Again, my name is Carolyn Millett. I'm the Director of Reimbursement and Regulatory Affairs at the Academy. Thank you so much for joining us for the Outpatient Mastermind Series, Developing a Successful Spasticity Practice. This is our first of the Mastermind Series, so we're really excited to have you with us. Our faculty for this session are Dr. Christina Kwasnika, Dr. Zachary Bohart, Dr. Sachin Mehta, and Dr. Atul Patel. A few housekeeping notes before we get started. This activity is being recorded and it'll be available in the online learning portal. We are encouraging everyone to please turn on your camera and mute your microphone when you're not speaking. We really want this to be as much of a conversation as possible, so if your camera's on, then our faculty can get to know you a little bit better. To ask a question, you can use the chat feature. We'll be monitoring the chat feature throughout the session, but also feel free to raise your hand and unmute yourself when you're called on. Again, that just makes this more of a conversation. If you are new to Zoom, this is a little bit of how to do that. So in the lower left corner, where you can unmute yourself and start your video. And we'd also encourage you to use the hide non-video participants feature, which is shown with this arrow. That's gonna help you see just the faculty. A couple of other things we wanna plug tonight. One, we would really encourage you to join the Spasticity member community if you haven't already. This is on Fizz Forum. And if you go to your account on Fizz Forum and search for member communities, you'll be able to find the Spasticity member community and join that, which is a great discussion forum for spasticity issues. The other feature we'd like to highlight is that we do have a spasticity find a physician, find a PM&R physician feature on the Academy website. The only way that your profile will come up, if someone is looking for you on this feature, is if your member profile indicates that you practice in spasticity. So that's a four-step process, which I'm gonna walk you through really quickly. If you log in on the Academy website and go to my account, under practice information, you are able to select spasticity as one of the procedures that you provide. So we'd highly encourage you to do that. And if you have any questions with that, you can contact the Academy office. So thanks again for joining. I'm gonna turn things over to our moderator, Dr. Christina Kwasnika. Thank you. So I'm excited to be able to be here and allow each one of us to share what it kind of means to be in a spasticity practice. It's a great, varied group of panelists. And so we're gonna allow each one of them to talk a little bit about what they do. Please feel free, if you have questions, to interrupt us or to do the raise hand function so that we can make sure that we get to some of those questions rather than wait till the end and realize we've just been kind of talking to ourselves the whole time. Okay, next slide. So I'm Dr. Christina Kwasnika. I have been practicing in inpatient and outpatient neuro rehab since 1999. I'm a PMR trained from a rehab in Sioux Chicago, Shirley Ryan, graduated in 99. The story about how I got into spasticity management was a little unusual in that when I moved here to Phoenix, somebody who had been providing a lot of injections in town actually ended up getting sick. And they said, well, you just graduated from PMR residency, you know how to do injections, you've done a lot of them. And probably that was the luckiest thing that happened to me because I really enjoy it. It's my favorite part of my practice, but I don't know that it would form such a the center of my practice if it wasn't for that event. I've been the medical director for neuro rehabilitation at Barron Neurological Institute since 2000. I also have ran my own private practice. All the PMR physicians were part of a private practice until this just this August, where we became part of Barron Neurological Institute and started our department of physical medicine and neuro rehabilitation. Next slide. So why do I do spasticity management? And I thought a lot about this because I talk a lot to residents, medical students, and I talk to them about how they're making decisions. And I can definitely hear all the challenges about spasticity management, but the positives far outweigh that. I find it's the most fulfilling thing I do every day. Patient outcomes are significant with neurotoxin injections and injections. Not just with the neurotoxin injection, but also with making sure that they're getting the proper therapies and getting bracing and maybe intrathecal baclofen or whatever is necessary for that patient. My patients have seen me for many, many years. That longitudinal contact when you're talking to people who've been receiving injections for so long and who are coming and talking to you about how they're doing is really just, it's a great way to practice medicine. I like being hands-on. I like to be able to do injections. So having that hands-on approach to care is really a big positive for me. And then it really flows easily in my clinic. I do both