Thanks, Mike. Hi, everybody. Thanks for joining us on the spasticity community. This is basically a talk with Dr. Mike Salino and Dr. Ryan Hafner, and I'll let them introduce themselves as well as myself, with really kind of just tips on how to build a successful spasticity practice and some of the pitfalls that we've had to deal with. It's kind of a labor of love. You know, we're a small family that takes care of this. We all really are impassioned about the patients that we take care of. We're grateful to AAPMR for giving us this venue. But, you know, we've all kind of learned that in order to really build a successful spasticity practice, either in private practice or academic medicine or hybrid, whatever it is, you know, you really have to know what you're doing with regards to billing, with regards to marketing, with regards to awareness of how to build such a practice. And, you know, we're really fortunate to have Dr. Salino and Dr. Hafner, who are two real leaders in the field, friends and colleagues, to share their two cents with us today. Thanks, Zach. Appreciate the opportunity to share the virtual podium with Dr. Brohard, Dr. Hafner. Again, trusted brothers in arms in this small arena. Certainly want to echo what Zach said, that there's a small community of us who take on the challenging cases and the difficult situations to deal with. I am going to share my screen just so that we have a little bit of context. Where are we here? And here. That and... Can you guys see my screen okay? It actually shows the presenter notes. So I don't know what you're seeing on your end, but it's not actually the full screen. All right, let me see what I can do here. Whoops, why am I not doing this? I think you could say use slideshow. You see that on your top left? Oh, top left. It says like end show tips, swap displays, and use slideshow. Yeah, hold on. Let's do this. How about that? Any better, Ryan? Still the same. You know what? I have a second monitor on. Let me take that second monitor away, see if that helps it a little bit. Sometimes having two monitors kind of screws up the whole piece of it. That any better? Yep, perfect. Yeah, sometimes with the second monitor, it screws things up. What would a Zoom Teams call be without some technical glitch? So as mentioned, my name's Mike Salino. I am Chief and Chair of Physical Medicine Rehabilitation at Cooper University Hospital and Cooper Medical School of Rowan University. I'm based in Camden, New Jersey, and all of South Jersey, kind of across the river from Philadelphia. I'm also on adjunct staff at Jefferson. And my little piece of the puzzle tonight is to talk about combination intrathecal therapy, utilizing the powerful technique of intrathecal baclofen and combining it with a similar powerful agent of intrathecal drug delivery for pain control. These are my disclosures. I work with many of the pharmaceutical and device companies relative to both spasticity and pain. Much, if not all, of what I'm gonna be talking about is off-label because combining intrathecal agents, including combining two on-label medications is an off-label use in the United States. And because I have a leadership position at Cooper, you don't have to say that anything I say does not necessarily represent the opinions of Cooper University Healthcare. So as way of background, as I mentioned intrathecal baclofen therapy is a well-established therapy for the patient, the treatment of patients with severe spasticity, you know, now entering its fourth decade of clinical use. Pretty hard to imagine that it's been around that long, but indeed it has. Similarly, intrathecal delivery of other medications, sorry for the typo there, is also a well-established therapy for treatments with chronic pain. In the United States, morphine and clonidine have US FDA approval, but many other agents, including hydromorphone, fentanyl, bupivacaine, and clonidine are frequently used in this fashion, but are considered off-label in the United States. So the objectives of what we're gonna talk about is to review the literature and the utility of combining these two approaches, and then really kind of get into a bare bones of how do you do it, what are the pros, what are the cons, and how do you operationalize it? That was the challenge that Zach put to me is talk a little bit about the science, but also how do you do it? You know, how do you make it happen in your clinic? Important to recognize that spasticity is not the same as pain. I think everyone in this audience perfectly realizes that, but it's very common to envision a scenario where any individual who has spasticity might also have pain. You know, any individual who has spasticity because of an upper motor neuron lesion is at least at risk for neuropathic pain, and we all recognize that spasticity results in muscular imbalance, abnormal forces across joints and through muscles, and that can result in musculoskeletal pain. So really easy to see how an upper motor neuron patient can have both neuropathic pain, musculoskeletal pain, and spasticity. Why not use this powerful technique to try to control both? Here we are. And just from a population perspective, if you take the big five, you know, the big five spasticity diagnosis, CP, MS, stroke, brain injury, and spinal cord, just out of sheer coincidence, these are relative conservative numbers, you know, the average percentage experience spasticity and the average experience in chronic pain. Just by happenstance, you're gonna get a lot of overlap, and there may even be some synergies between those, meaning folks who are more spastic may have more pain. That's not a completely proven statement, but if you're gonna be treating spasticity, the words pain are gonna come across your clinic one way or another. So there's actually relatively few studies that have actually looked at this. Baclofen and morphine is the most common diagnosis. Actually going back now to 2002, where it was looked at spinal cord injury. It's also been looked at specifically in multiple sclerosis as well as other diagnoses. Some other papers have looked at baclofen and bupivacaine, baclofen morphine clonidine in combination, and baclofen and ziconotide in combination. In total, there's probably only 100 patients or so reported in the literature. Oops, there we are. This is the most recent study, this actually came out last year, and is the only study that looked at pediatrics, primarily a CP population, a small number of patients, eight patients, where first they added bupivacaine, and then if bupivacaine wasn't enough, they added morphine. If there was a concern about respiratory depression, then they added clonidine instead. So again, less than 100 patients in six studies. In almost all of the studies described, baclofen therapy was initiated, and then a second agent was added. All of the studies looked to maximize and optimize the intrathecal baclofen side of the equation before adding the second agent. Most patients were weaned of oral opiates if they were on oral opiates, if intrathecal morphine was the proposed agent. If it was bupivacaine or clonidine, that would be less of an issue. Pain relief was described in, again, these six as somewhere between fair or good, certainly not a home run in every single patient. Relatively little, if any, discussion about modes of delivery. Most of the papers described simple continuous delivery, no discussion about complex programming, or more specifically on the pain side, patient-directed intrathecal delivery. In general, it was a pretty well-tolerated technique by the patient study with less than 5% of patients dropping out, at least in these published studies. And this is an example from a paper that I had written a number of years ago showing kind of the typical morphine dosing, and you can see that there isn't a clear relationship between the morphine dosing and where people eventually wound up. Some people wound up on a relatively low dose, less than 500 mics per day in continuous fashion. And if you plot their ultimate morphine dosing versus pain relief in terms of improvement in their visual analog score, no real clear correlation. And this seems very congruent for what we see when we're on the pain side of the house. You know, why do some patients respond really well at 200 mics of morphine and that's all they need, where other patients need five or 10 times that amount? So it can get a little bit tricky in trying to find your way when you're dealing with two drugs. So what are the advantages and disadvantages? This gives you control over two relatively, quote, intractable conditions. The concerns about opiates is that when you prescribe opiates orally, you have lost the element of control. Patients can leave your clinic and take it any way that they see fit. And that results in a lot of the difficulties that we see