial and an L5 S1 transbranial plus an S1 transbranial? I wouldn't do that. Yeah, I wouldn't do that. You're again opening up yourself to a really, really tricky situation. Stay away from conflict, right? So the LCD, if you read the language, it clearly states, change your approach. You've already tried an L5 level. It has not worked. You have decided to move on to the next level. Move on to the next level. Don't say that I'm going to do exact. So what they can come back and do is they can deny your reimbursement to that L5 level. And they won't do that. What they will do is they will, as Dr. McCormick said, they will review your documentation and then they will ask for 100 more charts of yours and then decide how much of the money they're going to ask back. So stay within the confines of the LCD. If you're going to do that, I would change the drug, too. That would be like if you're using an ODI. So you would administer an ODI or there are other functional measures, but like that, yep, you can do PROMIS, but it's got to be like a sort of a vetted, standardized, validated tool, unfortunately. That's not unfortunately, but it just obviously adds burden, you know, practice burden. So most people are choosing to use pain scores, not necessarily... Now we try to collect an ODI on every patient who comes in our door, or an NDI if it's for neck and we have about an 80% hit rate of doing that when we really, really encourage our staff and our receptionists to give out iPads and get this done. As soon as we take our foot off the gas, it drifts down to about 50%. So it's hard, right? It's really hard to get, you know, consistent collection of these more intensive outcome batteries. The pain score though is definitely the... It is the low... The easy way to go, yeah, with documenting either pain or functional improvement. I think you can document just that in my opinion, yeah. And again, that's like there's no... There really isn't going to be guidance on that specifically and you know in these... in the LCDs or requirements, but if that's your judgment and you say, I reviewed the imaging, I reviewed the flora images, dye flow was inadequate, you know, there was no epidural flow, etc. Whatever, however you want to phrase it, in my opinion that would be... I think that keeps you safe and protected if... in making the decision to go ahead and do a good epidural for your patient. but it is per ruling as the gentleman noted over here. Can you repeat the question please? He was asking... You're just asking essentially should you basically send the patient to a surgeon to get the surgeon to weigh in about operative care if they're failing epidural injections? I don't think that's going to help you in the circumstances that we're describing. You could document a surgeon's opinion, but I think you'll still have to document medical necessity based on your own medical judgment. At the end of the day, I think the onus here is that we have to be exhaustive in our documentation. We have to be consistent in our language, and we have to be thorough in our rationale. Without those things, it's really what they're looking for is a pattern of behavior and a pattern of thought process that is traceable and reasonable. If you do that, and the goal of this is, again, to arm everyone with the tools they need to be able to use the same language over and over and over again, and to educate the people in your practice to use the same language over and over again, so that when they do review your one chart, they're like, okay, good. Let's move on, right? Instead of opening the door to where there's... The problem with these things is when you start reviewing 100 charts, invariably there's going to be something, and invariably that gets amplified, and invariably the money you have to pay back is a lot more than what you got for that procedure, much less all the headache and et cetera that you get from that process. So, consistency is the key here. Yeah. What date did all these take effect? These are already in effect. They're in effect. No, I said how long ago. December 2021. Yeah. Great questions, you guys. I'll pass it along. So, I think we're going to go over Facette, and yeah, this is a nice figure. It really shows kind of the same thing we were talking about. So, I'll pass it over to Dr. Kalia. You can talk about the other parameters, possibly, too. Yeah. All right. How's everyone doing? I think there are some Prozac or Celexa, which Dr. Mehul kept in the back. Well, I think, so we're going to go over some more policies which have either come into effect or will be coming into effect soon. But the key here to understand is that the messaging is go back and read the actual LCDs in your region. They will differ, right? So, what we are talking about here are most of the Medicare LCDs or NCDs. So, the difference is NCDs are National Coverage Determinant, which is put out by CMS. And then CMS has these contractors, these Medicare MACs, which are responsible for administering the plans in certain regions. So, you will hear names like, you know, Noridian or, you know, we'll go over some of the names. Can I interrupt you for a second? Yes. So, are people familiar with the MACs? Can we get a show of hands? Okay. So, about half the people. So, there's like nine MACs, I believe, in the country. And they're all, they don't have to adhere to the NCD. So, they can have their own LCD, which is ridiculous, right? And there's a lot of conflict between, I should be careful in Baltimore where CMS is headquartered. But