pediatrics and adults. And I just really think that injections are kind of the easiest part of what I do. I know what I want to do. I have a plan. I go in and we're able to focus on that plan. And it's a little more focused and directed and able to be accomplished within the time period I need an appointment. What are the challenges though? Reimbursement. I mean, we're gonna talk about that quite a bit, but we need to be good stewards of the resources out there. And we need to make sure that our patients are getting care that's being paid for. This is really about understanding the business. And I think that we all have responsibilities as inpatient docs, as outpatient docs, no matter what you practice in, we need to understand the business to be able to make sure that we maximize the services that our patients can get. I find one of the biggest challenges is needing to repeat neurotoxin injection every three months. And when people get pushed back because I might go on vacation or I might be out sick or whatever, that's difficult. And that's why I think having yourself surrounded by, or at least with a partner that's doing this as well, really helps you be able to be comfortable with that, that there's gonna be that pull on your time. The acolyte pumps are their own other thing. I've been hearing this frequently from my physicians that they love neurotoxin injection, they love general neuro rehab, but oh man, those Baclofen pumps, because they are an emergency all their own. And I do agree that that's a challenge. I think that it's one of those that is a cyclical kind of thing. So you can go months and months and months without any issues. And then all of a sudden you have three or four right in a row and you feel like you're drowning under Baclofen pumps. And it's just something that you just have to be aware of. And the more people who understand them in your practice, not just maybe the one person who might be managing a lot as an outpatient, but the inpatient docs, other people, the more people that are able to cover makes it easier to be able to manage the stress of Baclofen pump coverage. Next slide. So I think I wanted to put some take home points. I've thought about this a lot. I think we as PM&R are uniquely qualified to manage spasticity. We understand function, we understand disability. We understand all the other parts beyond the actual injection. I work very closely in a neurologic hospital with neurologists who are very good at managing things like EMGs and doing toxin injections for cervical dystonia and migraines and the like. But our patients have so many other needs. And it really is something that just goes very well with what we do in PM&R. But we need to run our department like a business, whether you're running it as a private practice or whether you're running it as a PM&R department, you need to understand that this is a business and you have to know your bottom line. And I think some of the other people will talk about that, but it really, I think we should be able to ask those questions and be able to say, hey, if I wanna treat as many patients who come to me who need neurotoxin injection, if I wanna treat them all, how can I do so and make sure that I understand I remain financially solvent, my patient doesn't take on excess costs and my department doesn't look as if it's doing poorly as well. And that's probably the best thing I learned from being a private practitioner and then moving into a department is I am running my department in the same way I ran my private practice from the perspective of spasticity management. And so I have the ability to be able to say, no, we wanna do, we wanna procure our toxin and we get specialty pharmacy. We would like to receive it via specialty pharmacy to change the cost that's coming to our department. We really need to think about that and be able to speak and advocate for our department and for our patients. Okay, next slide. I think that's it for me. And Dr. Mehta, you are on. I appreciate it, Dr. Kwasnika. Hey, it's great having everybody on here. Before I start, I wanna go over some numbers. So this is pretty astonishing. There's 5 million people out there that have spasticity right now. Less than half of them are getting treated at all, less than half. And out of that less than half, five to 10% are being treated well. And so there are literally people in our backyards, wherever we're at. There's little people in our backyards, hundreds of them that have spasticity impacting their function that are not getting any treatment right now. So if you're interested in treating spasticity and you wanna do a good job, the opportunity is there. And hopefully when we're done today, we'll be able to show you that we can, you can do it, you can do it well, and you can make some money off of it. But most importantly, we can help our patients. So my disclosure, I speak for ADDV. I'm from Indiana. I trained at Indiana University. I was the director of brain injury at the Marion Joy Rehab Hospital. Came back to Indianapolis 10 years ago to go home. Part of something called the Franciscan Physician Network, which is contracted to cover 12 hospitals. I work