with overdose and withdraw. Whereas when delivered by intrathecal, the control returns back to the physician. Even if you're using patient-directed intrathecal delivery, all of that resides back in the clinician who's managing the patient. And there's some suggestions, fully admitting that this isn't a huge population to look at, that it may be better tolerated compared to oral medications. Disadvantages is that once you start mixing medications, the only way to change one dose and keep the other dose the same is to reformulate. Remember, at a very simple level, all the pump does is turn the flow rate up or turns the flow rate down. If you want to keep the baclofen dosing the same and increase that second agent, you'd then need to recalculate. This either requires use of a compounding pharmacy or careful mixing of branded products. I take the approach of using a compounding pharmacy. If you are going to use a compounding pharmacy, do your due diligence. You don't want to use the mom and pop compounding pharmacy down the street that is literally just doing it on a bench. You want to use a compounding pharmacy that is used to making sterile solutions. I have used a couple in my career. All of them look almost like a drug manufacturing situation, class 10 clean room, doing antimicrobial and batch sampling to make sure that it's safe. Admittedly, you may get pushback from pharmacy. I've experienced that in my career also, that oftentimes if you're going to bring a medication into your clinic and your clinic is hospital-based, that requires a pharmacy sign-off. And many pharmacies, pharmacists will give you some pushback on that. The other biggest difficulty that we see, as mentioned in the beginning, is you could get very inconsistent payer coverage. Flat out, some payers will not pay for compounded products. Others will, but you have to keep an eye on this. If you're the leader in charge of the spasticity clinic, you absolutely have to keep an eye on your reimbursements and costs. I can tell you that some very significant places in this country have actually stopped doing this approach because they weren't keeping an eye on the financial end of things. Just a quick note, and I think my colleagues will go through this a little bit more detail. Several of the drugs that we utilize actually have a J-code. And a J-code means that how much drug was administered during a individual treatment session. So for example, Baclofen, if you're using 500 mics per cc, 500 mics is half a milligram per cc. Half a milligram times, half a milligram per cc times 20 cc is 10 milligrams. So if you're using a single vial of Baclofen, that is one J-code unit for J0475. And similarly, morphine, zirconatide, and hydromorphone, even though hydromorphone is off-label, have specific J-codes for a set amount. Fentanyl, clonidine, and bupivacaine do not have specific J-codes based on a given number of milligrams. It is just put in a wastebasket category of miscellaneous. Why this gets challenging on the financial end is your systems, most electronic medical record systems have the capacity to manage J-codes and pass it through automatically into the billing procedures. If you start using fentanyl, clonidine, and bupivacaine, now the drugs can't be processed as a pure electronic transaction. They need to be paper-billed, and that delays the billing process. Remember, you're gonna be paying for these drugs ahead of time, and then not getting reimbursed for a period of time. So every bit of delay that you have is money off of your bottom line. For me, and this is just a bit of the back of the house, at Cooper, if I'm using a branded product with a known J-code, those bills go out within 24 hours of my signing the note. Pretty decent at getting my notes done on time, but occasionally I might rest a day. On patients who I utilize fentanyl, clonidine, and bupivacaine, because it's a paper bill, the average time to get it out the door is 11 days. So you can see that there's a significant delay which can impact your bottom line, especially when you're just starting out. So when you're billing compounding agents, some payers will literally pay on the invoice. So you have to attach the invoice that you get from the compounding pharmacy. Some payers will pay only the invoice cost. Some payers will pay invoice plus a certain percentage. Some payers will pay via the J-code that we described in the prior slide. Sometimes when you're using compounding medication, you need to have the medication source, where did it come from, the NDC number, and lot numbers may actually be needed. Again, all of this delays the getting the bill out the door which can impact the bottom line. Sight of service is a very hot topic in the current administrative language. Right now, the common sites of service are listed on the left-hand side of your screen. Physician office, hospital outpatient, ambulatory surgery center, and inpatient hospital. And you can see the general rates of reimbursement based on sight of service. It also describes who bills the drug, who would reap any profit from the drug, or who might make a hit. Why this is super pertinent right now in 2025, maybe your hospital leaders and administrators have talked about this. There is active discussion at the federal level for site neutrality, meaning the different payer, paying amounts will not be different location to location. We will have to keep our eyes on that. And this is what I was just talking about. This topic is not completely new. It's been going on a little bit since 2015. The goal is to reduce unnecessary spending and eliminate financial incentives. In other words, a hospital may drive clinical services to a site of service that might reimburse the highest. Again, this is a very hot topic that is going on literally as we speak in both the legislative as well as the executive branches of our federal government. So future considerations, obviously we need more data on this. We have no data at all really right now about complex programming or patient directed programming. Conceivably the idea of a dual chambered pump with independent control, maybe somewhat of a pie in the sky. When you start getting into this, the fluid mechanics get really complicated. Things like the Bernoulli principles, the continuity equation in fluid dynamics, as well as the Taylor phenomenon, all kind of illustrated diagrammatically on your right-hand side, all become involved. Think of it like two streams coming together to form a third stream. It isn't an equal proportion of one stream to another. There are a number of different factors. Perhaps the idea of even a fixed ratio product that a single product that say a baclofen morphine combination product might be attempted for FDA coverage. And maybe we need to look at agents, a single agent that might cover both the pain and spasticity. I think the alpha adrenergic blockers like clonidine and tizanidine are the most likely candidates for that. There are some early reports of ziconotide as being a relatively potent antispastic agent, although that has not gained traction as we've gained more experience. So an awful lot of, we know, we don't know as much as we know. There's awful lot of info to be gleaned from this. And I think that's my last slide. This is where I work, where it's always sunny. And I will now hand the baton off. Let me stop my share. And Zach, are we going to take questions now or take questions at the end? why don't we do some questions now? I think just so because, because some people might be like logging on and logging off. Okay. Sure. Anybody have any questions for Dr. Salino? Zach, either I bored the hell out of them or confused this out of them. Yeah, yeah. As Ryan knows is often the case, uh, but, uh, why don't we, we'll wait for the end to handle any further questions. Excellent. Sure. Thank you, Mike. Sure. All right, Ryan, you're up. All right, let me get this going here. How about that? Does it look good? It does. All right. So to transition to my location where it truly is almost always sunny. Thank you, Dr. Salino, that was a great, great talk. I think you guys will like all of our individual lectures many lectures here they all kind of speak on, you know, different, different issues different things that I think come to mind when you talk about starting practice. I'm kind of gearing a little bit this talk towards big picture. You're not necessarily the science behind something or the building behind something but just kind of, you know, where do I start from, from all factors involved. And when I first made this talk I was thinking, you know, I guess this is kind of catered towards, you know, early career, new graduates that type of thing and I was like, you know, actually no this is, this is pertinent for anybody at any stage of their career, right, who maybe wants to start