there's a lot of conflict between central office and the MACs. The MACs like to operate like their own kingdoms. And when you go to Medicare and tell on the MACs, they get very, very, very unhappy and make life very difficult for you. So, there's various MACs. So, we're currently in Novitas territory. Novitas is responsible for between 30 and 45 million lives, right? So, it's a big, huge chunk of people. The biggest other one is Noridian, which is responsible for another 30 to 45 million. There's First Coast. There's Palmetto. There's... NSG. Yeah. And NGS? NGS. So, everyone... If you don't know it, that's okay. But I would find out who your MAC is, because that's whose LCDs you should be reading, in addition to the ones you read for commercial payers, because that's what's gonna be relevant to you. Now, there's... If you look at some of the things that happened nationally with the opioid crisis, there was a push to try to make all the LCDs adherent to the NCDs, but apparently no one got the message at the MAC level, because they're still putting out their own LCDs. Correct. So, just to build up on a little bit of that knowledge platform, so the difference between the NCD and the LCDs, LCD is known as the local coverage determinant, and the NCD is the national coverage determinant. As Dr. Mehul said, these MACs can come up with their own LCDs. Similarly, your commercial payers can also come up with their own LCDs. And the key will be for you guys to go home and read those individual LCDs in your region from commercial payers to your MACs, and then do the templates in your notes to justify and match what the criterias are there in the LCDs. If you can't find an LCD, great, awesome. Then you will probably go back to finding the NCD of the CMS, but there will be procedure codes where there is no NCD and there is no LCD in your region, so you're flying under the radar. Some of those procedures are genicular nerve ablation, your genicular nerve blocks, and what you're seeing now is in certain regions where you are practicing, if you were doing these procedures for a very long time, all of a sudden they're getting denied. The reason being that if you look at your commercial payers' LCDs now, they have deemed these procedures investigational and experimental. So it's a, I'm sorry I went on a tangent, but I think it's important to understand these codes and abbreviations which we have been using throughout this talk. So how many of you guys actually do facet joint interventions? Great. So be ready for another roller coaster here. So there is actually a proposal at hand where the CMS MACs are proposing prior authorization for all facet interventions for Medicare beneficiaries. If that goes through, just imagine doing, you know, you'll probably have to hire another one FTE, if not more, in your practice to just take care of these facet joint interventions. Yes? They started to, I'm in Illinois, they started to require our patients for medial benches via authorization. For Medicare? Commercials. Commercials. Yes, yes. Commercials, everyone. Yes. Commercials is, yeah. So this is, we're talking primarily about Medicare and MACs today. Yes? Not to my knowledge at this point. We're still waiting for the exact language. If Dr. Desai knows more... No, I think that when this was proposed I think there was like a collective conniption, right, because I mean, again, you could trace back a linear relationship or maybe an exponential relationship for your spend to acquire that dollar. So I think the hope is that this will kind of maybe just go away, because it's such a common procedure. It's like our second or third most common thing we do is facet intervention. So and some of the folks in this room probably have populations where Medicare is 50% possibly, right? So you can imagine what the lift would be for the practice to be able to accommodate that. So this is a slide similar to the epidural algorithm, again, from the ACIP documents put out. So again, I see people kind of taking pictures. Definitely, these will be available to you on the platform as well. The key points to take back home from this proposed change which went into effect was primarily about the bilateral and the unilateral radiofrequency ablation neurotomies. How many of you guys, if you have a bilateral pathology, how many of you guys do unilateral ablation and then bring the patient back to target the other side? Not anymore. Yeah, so stop doing those. In fact. What about TON? What do you do with TON? It's hard. It is. So. It's a little challenging. Yeah. It's a little challenging. Yes. Yes, it is. But I'm going to be the bearer of some bad news. So I've heard numerous, I've got numerous phone calls from a lot of providers in New York State where I kind of chair the New York State Advocacy and Policy Consortium. In the last six to nine months, there have been multiple providers who have had RAC audits happen. And in fact, they have been called upon by the MACs to give back the reimbursement they received for these procedures over the last six to nine months timeframe because this policy went into effect December of 2021. So everything which was done before that, the MACs, at least in New York State, I know we have been audited and most of the providers have received letters on this specific issue. So moving forward, if you are doing radiofrequency ablation, one side followed by the other side, you have to stop it. You'll have to do bilateral at the same time, unfortunately. Well, I think the part of this thing that people, I