at Franciscan Indianapolis for a 400 bed hospital on the south side of Indy. We have a 22 bed inpatient rehab unit. No university affiliation, only one residency program in the practice, and that's family practice. So no physiatry. And yet we've become the number one or two leading spasticity practice in the state of Indiana. So I'll kind of share my story about how we did this. So the history of Franciscan back in 2013, a couple of slides, I know one more slide forward. We had four physiatrists, all pain management and some inpatient rehab. So no one followed up these inpatients or once they got discharged from inpatient rehab. Opioid management, really good spine doctors doing interventional spine. Everybody thought that PM&R stood for pain management and rehabilitation. So when we came in, we really had to start from scratch, by not just educating on spasticity. We had to start by educating about our field of physical medicine and rehab. And now on the next slide, we have six physiatrists, five APPs, which are nurse practitioners. We have a comprehensive PM&R clinic. We have 250 patients receiving toxin, 100 patients with a back up and pump. 92% of our patients receive a second round of botulinum toxin injections. And the recent numbers I saw is about 60% for the national average. So again, lots of opportunity for us to improve the care that we're providing for our patients. So how do you do it? How do we do it? Well, the first thing we had to do is get referrals, right? So how do we get referrals? And we'll go over that. And the next thing we had to do was we wanted to make sure we treated them well. So we got the referrals for spasticity. How do you do a quote unquote optimal job to treat these patients? So we started educating. We didn't focus on spasticity. We focused on the entire scope of PM&R. If you have a change in function for whatever reason, you should see a physiatrist. If you've ever had a stroke, a brain injury, a spinal cord injury, you should see a physiatrist. You have your neurologist. Who's your physiatrist? Who's your PM&R doctor? So we went around face to face and started educating at grand rounds, conferences. We have medical students and the family practice residents rotate with us so that when they become our peers, they know what a physiatrist can do and what type of patients they can see. Then the other thing we started doing is we started doing automatic consults on every stroke patient on acute care. And we will follow up with these stroke patients the rest of their lives. And so if you do that, we have 600 stroke patients admitted every year. Just by the physiatry group following up with every one of them as much as we can as logistically possible the rest of their lives, you're gonna capture a lot of spasticity that way. And then, so we wanted to make sure that part of our consult service was to obviously optimize function and disposition and bowel and bladder and pain and things like that. But we also wanted to follow up these patients in the office and then continue to follow up with them as long as their function is impacting themselves. And then we also encourage referrals directly from therapy. You know, a lot of our, if someone hurts their knee and they go to see their family practice doctor, they go to their physical therapist. The physical therapist is like, this is spasticity, go see the physiatrist. So we got a lot of referrals that way as well. And so that's kind of a really short kind of quick way that we were able to kind of rapidly grow just general PM and R referrals knowing that if we got a lot of PM and R referrals, we're also gonna get a lot of spasticity management. And then we utilize a day rehab model for our treatment plan. We believe in working as a team. I'm a big believer that PT's, OT's, speech, neuropsych, PM and R, surgeons, neuro-optometrists, neuropsychologists, if everybody works together, patients do better. So we utilize this in our outpatient spasticity program as well. And the most important thing about our program is that we do a face-to-face visit with our outpatient therapy team on a weekly basis. So every week for 45 minutes, I meet with my entire team. We have about 120 patients and we just, we quickly go over how these patients are doing, not just spasticity, but in terms of any of their barriers to their recovery. So an approach that we utilize is if I get a referral for spasticity, I will get them into a one-time PT and OT evaluation for a pre-spasticity treatment evaluation. Then in one of our weekly meetings, we will discuss what's the best way to treat this patient. Is it botulinum toxin? Is it medication? Is it purely therapy? Is it orthotics? And then let's say we decide to do toxin, we will very specifically discuss which muscle groups and dosing and things like that to do based on all of our assessments. We then do the treatment and then we get them back into therapy for four to six, 12 weeks. During that whole time, we're meeting with the therapy team on a weekly basis, getting updates on what's getting better, what's not getting better. Next time, can you put more over here, put more over here, put less in the finger flexors