setting up a specific practice so this, this is equally applicable to, you know, your senior level fellow right that's going out or equally somebody who's been in clinic for 20 years maybe with more of an MSK focus or something like that and they want to, you know, kind of delve into spasticity and maybe they kind of found found found the light and they want to, you know, jump into this, this world. So, yeah, so I'm Ryan Hafner chair and medical director down at Sarasota Memorial Hospital. I had the extreme pleasure of training in the interventional spasticity fellowship in Philadelphia, Jefferson, under the tutelage of Dr. Dr. Salino, Dr. Hecker and others in the fellowship. I really a fantastic fellowship so if anybody has any always put a shameless plug if anybody has any questions about the fellowship, feel free to chat me or message me and I'm happy to, to speak about it. So, just a few things my disclosure slide so certainly have some companies that you know I do some, some work for and provide educational materials and teaching and everything like that so I during my talk I will not be discussing any branded medications or off label treatments so I always start all my talks with this comic, just because I feel like we all experience this on a day to day basis we love what we do. I'm not and we and we do amazing things, but I think all of us come across this this situation here. Physiatrist, especially if you use the word physiatrist right that that's that's a loaded word right and that's going to be that's going to get your, your physicist or your physical therapist you're mostly psychiatrists right they're going to say I'm not depressed you know I'm here to talk, you know, okay. But, you know, again, we all know what we do, we all went into the specialty for a reason. It's an amazing specialty but you probably will spend the latter chunk of your career explaining a little bit to patients, what it is that you do, and then once you do that, they understand. Usually, usually when patients come into clinic and they say, I've been looking for a physiatrist usually that's, you know, your patient with cerebral palsy who grew up, seeing a physiatrist so they they they're in tune they know what's going on. So, I don't want to spend too much time on this, just a little blurb about you know my training so you know I my interest in spasticity and neuro rehabilitation. I did my residency at Temple Moss rehab in Philadelphia, where I had exposure to gate labs, we did some grant funded research on 3d printing of orthoses had an ultrasound club where we'd meet up at, you know, 6am 630 and we'd bring coffee and ultrasound each other and learn about, you know, how to do MSK ultrasound. Obviously fellowship wise, got me a lot of exposure to you know comprehensive spasticity and dystonia management so the more and more I got into this the more I realized, you know, hopefully, reaching out and helping others and kind of guiding others in this path of treatment is just something I was so passionate about. A few pictures of the gate lab. Again, that's at Moss rehab really cool spot force plates ground reaction force lasers, you know, bio kinematic motion analysis and everything like that so that was always fun to do that and see you know what part of the gate cycle was abnormal slap poly EMGs on muscles and see which muscles were active or inactive or inappropriately active. Some pictures of the research the 3d printing orthotic research but really I want to get into the meat of this talk here I have three kind of points here. When I talk about where do you start. There's three big topics that all kind of have to come together if you want to have a chance of success in this area, and I don't I don't I'm not trying to scare anybody away from this but I think it's, you know, the more that you hear about this, I think, will bode well for keeping an eye out for things that are maybe missing right in your, maybe it's your first job that you're starting at, maybe it is the job you're in right now. And you think about what you're surrounding yourself with what resources you have. And how does that need to change in order to provide you with the clinic experience that you want for you and for your patients. So first we'll talk about desire and training. Right. So, first and foremost, you know, do you really want to do this. I think that's, you know, if you don't want to do it then you know it's that that's kind of first thing you rule out. But you know I think for me, I love the exposure to the the wide variety of patients, the fact that every encounter is so unique. You have to always keep that painters palette in mind, you know, how do I best treat this patient given the scenario given their presentation and their exam. So it's just something that I again love so much that I wanted to do an extra year in fellowship and really hone in on my skills with this. Obviously, if you've figured out I really do enjoy this material I enjoy the patient encounters and the, the treatments, you know, what type of training do I need and where can I get it right. So obviously, there's a wide variety of training experiences across the country. Right. Some residencies have phenomenal spasticity training and obviously if you feel good about it and you you feel like you've seen what you need to see, and you just want to kind of get out there and jump into it that's totally great. Obviously, you know, fellowship wise when I when I talk about a spasticity fellowship. Those are on the rare side. They're the zebras of the, the fellowships. But, but they're out there, you know, it's mostly outpatient focused, but you know you have a lot of great spinal cord injury fellowships and brain injury fellowships that get a lot of great spasticity training too so it's really kind of what, you know, looking at your training looking at your experience and do you feel good about where things are at or do you feel like you need some more. Is it the primary focus of your career or is it another tool in my toolbox. So, you know, there are a good amount of attendings around the country that, you know, they do this and they are the go to person right for for spasticity, where you know your clinic on most days is spasticity based and, and that's really where you focus your career, and some people, a lot of providers, maybe do like a half day a week of tone management right so there's a wide variety in terms of, okay, how much of your day to day do you want to be focused on spasticity. Same thing here, you know, do you want to just be injecting toxin, or do you want more of a comprehensive tone management clinic right so toxin certainly can provide a lot of great benefits to a lot of our patients. But you know, do you want to have a bracing clinic do you want to add intrathecal therapy, and all the other treatments that are coming out to be able to treat people in all different manners. Importance of variety and trainers and mentors so certainly my own experience, you know, I think it's good to spend as much time as you can if you're in the training mode to spend as much time with different individuals. Right. Or the first treatment that they would go for. So I think having a wide variety of mentors and people training you I think gives a different perspectives to so that way you're not pigeonholing yourself into your one attending that did things always a certain way. I think it branches you out and helps you think about it a little bit more comprehensively. So, you know, anatomy and biokinematic so I always say it only always starts with that so if you really really really want to delve into spasticity management. I think it behooves all of us to have it all starts with foundation of anatomy, and not just anatomy but the functional anatomy, right, understanding what muscles are involved in different activities obviously if you're talking lower extremity, understanding what are agonists and antagonists what are involved in different parts of the gait cycle if you weaken you know the quads what happens to this individuals ambulation pattern. Or if you take away the tone of their calf, right, do they have the strength to accommodate for that, etc, etc. So I think, you know, understanding your origins and insertions and your anatomy will help you to understand your exam better and make and give you a better treatment regimen a better treatment plan for your patient for a successful outcome. So, it all starts with anatomy exam, and then you know if you if you really get those things down the rest of it will will come along. And then finally, what's critical I feel like for the training part is you know training on how to inject versus how to evaluate new patients. Again, loved my residency exposure. I feel like at the end of residency I felt very comfortable injecting various muscles and refilling and you