mean, the background to this is what was happening. If you bill for a bilateral RFA, you're getting the 50 modifier is reducing what you make, right? So people were doing bilaterals just a couple weeks apart and collecting the full fee for both. And that's why we decided to cut this. So that was like a kind of ubiquitous practice. Now there are obviously exceptions like third occipital where maybe there's more of a necessity to do. And again, you could probably make a case as long as you document it appropriately about a taxia, as you were describing, or other complications. But generally speaking, they're after people, they're trying to stop people from doing that, taking advantage of that modifier. And then the second facility fee too. It's not just the full payment on the second side, but a second facility fee on top of it. Or even a global, right? Like, I mean, for us, like I'm an office base, it's still like, there's huge practices in this area that their practice was always to bring back patients. A342, you ask the patient, the patient claims to be 80. You could use a chat online trick with the patients and say, you know, it's not 80%. I can't do this. Well, no, well, it was only 60 or so. OK, well, it's not 80. I can't do it. You know what? It'll be 80. It's all right. It'll be 80. No, no. It's already 80%. Thankfully, this isn't recording. I'm just kidding. So how do you get the number value? I just do the numbers. I don't think there is anything. But if it goes, it looks pretty strong. But it wouldn't be often. Maybe we will discuss this with them in a little bit of the context. I think you make a great point, though. I think it behooves all of us to document both, if we can, right, to document the pain score difference. Because there's a lot of times, because pain's not an interval scale. It's an ordinal scale. So there's no way it can always be those numbers Someone's 6 to 4 might be 80% for them, right? Yeah, that's a great point. Yeah, that's actually a great point. So moving on. So these are, the language is actually straight out of the LCD. You have to make sure that your patients are meeting all these indication criterias to become a candidate for a diagnostic block. When you're doing a diagnostic block for set joints, it almost have to follow the SIS guidelines of differential diagnostic blocks. The first diagnostic block, you know, 0.5 mLs. You can use either 1% lidocaine or 2%, whatever you use. And then the second has to be a different local anesthetic with different duration of action so that you can meet that criteria of differential diagnostic block. If patients report more than 80% improvement, then they become candidates for either a therapeutic facet joint injection or radiofrequency ablation. So based on the LCD, you can proceed with a therapeutic facet joint injection as well if clinically and medically indicated. Yes? Did the early criteria change? I thought that you never changed the anesthetic. I'm sorry? I don't think... I'll have to double-check that, yeah. Go ahead. No, yeah. And I think what's on there is... I think what you have on the slide is 1% or 2% and there are people that use 4%. I use 4%. Yeah. I had until we had the shortage and now I can't get it. Yeah. So, but is that 5% or 4% or are you going to make me in trouble, I guess, with the question? I don't think so. I think as long as... Again, you might want to put some documentation in of why you use it. For us, I think part of the problem, we use 0.75 for bupivacaine and 4% for lidocaine. Part of the reason we do that in our practice is because to some extent what Dr. Furman just talked about, patients get really confused by what they're supposed to experience from diagnostic blocks. And sometimes it's just helpful to have something that's either more dense or more long lasting. And that's been the rationale for us to use it. For me, in my practice, 1%, it's like gone. Yes, you can't bring it back the next day or the next week. Correct. It's 14 days. Yeah, this is probably a local LCD by commercial pairs. Is there a maximum time that they can do? Like, they can't get in, and they're going to Florida, and then they come back for three months? I think it's three months. For diagnostics or? Yeah, for diagnostics. I think it's three months, if they're not sure about that. Because I think what happens after three months is it resets. It's almost like you have to do the second block within three months or the ablation. Otherwise, you have to do it all over again. If you want to repeat an ablation, but it's been more than two years, even if they said, I felt great for six or eight months or whatever, you have to repeat the blocks again, which is unfortunate. Even if they got benefit for the full two years, you have to repeat the blocks. Yeah, if it's been more than two years since the last RFA session, you have to repeat the blocks. Medicare. It just costs them more money. Yeah. Now, I just want to clarify that what we are discussing here are the Medicare LCDs. You may have a different LCD from your commercial pair, which may not have. Most of the commercial pairs will follow the Medicare LCD. They'll just copy paste it. But sometimes, you will find some changes or some nuances in your commercial pairs LCDs. One of the things I would strongly advise people is to create a matrix, y-axis, x-axis. Y-axis is all the pairs. X-axis is all the requirements. And you just put x's on what it's supposed to be. So for example, Cigna used to require one block at 50%. And I think they've changed