because they lost their grip. So we're having those conversations on a weekly basis with my team. In six weeks after the injection, they'll follow up with my nurse practitioner and then in three months for us. And so that's kind of a quick blurb about how we kind of run our practice in Indianapolis. And with this, we've shown that we're able to, patients are coming to see us, they're coming back for repeat treatments, they're getting really good therapy on top of it. I'm not gonna speak a lot on the finances of it, but I can get into that later. But part of us growing our practice was proving that downstream revenue to our therapies, our therapy programs, which has really helped us become a successful practice. So for my summary, to me, focusing on the entire scope of PMER will directly or indirectly increase your spasticity referrals. And then when possible, if we can work as a team, multidisciplinary approach is a really optimal way to treat these spasticity patients. So again, thanks for your time. If you have any questions, let me know now or later. You can also reach out to me through the portal as well. So thanks for your time. Okay, it's me. Okay, Atul Patel, nice to see everybody. I don't see everybody, so please, if you don't feel, if you're not eating or even if you're eating, it doesn't matter, go ahead, turn on the camera. Let's see what you're eating. A lot of things I was gonna say have been covered. So let me just take a really high level view and add to this. My disclosures, by the way, are listed here. Next slide, please. So my background, I finished my residency in the 90s. And then when I came and started practicing, I thought my main goal was gonna be working with musculoskeletal patients and seeing EMGs. I love electrophysiology. But ended up seeing patients with, 40% of my patients at that time was stroke patients. And I realized that I needed to figure out what's best for my community and my patients. And I started taking care of just general rehab patients in my inpatient unit, and then followed that into my outpatient practice. And this was in academics at that time. So I've been doing, I've been managing patients with movement disorders, spasticity, and things like that for about 30 years. I use all the different botulinum toxins in the market. One interesting fact is that when I started treating patients in the 90s, the only approved indication for botulinum toxin at that time, the only neurotoxin in the market was Botox, that was for blepharospasm and strabismus. So I have been treating patients with all the different conditions before they were FDA approved. And that, I mean, it's really broad now, right? It wasn't just spasticity, cervical dystonia, limb dystonias, tremors, some of them I'm doing studies right now, but then also things like hyperhidrosis, chronic migraine headache, all of those things I was treating before they were FDA approved. And if there are questions, I can come back to that, but how that, I want to impact upon you, how you can develop your career and your practice and go in the direction you want to and be in the forefront if you want, but you don't always have to be there, but I'm just saying that there's an option and that's the way I kind of built up my practice. Multimodal comprehensive treatment. And so like others, I take care of not only patients with required botulinum toxin injections, but oral medications, therapy, intrathecal baclofen. I have about 100 ITB patients currently and over 200 or 300 patients with spasticity and another about 150 to 200 cervical dystonia patients. I have experience in the academic setting. I was at KU Medical Center. Then I've also worked in the hospital as well as afterwards in an office in a community private practice. I'm currently in an orthopedic group and I'm the only rehab physician there. And I think somebody else brought up the point about you're building up this practice and working in the interdisciplinary team. If there are questions, please ask about that or something you may wanna learn about. As a private practitioner, how do I set up this whole network outside of my practice so that my patients get therapy, get the appropriate therapy and things like that? I'm involved in clinical research and trials and I've been doing that for about 20 years. Over the years, I've become more and more proficient at electrodiagnosis. That was one of my loves when I left residency, but then I learned how to do ultrasound by myself, doing cryotherapy and keeping up with new technology as it comes along. And then also Dr. Mehta I think mentioned is educating the people. So I spent a lot of time giving lots and lots of lectures to family practice residents, internal medicine residents, PM&R residents, ortho residents, all the PTs, OTs and everybody in my town, speech pathologists, everyone locally training and educating people, doing it nationally and now even internationally and involved in several different organizations, including the American Academy of PM&R. Next slide. So I think I'm gonna just highlight a few things up here. There's a lot of stuff here, but basically how do you improve the efficiency of running a