know refilling an intrathecal pump and things like that. But what I felt was very, you know, lacking in my regard was, I don't feel like I'd seen enough new patients. And to me what I found at the end of the day, that is the, the hardest part of this is not necessarily, you know, localizing your injection to a muscle right you can learn those things with training and repetition and everything like that and getting But it's really it's not so much how to inject but you know when your patient comes in for the first time in the clinic and they're walking a certain way or they're doing something a certain way. Where do you start, what do you say, how do you ask the questions, how do you educate the patient to to go through the treatments that you're offering. And how do you, you know, how do you convince them, how do you come up with your treatment plan that's that is the toughest part and so I think I'm very thankful for my, my fellowship because we had a lot of new patient referrals outcome in where you know, it was on me to figure out the treatment plan and go from there. So, I think, learning those two things, you got to, you got to parse those out, what do you feel, do you feel comfortable with both things or maybe in your residency, you feel comfortable, you know, reading the injection plan that you're attending has had for a while with this patient and doing the injections but maybe not the new patient evaluation. So that's first part desire and training. Next, what I would call support and resources. So, what do I mean with this, a lot of words on this slide so I'll try to go through it somewhat quickly. First, administrative support. Right. So, you figured this out you got the training you're coming in, and you're feeling good, you know, I'm a spasticity guru. You know, I feel good about where I'm at. Now, you know, what are you surrounding yourself with right so administrative support right outlining your vision and your budget right obviously if you are considering a new job or, you know, when you're wanting to modify what you do currently at your current job. You know, making sure that you know administration understands what you're trying to do and at the end of the day will support you in that endeavor, whether it's obtaining, you know, authorization to use all the toxins. You know, getting the crew together to start intrathecal therapy and budgeting for that. You know, in the clinic itself, making sure you have effective efficient pre clinic paperwork right so there's a lot of things to talk about with the patient on that, that first patient visit. So, you know, the more info you have when you walk into the door as if your questions you have to ask you have things written down you can kind of glance over it. And then really your patient encounter is, is the meat and potatoes it's asking you know goals, examining them and spending some time on education with them developing that rapport, right, and not not asking, do you, you know, do you straight cath or do you do a fully cath and this and that. But to to have all that down on papers that we really can make it efficient scheduling right so making sure you ask for the time you need. You know how much time you want to spend on a new patient appointment follow up appointment which is a procedure appointment, and everybody's a little bit different. A few of my mentors had mentioned for all their new patient appointments they have 45 minute to hour long slots, which for some clinics that's not really feasible, if they're wanting you to see a certain number of patients in a given day. So, you know, making sure you know what time do you get what time do you need to do the job you need to do it well. Staff support. So, you know, front desk. Do you have an MA right for not just for intake but you know reconstitution support if you need it positioning assist is a big thing. Right. I know some of my colleagues that have tried to kind of do it all on their own, and they find very quickly that managing the syringe managing the machine holding the patient in a certain way. And, you know, getting them on the table and stuff is it's not an easy task. So, you know, at least having some support staff with you to make that easier is makes the whole thing much better EMR support right so templates phrases streamline prior authorization. Obviously this goes without being said, I didn't even include AI in there I know Dr Selena has been teasing around with AI and using it in patient encounters and stuff like that, you know, all these things that you can do to streamline and make your notes more efficient and so again at the end of the day, you have more face to face time with the patient and not so much typing everything away. Fluoroscopy or CT you know if you say if you're doing intrathecal therapy and you want the support to do a CT myelogram during troubleshooting right what what guidance techniques do they have know your reps. So, lots of company resources, you know, all of your local medical science liaisons or sales reps for all the various companies they're all wanting people to jump into this field there's there's such a lack of proficient providers in this area so certainly whether it ranges from education to free samples to workshops that they can bring in, you know, really really reaching out to your companies is important. So, be sure to reach out to your local gym, orthotists, social workers, etc. So, keeping up on all those things and making sure you have savvy billing crew with you will help. And then finally, inheriting patients were proactively finding them. So, you know, you might come in, you might walk into a situation where you have an attending who has been doing this for 20 years and they have a very healthy patient population and they just want to basically gift that patient population to you, versus others where you know you're starting out, maybe nobody's been doing spasticity in the community, and you are numero uno, providing this type of treatment, those are very different things, very different scenarios with each with their own pros and cons. And then the third part, right, we talked desire and training, maybe you have the desire you got the training, and your, you know, environment is conducive to a successful practice. This is the last third component that I think really comes into play here is clinical confidence. So, or swag. I like calling it swag too. I think that's the unofficial way that I like to kind of talk about this so. So what do I mean by clinical confidence right. So, you know, for anybody, again, whether you're a new grad coming out and is attending or, again, maybe you've been in a full inpatient PM&R position for 15 years and now you want to do this right first patient is always a little mind boggling little anxiety provoking, you know, am I examining them right, am I truly providing the treatment that is best for them to start, you know, all those things. And I think, you know, don't be afraid to reach out to your mentors if you have questions, does it is this the right move is this, you know, do you think that this is the right way to go. But that's always I think that's nervous jitters with anything. It's not necessarily particular to just spasticity but I think it's something that really plays a role. Again, physical exam and goal discussion is everything. The, you know, starting with that starting with the anatomy, getting your exam down, getting the time in to educate them and talk about goals. That's really going to prevent them from falling off the map and giving up on it, especially if they're frustrated with maybe the first cycle of toxin, or maybe you know they got a pump and, you know, the first few months, they're not feeling an effect, right? You gotta make sure that you're educating them and that they're gonna stick with you on this. For toxin, I always tell people the good news and the bad news. The good news is that if you don't like how it makes you feel, it wears off after about three months. The bad news, if you like how it makes you feel, it wears off after about three months. All right, so saying things like that, allow people, they kind of hold onto that. And that kind of helps remind them a little bit as we're going through this process. And, you know, knowing when to inject and when not to inject. So selecting the right patients for best success. I think that's, again, goes back a little bit to anatomy, understanding what muscles are involved in different processes. You know, certainly I always tell trainees, it's not hard to evaluate a joint motion and give it an Ashford scale. What's hard is figuring out when, why, and how do I treat this? Why am I treating this spastic muscle, right? Am I treating this elbow flexion spasticity because it seems tight? When in reality, maybe they don't have any volitional strength. And so