that. But it is helpful sometimes to have failed six weeks of PT, four weeks of PT, whatever it might be on one axis and all the pairs on the other, so that at one glance, your billing pair people can just look at it and be like, OK, this is where we're at and advise you. Or we have it up in all our offices so that the docs also can look at it and be like, this is what we need as a basic. Because there are differences, at least subtle differences these days, between the max and then the blues, or the Cignas or the Uniteds. Intra-articular steroid injection. I thought they would do that with a cyst. That changed. So 2021, January, when this new LCD came into effect, if you have done diagnostic blocks to identify a facet joint as a pain generator, you have two options moving forward. You can either do a radiofrequency ablation or you can do a therapeutic facet block. I believe that's if- I don't want to find a needle bench block for steroid therapy. I don't want to- No. I believe you have to document why they can't have an RFA. Yes. You have to prove, you have to put that in your note. Why is it they can't have an RFA? So they're shunting people to RFA as opposed to facet joint serine. I want to make sure that we're not going to be okay with any intra-articular? Yes. Would that mean a little therapeutic diagnostic block? That's a block. Block is not intra-articular. Yeah. In this case, in this context, the reference is to intra-articular steroid injection. Yes. It is confusing though. Yes. I agree. Yeah, I agree. Yes. So this all applies to Medicare A and B, right? It's not managed Medicare, like ethnomedicare? Yes. So that's an excellent question. So- They're amazing. Yes. So these are like straight Medicare. If you have a managed Medicare plan, more often than not, the managing pair, be it Excellus or your local other insurance company, they will have their own specific LCD, follow those Medicaid Advantage plans. That's exactly the reason why we have not been able to do a lot of procedures which have an NCD or a local LCD with Medicare, but they fall into the managed Medicare plans from the local insurance companies which deem those procedures experimental or investigational under their individual LCD. I will say there's some actually pretty significant lawsuits ongoing currently about this issue. Correct. Because it's actually illegal for a Medicare Advantage plan to use their own LCD. They're supposed to default to the NCD. And so, but they're doing it anyway. They've been denying care for years because that's how they make their profit. So it's interesting, there's a bunch of law firms that have represented physicians, I mean, sorry, patients to sue these groups. We'll see what comes up, but it is, by the letter of the law, they're not supposed to be allowed to do that. We can't be audited, can we be audited for managed Medicare or because they gave off, we're just saying. You can still be audited by any payer. It's just in a different way. Like OIG's not gonna come to you, but they can ask, any payer can ask to review your charts. And you still might have to pay them back or there might be fines or whatever, but it's not the same. Correct, correct. So I'm gonna give you an example where I practice. I practice in Rochester, New York. About 70% of our population is covered by Excellus, which is the third party administrator of Blue Cross Blue Shield. And most of our Medicare patients have managed Medicare plans through Excellus. So straight Medicare is only about 12% in our region. So even though I have wonderful therapies I can offer to straight Medicare patients, those therapies, including some therapies like even dorsal root ganglion stimulation, which is level one evidence, is deemed experimental under the LCD of that Excellus policy. So all the managed Medicare patients, despite being Medicare, I can't offer them DRG stimulation because they fall under Excellus LCD. So that's what Dr. Desai is mentioning, that there are these lawsuits, because technically if they would have stayed with straight Medicare, they would have gotten that therapy. I can't offer them therapy now because their plan is being administered by Excellus. Did I hear you mention TLN? What's wrong with TLN? You were actually listening. Oh, my only reference there was, you know, I think many are familiar with the risk of ataxia, persistent ataxia, if you burn the TLN bilaterally on the same day. Is that what you're referring to? Some of the insurance companies... Are denying, yeah, are not considering it facet DRG, which it is, right? Yeah. True, I will say that I think if we were to rewind three or four years ago, more payers were actually denying TLN RFA, C23 facet joint RFA than are now. We just saw that new one come through. Was it United? I think so. It was United that... United also decided not to cover STEM for low back pain anymore, not surgical low back pain. But I would say overall, at least I've seen very few commercial payers denying TLN RFA. But it could be regional too, depending on your payers. Yeah. As far as some limitations in that LCD around the facet joint interventions, only light sedation is permitted for diagnostic blocks. If you are considering using MAC or moderate sedation, it is permitted for radiofrequency ablation neurotomy. If clinically indicated, you'll have to justify and document in your documentations. Opioids cannot be used for diagnostic blocks and facet joint interventions are contraindicated in patients with fusion, especially the ALIF and the anterior