spasticity clinic? And really we're calling it a spasticity clinic, but others have alluded to this. Spasticity is just one thing, right? So you need to become really good at taking care of neuro rehab patients because spasticity doesn't exist in isolation. It's one of the things that happens to people with upper motor neuron syndromes. So you need to become better at taking care of these patients. So proper patient identification, assessing them and following up and scheduling, all those are little, little simple things, but they all make for an efficient clinic if you start paying attention to these little things. And it may be interesting. So you have to look at the situation, what situation you're in. If you're an academic, somebody else might be hiring the staff. Somebody else is picking out the program and what your template looks like. Try and influence that as much as you can. In private practice, I have full control so I can do all those things, but I was manipulating some of those things even when I was in academics to try and improve my situation and make the throughput better. Timely and efficient use of tools, understanding patient situation and setting appropriate goals. So this is really key. And the reason I bring that up is because so many patients don't come back for the second and third injections. Dr. Mehta just mentioned that 92% of his patients come back for a second injection. That's amazing. And I feel like my numbers are similar too, but why does that happen? Because we spend a lot of time understanding the patient and setting up appropriate goals. So some of you may be thinking about starting a practice and including spasticity management and taking care of these kinds of patients. It's not an all or nothing situation. You can just start out, do a little bit and whatever you do, this is what I tell my team, the bar is so low that even if you just got somebody an AFO, you've just raised the bar. Even if you just said, hey guy, you need a little bit better wheelchair. This wheelchair is made for a 300 pound patient and you are only 150 pounds. You need a smaller wheelchair. You've made a huge difference in that person's life. I'm just telling you the bar is super low and you can start out by doing those kinds of things. The other thing is all these communities, especially outside of the big cities. So I'm in Kansas City and really I'm in a desert and as far as PMNR is concerned, because in most people's mind, PMNR equals pain management. So they don't even send their patients to PMNR doctors for that. So it's taken a lot of education in telling people, but if you are a pain, there's nothing wrong with it. We are a broad field and we do so many great things, but this is one of the thing that you can help out your community and your patients and you can start very simple and then slowly start adding things. So it's really easy to do it that way. And if you enjoy it, then that's going to be something you'll keep growing and helping out the community that way. You need to figure out how to assess the clinic flow. And I can talk a little bit more about that if there are questions about the process. It sounds really simple, but the process is what you want to constantly look at and make yourself more and more efficient. The cost of operation is going up. Inflation is going up and reimbursement is staying stagnant if not going down. It's actually going down, right? So how do you survive in private practice? And even in an academic center, how do you survive? How do you make your RV use look good and all that? So that comes down to improving the process and optimizing things. Again, setting appropriate goals and optimizing outcomes is the thing you want to do. Our healthcare system's changing, so it doesn't matter what you're doing. One of these days, it's going to be more and more based on outcomes, right? They keep talking about this. We haven't got there, but that's where we're headed. So the better care you take care of your patients and the better way you can optimize outcomes, the more valuable physician or provider you're going to be in the community. And then the last thing on this slide is basically keeping your team engaged because it's not just you. You've got to get your whole team excited and you have to think about the whole team because the team also influences the patient and that helps out with the whole thing about being efficient, them coming back to show up for their second and third treatment and things like that. Next slide. So next slide, please. Yeah, just a few tips here. So what has worked for me, big picture. The big thing I would say, it doesn't matter what you're doing in medicine, you've got to do something that you enjoy and you will enjoy what you're doing if you get rewards. And gratification is not just money, right? It's gratification. Every day, somebody tells me, God, you helped me, you really made my life better. When you hear that, that just makes you feel really good and also reduces your risk of being burnt out. So think about the long-term, not the short-term, but the long-term, big picture. What do you want your career to be? What makes you happy? And