they use that forearm to carry a grocery bag, in which case I may not treat that spasticity. So, you know, understanding the when and when not to, it helps with your swag, your confidence. Follow-up evaluations. So maximize the outcome, minimize the confusion. There's a lot of providers who, you know, will do a treatment, say again, with neurotoxin, do the treatment and then say, I'll see you in three months, right? And then the patient comes back in. This goes a little bit with my, I call it my 50, 30, 20 rule. And I might trademark this. Anecdotally, I feel like when, and I felt this, you know, in my first few months when I started out in my clinic, I say 50% of the time, you know, cause typically the MA will do the intake and the MA will ask the patient, you know, did it work? How do you feel? And then they come back to me and they at least give me a one sentence blurb about how things are going. And I found that 50% of the time, you know, patients come in and they say, hey, you know, I feel good, this worked well, right? And then I go in and I assess it. And certainly that's the case. 30% of the time, patients will probably come in and say, you know, no, it didn't work, right? And when you hear that as a provider, you know, your MA coming in and saying, ah, yeah, they said it didn't work, right? It takes a second to kind of sit through and say, oh shoot, what did I do wrong? But I say 30% here, what tends to happen is MA comes in and says, hey, it didn't work. But then you go into the room, you do your exam, you talk to them and actually, you know, what you were trying to do treatment-wise and what you're trying to do goal-wise, you know, patients are like, oh yeah, yeah, that actually is a lot better, right? So usually it's a little bit of reframing and examining and clarifying what we're doing here. That's kind of that 30% area. And then 20% is, you know, your MA comes in and says, hey, they said it didn't work. And then you go to the room and you examine and you're like, yeah, yeah, I would agree. You know, we either underdosed certain areas or we didn't choose the right treatment or, you know, they didn't tolerate it. And that's totally fine. So, but understanding, you know, there's a whole spectrum of patients and what they're going to tell you and how you examine them that, you know, you're not doing it wrong necessarily, but, you know, sometimes their perception of it may change. But that being said, utilizing guidance to remove any doubt of procedure efficacy. So, you know, I always tell people, you know, using EMG, Eastin, ultrasound, I usually use a combination of all three of those at the same time. That removes that one variable of, did I hit my target? So if I take that doubt out of the way, then when they come back in and something didn't work the way I was planning to, I know that I hit the muscle that I needed to, that I don't have to worry about that. Now I can say, oh yeah, I need to go up on the dose. I need to do a few more injection sites. I need to dilute it some more, et cetera. And then finally, don't be afraid to ask for help. Mentors, industry, reference books. I think any of us that go into this, you know, having that insatiable desire to keep learning and keep perfecting your craft can only do you well. So those are all three. And if you have all three, that's a solid, solid practice you got there. So special thank you to AAPMNR for hosting. A few pictures of Sarasota Memorial. I always enjoy asking patients on the inpatient side how their golf game was that day. So we have a little putting green on the first floor. Of course, it's a total Florida move. My crew here, that is my license plate on my car. It's my favorite muscle. And that's it. So any questions? I want to hop over to Dr. Bohart, but any questions? Ryan, I have a quick question for you. You know, both of us had the benefit of a full-fledged gait lab during parts of our career. Where do you see gait analysis going in terms of maybe the more average program of private practice or a university program that doesn't have the half million dollar gait lab? And maybe even touch about where the coding and billing of that plays in. I mean, do you do it to just add a higher level of E&M complexity? Are there separate codes? Are there separate programs? Yeah. Yeah. So as you mentioned, and there's less than a handful of actual full instrument of gait analysis laboratories in the country. It's considered experimental. It doesn't really reimburse that well. So I know speaking to colleagues at Moss Rehab and others, I know Penn has a gait lab too. You know, it's not necessarily a lucrative program to have a full gait lab. It's a program that's designed to be used in a very lucrative process, but it's instrumental for research projects and things like that. You know, in terms of applying it to other practices, other institutions, something that I've been wanting to implement, but I just haven't yet per se, is, you know, setting up maybe in your hallway at your clinic. You know, you had to kind of certainly get permission and waivers from patients, but, you know, almost having like a little iPhone on a tripod and, you know, take videos of patient's gait like a before and after, right? Or video of before and after with regards to gait, because then you can take a look at it. You know, nowadays with iPhones, you can slow it down, do slow-mo and really evaluate, you know, their walking pattern, then, you know, do the same video after treatment and see how that changed. That's kind of what I've been hoping to do is to set up something like that, kind of a poor man's gait lab. And then in terms of reimbursement, I think biggest thing I would say is I just increased the complexity of the E&M code. You know, obviously if I'm analyzing and describing somebody's gait in a note and talking about the time spent analyzing the gait, I think that's a very easy argument for complexity of the visit. Awesome. Well, that's all very good. Any more questions, anybody, for Ryan? There was a question in the chat, Zach. I don't know if you saw that. For toxins that we never used in residency, but toxin sales reps are trying to sell us, what's our approach to use those new toxins without one-to-one conversion table available? So yeah, great question. And I think that happens a lot. I think a lot of residencies may not have some partnership with certain companies or attendings that have only used one type of toxin and that's all you're exposed to. I do think, again, the industry representatives, I think, you mentioned the toxin sales rep. Again, all of these companies have not just sales reps, but they have medical science liaisons, they have education support that they are willing and very much happy to introduce you to to become more acquainted with that and get some training. A lot of them have peer mentors and workshops where you can get comfortable with their product. That's probably the best way I would imagine to at least get the process going and feel more comfortable with it. I would also add that there are no clear ratios. So for example, Botox to Dysport or whatever, there's no magic formula. I wish there were because in my state where I practice, Spasticity, Massachusetts, Blue Cross Blue Shield of Massachusetts mandates Dysport first. And so I always kind of have to do my fuzzy math and figure this out and figure that out because I did learn on Botox. It was easy to convert over to Xeomin for obvious reasons, but Dysport is always a challenge. Yeah. The question there, do any of you do neuro, what did it say? Oh, cryo? Cryoneurolysis, yeah. I am not doing that myself. Yeah, I don't wanna spend too much time on that. I know Dr. Salino and myself were involved in some research studies for cryoneurolysis devices. So certainly for that's a whole nother topic that I'm happy we can provide our information to talk more after this session about that. If you'd like, we're happy to do that. And there's another question here from Caroline Smith and I'm gonna tackle that one in my talk, if that's okay. Perfect, that's a great segue there. So I'm gonna stop my screen here and give it off to you. Thank you, Dr. Bohart. All right, thank you, Ryan. Let me share my talk, give me a second. Here we are. That there, good. And let me, there we go. Can you see that guys? Are we good? Excellent. So again, my name is Zach Bohart. I am at, I head up the specialty program with our residents at Tufts Medical Center in Boston. And there I do a lot of botulinum toxin injections and also a lot of intrathecal, baclofen pump management as well. And I'm also at University Orthopedics, which is a physician-owned private practice in Rhode Island and Massachusetts, two states are neighbors. And there I primarily run an orthopedic EMG practice, but I also do a fair amount of botox, botulinum toxin and intrathecal