approaches. It's such an interesting policy that it's no longer covered for anterior surgery. Knowing that anterior surgery, probably one out of nine in the literature, but probably more often, actually results in facet joint dysfunction, right? So if you fuse someone anteriorly but you use too big of a prosthesis or too small of a prosthesis, you're gonna actually cause iatrogenic, facetogenic pain. But yet, according to this, you can't ablate those areas anymore. Any questions on facet joint interventions before we move on to another topic of pedophile nerve sedation? Oh, I see a lot of questions, great. Can you just comment a little bit about the number of levels that can be covered at a time in the bilateral versus bilateral? Yeah, that's a great question. So with the updated LCD, you can only target two levels. So three medial branches. Three medial branches and two facet joints. Bilateral is okay. Yeah. And technically there is wiggle room if you wanted to treat a third joint, but you're gonna... That won't be sufficient. You'll have to document more of a medical reason, like there's degeneration, whatever it might be. I think historic utilization won't fly as necessarily a justification. Dr. Masey? So, what you code is, so epidural depending upon interlaminar or transforaminal, you use one of those codes. And then for the facet cystotomy, you're using the facet code. And you can use those codes in conjunction only in that specific situation. Please make sure you're using a modifier, either 51 or 59, to let them know that it's a separate entity. Otherwise, depending upon where you're practicing, there are CCI edits, so your coders, once you submit the bill or you're getting the prior authorizations, they will run those codes through a software. And if you have not given them a modifier, the CCI edits will push back and say, you can't use them. And then you will have to go back and forth. So make sure that when you're getting the approval, just throw in a modifier there and that should get it through. Otherwise, you'll only get paid for one or none. And I think the other thing is using the right ICD-10 codes in that situation, so making sure you're using that and then having a description of why you decided to do both in both your pre-procedure note and also adding that in into your actual application. I think what you're mentioning is probably your local, yeah, probably your local LCD for a commercial pair. That's not something you guys are seeing. Well, that's not in these. This is like coming from Medicare. This is Medicare. It's probably a coverage policy of one of your, like, your local or your regional commercial pairs. Medicare, but it must have been local. But they're not letting us do more than five and a 12 month waiting period. What's your... If you do diagnostic MVDs in an RFA, if you run to the other side, by the time you do diagnostic MVDs, you're out. What's your MAC? I'm in Jersey. Jersey, so Novatox. Novatox, yeah. So I think what you might be running into, though, is that I think from their... And this is me putting myself into the brain of someone at the MAC, so who knows, right? So this is purely speculative. But from their perspective, it's like medial branch, medial branch, RFA, six months later, another RFA. That's four procedures. They're giving you a little latitude for, like, a facet or, like, intraarticular or something else, but that's the MACs. Like, they're done after that. So I think that's where that's coming from. So you're saying after three months, you can do a therapeutic, but you're going to run out, like, you can't do three... But I think their thought process is, if this therapy's not working for at least six months, then why are we paying for it anyway? But you can't do that, you can't do the other side. Yeah, well, that's why they're basically saying to you, don't even bother doing one side at a time. Or just give you a, they thought it was one side, and you're actually trying to do the other side. It doesn't all make sense. I 100% agree. I think, you know, going back to the two-week wait that... Like I practice in an area where we have people drive for four hours in each direction to come get specialty care and to make them... It used to be that they could stay overnight, right, and they could get a couple of ranch walks. You save them eight hours of driving, we can't do that anymore. So... But that's the repercussions of this stuff. I think there's one more there. There's two questions. Yes, it's. I think this is one of those where you have to figure out like how to document it, create medical, like a document medical necessity and justify the code you decide to build. I mean we do, I do a fair number of C1-2s and I actually do C2, like I'll, I'll blade it once in a while, like the C2 dose from Rami, but I used to do it a lot when I first came out of fellowship. I don't need to hear this. Well, ultimately, it's always on you. Ultimately, billers, coders, none of those people are. It's always on us, right? The buck stops with us. We tell our trainees, you think, some people go into the specialty thinking, oh, it'll be fun. Well, fun's fine, but it's also like you can hurt someone. So similarly here, yeah, the onus is on us to continue to stay on top of these things. I think the takeaways for me are we probably need to have these kinds of sessions annually because probably these things won't change so much, but new things will change. There'll be more things on the table that they're going to want to change, A. B, we need more singular