management there as well. Basically, all of our patients are disabled. So I tell them, whatever's the shortest commute, just come and see me there and I'm happy to do it. Here are some of my disclosures. So let me move this out of the way. So I've done a fair amount of work with AbbVie, with Medtronic and Pyramid Critical Care, which makes gabafin. My own personal view is that I use industry as a friend to really helping to spread the gospel. It helps me basically raise awareness for what I do in my geographic area. The biggest problem with our patients is that there's very few physicians really treating their conditions. And working with industry has really been an invaluable way for me to really kind of promote what I do in my geographic area and also to educate others. So I really do love it. You know, none of us learned any coding or billing in medical school or residency. So this is really the first thing. Is it important? Absolutely, hell yes. You know, more and more we're being asked to run our clinics in a manner that is financially viable, either whether it be in an academic setting, in a private practice setting, in a group practice setting, whatever it is, if your clinic is not at least close to financially viable, it's gonna get shut down, it's gonna get curtailed, it's gonna get controlled, or you're simply not gonna get the support that you need. And this is pretty much across the board. You know, some very large hospitals in Boston, which are very prominent, have had to lay off tons of staff recently. This is really across the board. The medications that we use, and Mike Salino kind of talked about this, medications that we use, Botox, Xeomin, Dysport, Gablofen, or Leoracel, these are all frightfully expensive medications. And, you know, regardless of whether they should be expensive, you know, that's really another conversation for another time, but they are very expensive. And if we don't bill for them properly, if we don't know how to properly get reimbursed for these medications, many of which we are forced to buy and bill, meaning that we, our practice, you personally, whatever it is, we buy these medications, and then we get reimbursed for what we paid for. If we don't do that properly, you can lose 20, $30,000 in a day running a busy spasticity practice. So you really need to know what you're doing. You have to be well-versed in prior authorizations. You have to be well-versed in billing and coding. And there has to be a mechanism in your practice to really make sure that your practice was reimbursed properly. I personally, in my EMR, in my private practice, I use Athena Health and my own, you know, the way I really approach is that every time I see a patient for a retreatment, I make sure that with the last treatment that it was reimbursed properly. And if not, then I press the pause button and problem solve. Medicare is not really in the business of, you know, short-changing physicians, I would say. You know, you kind of know what you're gonna get. They reimburse quite fairly. But a lot of the commercial insurances out there, UnitedHealthcare, especially the national ones, UnitedHealthcare, Cigna, Aetna, they can be really, really very tricky and, you know, kind of haphazardly reject payment for some reason or other. So it's really important that we know what we're doing and that we have a mechanism to really follow up on this. Otherwise, the clinic is just not gonna work. So how do we acquire and bill for our medications? You know, I really had to start up my spasticity practices in really three different types of environments, one being purely academic at Tufts. There they have the luxury of 340B pricing. So, you know, there's a little bit of wiggle room there. At University Orthopedics, though, you know, that is a large orthopedic practice with about 60 or 70 surgeons. And we each have our own call center. So I really have to be very aware of, you know, billing properly and acquiring the medications properly. And I also am in private practice one day a week as well. And the same applies for that. So you really do have to know this stuff well. There are two ways to really procure the medications we use in treating spasticity. One of them is buy and bill. So what is buy and bill? That's when we purchase the medication directly from the pharmaceutical company. So if you're using Botox, you're getting it from AbbVie. If you're using Gablifen, you're getting it from Pure Milk Critical Care. If you're using Xeomin, you're getting it from MERS, you know, and so forth. So we're literally buying it from the pharmaceutical company directly. And then we bill the patient's insurance for it. You are on the hook if you do that. And if you don't bill properly, then you're gonna lose a lot of money. So let's say if you use 600 units of Botox on a patient, that's a lot, you know, that's about $3,700 of Botox right there, maybe a little more. You know, if you don't bill for that properly, you're gonna lose $3,700 in, you know, a minute, you know? So you really have to know what you're doing. You're on the hook for that. The other way to acquire medication is going through a specialty pharmacy. So a specialty pharmacy is a pharmacy that a commercial insurance company, or also in my state, Medicaid, it's called MassHealth where I work, and they have their own pharmacy that will mail you their medication. So if I wanna use 400 units of Botox on a patient, they will, the pharmacy will mail me 400 units, and I'm not actively paying for it. The patient is being billed from their insurance company. The nice thing about that is that you're not on the hook, but there's zero profit in it though. My approach is that for Botulinum toxins, I only buy and bill, my own personal approach, I only buy and bill if a patient has Medicare with some form of a supplemental insurance, and Medicaid is one as well. For all commercial insurers and Medicaid, I only use specialty pharmacy unless mandated otherwise, and some commercial insurers mandate that I buy and bill. Why do I do that? I do my own buying and billing for a while now, and I've kind of seen that the minimal profit in toxins is not really worth the risk. We're supposed to get 6%, which is above average sales price, but we don't. With sequestration and all these other things, we don't really get 6%. It might be 2%, it might be 3%, it might be 4%, it might be 1%, it might be even, depending on what you're paying your biller. So the minimal profit in toxins, in my humble opinion, is not really worth the risk, and the physician fee to inject is considerable. Medicaid and commercial insurers frequently for some reason don't reimburse. I just had a patient, I'll tell you, just last week. She has multiple sclerosis. She works for a major pharmaceutical company. She has a intrathecal baclofen pump. She has MS. She absolutely needs the baclofen pump. It's FDA approved. Nothing cowboy about it. Her insurance is Horizon Blue Cross Blue Shield, which is a company out of New Jersey. For some reason, they said they're not, I used the baclofen buying and billing to fill her baclofen pump, and then I found out that they didn't pay me back for the baclofen, because they said it wasn't medically necessary. They actually claimed that it wasn't medically necessary or justifiable to fill her baclofen pump. So of course I'm gonna fight that, and I'm sure that I'll win at the end of the day, but it's gonna take me hours and hours and hours to really recoup that. That's really a very time-consuming challenge. This is a patient with MS, with a baclofen pump, total FDA approved use of the medication, and they're saying that there's no reason to fill her pump, which we all know is insane and wrong. So if they can claim that, they can really claim just about anything, and I've seen just about every trick in the book. For baclofen, I do always buy and bill. The profit in the medication is considerable. If you negotiate with the manufacturer of the baclofen, you can really negotiate a pretty good price, so there's a pretty good profit between what you pay and what you get paid for it. And the physician fee for administering the medication, 62,370 is really not that high. So if, you know, in order to make a significant profit out of, and remain financially viable from treating patients' tobacco and pumps, you really do want to buy and build, because it really is rare, despite my example, it is pretty rare that we don't get reimbursed for that. And, you know, we're really not getting paid that much to actually fill the pump. You can actually make way more out of the profit from the medication, whereas with the toxins, it's reversed. We do get paid more to administer the toxin, you know, with either EMG guidance, ultrasound guidance, e-stem, plus, you know, all the muscles that we're injecting, but the profit in the medication itself is not really that great. So I hope that makes sense. So what are some of the CPT and J codes for the Baclofen pump? To refill a pump, and please feel free to take a picture of this if you want, for those of you who are starting up, for the Baclofen pump, to fill it, it is 62370. To change the dose of the pump, so if you're changing somebody's dose from, you know, 100 to 125 micrograms a day, that is just 62368. If you're just interrogating the pump without changing the dose, you just want to know what it is and when's the next refill date, that's 62367. The J code for intrathecal Baclofen is J0475. Then you need to bill, this is crucially important, you need to bill for the number of units that you use. Why is that? Because each unit costs roughly 150, 175 bucks, maybe a little less, maybe a little more, depending on whatever price you've negotiated with your pharmaceutical company. So as Dr. Salina was saying, 500 mics per mil of Baclofen in 20 cc's of that, that's one unit. So just do the math. So 1,000 mics per mil, 20 cc's is two units, and then so forth down the line. 2,000 mics per mil times 40 cc's, if it's a 40 cc pump, that's eight units. So if each unit costs, let's say, just to make the math easy, if each unit costs 150 bucks and you use eight units, that is going to be 1,200 bucks. But if you only bill for one unit, then you only get reimbursed 150 bucks, so you're gonna lose over $1,000 if you don't bill the number of units. So you really do have to know the number of units and frequently, whenever there are problems with buying and billing in spasticity clinics, this is really one of the really big problems that the post-mortem billers find. Another very important thing is that, at least in Massachusetts, if a patient has primary or secondary Medicaid, you have to bill the correct NDC code, which is written on, for Gablofen, which I use, it's written on the box. You have to bill the correct NDC code, otherwise you're not gonna get the 20% supplemental if their Medicaid is secondary, or if it's primary, if they're primary Medicaid, then you're not gonna get paid at all for that, so then you could be out 1,200 bucks like that. So you definitely have to put in the NDC code. So what are the CPT and J codes for the botulinum toxins? For Botox, it's J0585. For Dysport, it is J0586. And for Xeomin, it's J0588. So what are the CPT codes? And again, you need to use the correct number of units. So if you're using 400 units of Botox, you need to do J0585 times 400. Then in order to also bill correctly and get reimbursed properly for what you do, you need to use the correct CPT code for what you inject. So if you're injecting one limb with one to four muscles, so let's say you're just doing three muscles, biceps, brachialis, and brachioradialis, then that would be three muscles, then you would do a 64642. If you're doing one to four muscles and additional limbs, so let's say you do three muscles on one limb and then three muscles on another limb, so the leg, then you do 64642 and 64643. And then if you do just one limb with five or more muscles, then same thing, it's gonna be 64644. Then if you do another limb with five muscles, you do 64645. This is an important tip to maximize reimbursement. If you inject two limbs and do five muscles in one and then three muscles in the other, in medicine, you always wanna bill the primary CPT code always has to be the one that reimburses higher because the second CPT code reimburses half. So if you inject two limbs, you do five muscles in one and three muscles in the other, you wanna do 64644 and 64643, which is five, the primary one being five muscles and the secondary one being one to four muscles and not the other way around, not 64642 and 64645, because that would pay significantly less than 64644 and 64643. I hope that makes sense. Remember, the margins that we're working with are really very small, and that's why I've really learned how to do this stuff. So we, again, to remain financially viable. EMG guidance is 95874. This Medicare allowable for this is about 70 or 80 bucks. Ultrasound guidance is 76942. To answer that other person's question, I'm sorry, I forget your name, but for Medicare, Medicare reimburses for both EMG and ultrasound guidance at the same time. And I don't need to say I'm doing EMG in this muscle or ultrasound in that muscle. I just say under EMG and ultrasound guidance. That's what it says in my procedure note, and then I do save the ultrasound image in my hard drive, but I just document that I used EMG. But if I do EMG in just one muscle and ultrasound in another, then EMG and ultrasound in another, then I just bill EMG and ultrasound. You don't have to do it in every single muscle. Whether or not your commercial insurance will pay for both, it varies all the time, and I can't really answer that. It depends on what state you're in. You'll really have to just kind of just start doing it. Some commercial insurances don't pay for x-ray, just even do ultrasound at all. So it really does vary where you are. But Medicare is really the primary insurer for most of our patients. At least for me, it's about 75%. So if they reimburse it, then I feel good. But please remember to add the NDC codes if the patient has Medicaid primary or secondary. There are many clinics out there that just forget to do that, and then they're literally losing out on 20% of their buy-in bill. So again, if you've injected 400 units of Botox, let's say that's 2,500 bucks that you've had to pay out of your pocket, out of your practice's pocket, out of your hospital's pocket, whoever it is, if you don't collect regularly on 20% of 2,500 bucks, that's like, let's say 500 bucks, that 500 bucks is more than you're getting paid to actually inject the medication. You're gonna be out of business really very soon. So what about billing for waste? This is another very important point. If a patient has Medicare and Blue Cross Blue Shield, in my state, and I think UnitedHealthcare is doing this as well, and a bunch of other insurance, commercial insurances are starting to do as well, you have to bill for waste. So the waste is the JW modifier, or if there's no waste, it's a JZ modifier. The way I remember that is a JZ never leaves anything on the floor. He just lets it all out. No waste with JZ. This is my own little silly way of remembering that, the musician that is. So let's do a couple of examples. So if you inject 300 units of Botox, you do a G0585 times 300 slash JZ. That way there's no waste. Medicare mandates this. If you inject 250 units of Botox and you waste 50, for those of us who use Botox for the migraine protocol, there's always a 45 unit waste. So this would be another instance in which we bill for waste. So here we would do J0585 times 250, and then J0585 times 50 with a JW modifier because you wasted 50. We're not supposed to be, if we do 250 units, you're not supposed to just bill for 300. You're really supposed to do it this way. Will Medicare stop payment if you don't do it properly? I don't know, but this, they could always do a callback. They could always ask for our notes. And this is really big bucks here. So we really do have to get this right. So please do remember to bill for waste or not. Here are some of the commonly used ICD-10 codes for spasticity. Why is it important to do this? Of course, there are other diagnoses out there that are spastic. I remember there used to be one that was spastic gait, spasticity of muscle. There were a bunch of others that other insurers did not associate with the administration of Botox or the Baclofen pump. So they wouldn't pay. Even if they had a spastic gait or they had spasticity of muscle, it wasn't automatically linked to the payment of Botox or Baclofen within their computer systems for these health insurers. So these all are, and these are the ones that I always use and they always go right through. Interestingly, my own personal philosophy is that if someone has had a TBI, then I just basically do right spastic hemiparesis and left spastic hemiparesis because they have basically spastic quadriparesis in this example, and that always works. But these are really the major codes that I use. So what about billing companies? I know we're running out of time, guys. I'll be done in a second. Billing companies, just for those of you who are starting up, they are a for-profit business and they want your business. So when you're starting up a practice, please interview a few of them, find out what's appropriate for you, find out how much they're gonna work for you, make sure that they don't just go over the low-hanging fruit. Make sure that they also go after claims that have been rejected and they try to pursue those rejected claims because really, if you just miss out on one or two buy-and-bill claims in a day, that could be your week's