voices. Right now, we are an incredibly fragmented subspecialty amongst so many different specialties. We need to do a better job of getting, whether it's using the NPW as a proxy for a singular specialty or getting people on the same page to be more better about advocacy. None of us, there's very few people on Capitol Hill that are advocating for us, truly in this area, right? Like even some of the biggest societies that you can think of don't have a full-time person in D.C. And I meet with those people all the time. I meet with congresspeople, senators, I met with Medicare, but we need that to be happening all the time, not just when there's a catastrophe about to befall people, right? So I think those are the kinds of things that we need to energize people about, is not that we need to sort of continue to be protective, but we just need to be appropriately aggressive about engaging all the stakeholders in what we do and the value in what we do. You know, I'll add another comment, Aaron, because I agree, it's kind of overwhelming. Every year, we're going to have to basically make changes, these little nuances are going to change, or new things will come up. But I would just say that many of you out there, myself included, are in a group practice setting. You have partners, and kind of sharing the load of reviewing these things and changing your templates and re-educating staff, I think, pull each other into it. And then the same thing, everyone in the room, we're all in it together, and sharing this knowledge and sharing templates or processes, I think is much better than everyone going home and developing them in isolation separately. I would just encourage people to share resources and help each other out. My last parting comment would be, if you're not on the table, you're on the menu. So be open to, you know, all these changes. These are part and parcel of our lives as physicians. You know, we are seeing more and more drifting of physicians into, you know, organizational practice, and I just skipped, in the interest of time. I think we are. Well, I think we're at the end of time, but if we could, there's one last couple things we should probably just quickly talk about. With peripheral nerve stimulation, which a lot of us do, there was, Novitas and First Coast had a draft LCD that came out. They, for some reason, forgot to put insertion or replacement of the actual IPG in their draft proposal, which would mean that most of PNS would go away, because you couldn't actually put the IPG in. I was on that call, I testified on that call to remind them that that's probably something they need to put back in. They also completely changed the coding. If you look at the draft LCD, you go online, it looks like a summer intern cut and pasted a bunch of stuff together, and they're like, let's go with it, right? And instead of it being like, so what they basically did is they kept some of the migraine codes and headache codes, phantom limb, and then they kept, they added a bunch of lumbar codes. They took away every other code, CRPS, mononeuropathy, anything that we've traditionally done peripheral nerve stimulation for. So there's a bunch of letters that went out for that too, so we're hoping that that gets addressed. Last, a posterior sacroiliac joint fusion for those people that do that. It's been a rollercoaster year for that. First, the Category 1 code became a Category 3 code. The lateral fixation was still Category 1 code, but posterior fusion went to Category 3, and now it's back to being Category 1 code, like things just happened a couple days ago. But there's no valuation yet on the Category 1 code, so it's very likely that the Category 1 posterior fusion code will plummet in terms of what is made from it, because people were making $13,000 a pop on that procedure, so, at the ASC at least. So that's sort of a huge amount of utilization, and then now there's the dip. And then maybe some fun good news to end with. A couple things, there's two new codes, and these will dovetail nicely into some of the really exciting new technologies and therapies we have. First, there's a vertebrogenic low back pain code. If you're documenting modic changes and thinking about doing basal vertebral nerve ablation, you should really use the vertebrogenic low back pain code instead of a nonspecific or lumbar spondylosis or discogenic pain. Please use this code, because it will allow there to be more leverage and more momentum for using this code. And this is the code you want to document if you're thinking about doing a basal vertebral nerve ablation. And starting, I think, October 15th or so, there's now a muscle wasting and atrophy code specific to the lumbosacral spine. This is the code that you would want to use for multifidi atrophy, if you're thinking about medial branch stimulation, specifically with a specific product. But you want to also make sure you're documenting this code if you're thinking about doing that procedure, because that is also something that's brand new, and we all want to be able to trace how many patients get diagnosed with these kinds of things. I feel like hopefully everyone got a chance to ask their questions. Again, I would say first round's on me, but I'm poor, so I can't do that. Yeah. But thank you everyone for being here. Thank you.

spine and pain management procedures

advocacy

coding

reimbursement

sedation policies

epidural injections

Medicare fee reductions

payer policies

thorough documentation

facet joint interventions

prior authorization