profit right there. So you really do have to know who you're working with. They are a pivotal ally in your ability to take care of these patients and to stay open and financially viable. The way all of them work is that they charge on a percentage of revenue collected. Some of them are flat fees, but the vast majority are a percentage of revenue collected. So please try to negotiate the best possible deal with them and always the best time to negotiate is before you sign a dotted line in life in general. So negotiate a good deal with them. Don't be afraid to play hardball with them. Every 1% counts a lot. If your gross billings are $750,000 a year, 1% of that is a lot of money. That's money out of your pocket. So you really do owe it to yourself to negotiate hard with them. And don't be afraid to play one off the other. Another thing that I've learned is that because, as I've talked about before, because the profit on botulinum toxins is really minimal, you can always negotiate that the billing company that is working for you, either not charge on the J-Codes or charge less. And this is important because you can really be underwater with botulinum toxins. The way, remember, the way that the reimbursement for the botulinum toxin is supposed to be, on all medications, it's supposed to be average sales price nationwide plus 6%. If a billing company is charging you 6%, then there's your profit 100% from Botox. Again, because of sequestration, that 6% has really gone down to 3% or 4%. So if you're paying 5% or 6% to a billing company, you're gonna be losing money every time that you use Botox. So you can try to negotiate with them to either maybe pay, charge 3% on J-Codes, 2%, or none. Some of them will even agree to pay none, to charge you none on J-Codes. If you use a billing software, make sure that you can usually tell if a patient's insurance is reimbursing properly every time and that they make sure the insurance is valid. I use Athena Health. And if there's a problem with the insurance, it lets me know there's a big flag on the screen. And then every time I retreat a patient with Botox or refill their backfill pump, I'm able to look retroactively into the previous treatment and make sure that it was paid. And again, if it wasn't, if there's a problem, then I press pause and my secretary or I try to figure it out. If you are using a billing company, meet with them regularly and ask for monthly reports on collections. If you're working in a large private practice, make sure that your billing person who takes care of you is going through this every single time. Don't trust them to do it. Make sure that you ask them to get these reports and make sure that they're looking over the stuff properly. My summary here is that I really love treating spasticity. It's really rewarding. If I had to do one thing all day long, it would really be that. It's very helpful for our patients living with crippling spasticity, impairs all levels of functioning care, basic human dignity. There's a tremendous shortage of docs out there treating this patient population. You can really build a booming practice quickly if you start it up. I really do believe that physiatrists do it way better than neurologists or anybody else because we really understand function. We have orthopedic function. But in order to treat this population properly, we really have to be clinically adept, obviously, what we do, like what Ryan was talking about, but we have to understand the business side and billing and coding of this. And the reason why it's so incomplex is, and we're not taught this stuff in med school or residency, and the result of this is that there's really not enough physicians out there treating this patient population. I think if we all knew this, this would be our way to empower ourselves and there'd be more of us treating this at-risk population. If we don't treat them and if we don't do it properly, the clinic's gonna fail. The patients will not get the care that they need and deserve. And I think that's it for my encyclopedic presentation on billing and coding. I hope nobody fell asleep from it. But for those of us who are in the trenches, it does matter. Does anybody have any questions for us, for me? Dr. Senior, are you asking a question? There's a question in the chat, Zach. Oh, thank you. Scroll down here. It says, for cervical dystonia, do you bill 64616 with modifier 50 when bilateral? That's a good question. I don't do as much cervical dystonia as I do spasticity. I've, you know, sometimes I've done that and then I don't get paid for it or it slows it down, but then I do times two and then I will get paid for it. Ryan, do you do a good amount of cervical dystonia or Mike? Yeah, I'd say the 50 modifier makes sense for bilateral purposes for that. Yeah, because there's really not, you know, it's not like, unlike the extremity billing, you know, you don't have like left side of neck and then right side of neck, you know, it's all encompassing. So, you know, I do the 50 modifier for bilateral. The other quick blurb on modifiers that I kind of came across this recently, I did not realize this, but in my own billing, if you're using toxin for different indications, say you're using, you know, Botox for migraine treatment, and then with the rest of the waste, you're, you know, injecting for a little bit of cervical dystonia or some blepharospasm or things like that, that you actually should be billing a modifier 59 which represents services that are not normally tied together. And it's basically saying you're, I'm doing a few different procedures in the same visit rather than having them come back for, you know, a separate blepharospasm treatment, et cetera. Separate and distinct. And then the, but make sure that the 59 modifier, another tip that I've learned, you're absolutely right, Ryan, is that the 59 modifier should go after the procedure that reimburses less. Because whenever you do 59, you're going to get reimbursed less for the second procedure and you want to make sure that the second procedure that you're billing is the one that pays less. Right. So half of less is less. Right. And half of less is more than sometimes if they don't pay for it. So something's better than nothing. Yeah. Yeah, yeah. I've noticed that some insurers do not, the reason why I kind of hemmed and hawed is because some insurers don't recognize the 50 modifier. And I don't do enough cervical dystonia to really figure that out. Mike, did you have something you wanted to add? No, I agree with what you're saying. We have it built in our EMR that when you do anything bilateral, the 50 modifier kind of forces you into it. So, and we have not, I've not seen pushback from payers with using that modifier. I have a quick question. When you mentioned the, including the NDC, specifically for the Medicaid population, where do you, do you put that in like a comment section, like with your J code or do you put it somewhere in your note or how do you, where do you put that info? So I use Athena in two of the places that I work and I use Epic at Tufts. With Athena, there is, I'd have to show you, basically right before you submit the bill, there's a place right underneath the J code to add the NDC code. For Botox, it's added automatically and that never changes because I only use 100 units. I don't use a 200 unit vial, but it changes obviously for Gablifen, for Baclifen because 500 mics per mil is a different NDC than a thousand mics per mil is a different NDC than 2000 mics per mil. So I literally just have to kind of copy and paste each time. So I add it in and if you don't, again, you're losing out on 20%. So it's a significant amount of change there. For Epic, the template that I have in Epic, it's procdoc.procdoc. And then the NDC is automatically added. And I had the people who built the template put that in. Okay, thank you. Sure. Zach, I think you did a terrific job with having this many people stay even longer than the time. So you're to be congratulated in herding the cats. All right. Well, thanks, Mike. And thanks, Ryan. And everybody, please feel free to reach out to us at any time. We all really try to remain bioavailable to everybody. We really all love what we do. And if you have any questions, we're all heavily engaged in teaching residents and junior attendings around the country. This is something that we really love doing and we want more people to do it. So if you ever have any questions, please feel free to reach out to any of us. And I know that we'd all really be happy to share our pearls of wisdom. Couldn't say anything better. Have a good evening, everyone.

spasticity practice

Dr. Mike Salino

Dr. Ryan Hafner

Dr. Zach Bohart

intrathecal therapy

billing and coding

CPT and J codes

Baclofen pumps

Botulinum toxins

payer coverage

clinical workflow

financial viability