if you start doing this, I think you're going to hear from all of us. We love taking care of these patients. It's so gratifying and the rewards are just tremendous, but that doesn't pay the bills every day, right? So you've got to figure out how to make a living too. You've worked hard, you've gone through medical school residency and you're in practice now. You have to make a living, right? So we can talk about a little bit on how to do that and be profitable and make money. Referral source, for me, it has been word of mouth. Friends and family of healthcare providers. It's ridiculous, really. I mean, there are clinics where I've gone in and tried to educate the physician and the physician says, or the staff says, why are you here? We already have PM and R covered or something like that. And then I'll go and tell them, oh no, I'm just here for the physician. And then I'll tell the physician, in case your family member has a stroke, because every 45 seconds somebody has a stroke in America, I'm there for you. I'm not good enough for your patients, but I'm good enough for your family because they all know me in town. Whenever something happens to their family, they're at my door, but they could have a half waiting room full of people with spasticity or stroke or something like that. They never send them to me. They don't even think about it. So we have to change that. We got to keep educating them and doing all that. But for me, the biggest referral has been word of mouth. Biggest barrier for me has been the people who are taking care of patients in inpatient. I think someone else already mentioned where they have patients in the inpatient setting and they never get seen by somebody who will take care of them afterwards. So our system is so fragmented and I've tried very, very hard to try and talk to all the inpatient services, the physicians, the hospitals, and I'm still struggling with that and trying to get there. But I think that's a pathway, especially if you're in a setting where part of your group is working in the inpatient, then you can partner with them, make sure the patient comes to your outpatient clinic because really, you're not going to be able to do much in the inpatient setting. The length of stay is too short. And also with spasticity, it doesn't occur at the time when these patients are, when in the inpatient setting. Let's see, I'm just going to quickly go through this. Yeah, be a generalist and get expertise in different areas. That's what I've done in my entire practice, right? I've gone into different areas and become an expert in different areas. But at the end of the day, I'm still a generalist as far as a PM&R physician is concerned, I see everything. And even if you're doing a pain management or musculoskeletal clinic and you're in a small town and nobody else is going to take care of these patients, you can help out the community by doing some simple stuff. And guess what? Those patients and those physicians will remember what you've done for them and they'll send you patients with other conditions and you can build up your practice that way. And that's the way you can somehow use that. You know, you're taking some of these patients and helping them out and not really losing much money or not losing money, but just making very little. But then you get other kinds of patients where you can make more money. And then overall, you're helping out your entire practice and diversifying. I already talked about running the clinic efficiently and I can talk more about that. I want to save time for Q&A. Learn ways to keep the healthcare team motivated and energized. That's a key thing. And happy to answer questions about that as well. Ensure Clinica provides return on investment in healthcare. And I kind of alluded to that a little bit, right? What is the return on your investment? It's not only financial, it's gratification, a great career. What kind of a career do you want? Where do you want to end up 20, 30 years after you've been practicing? Think of the long-term. And of course, none of us can predict how healthcare is going to change. So you've got to be somewhat nimble. You've got to be able to adjust to different things. And again, please ask questions about how or situations that we have dealt with and how we have adapted. So we can talk a little bit about that. Again, I can't see the whole screen, but please, if you don't mind and you feel comfortable, please turn on the camera and I'm going to pass it on to the next speaker. Thank you. Hi, everybody. How are you doing? My name is Zach Fulhart. I'm in the Boston and Rhode Island area. Rhode Island's about the size of Boston. I have a slightly different practice than everybody here. And frankly, everybody here does have their own practice, which really works for them. And I think that's something that's really important here. And Dr. Patel was talking about this, is that you really have to find a way to make it work in your environment, in the geography where you are, in the healthcare setting, which you are. I work in really two settings, primarily. I am in private practice. I am at a university orthopedics in Rhode Island and Massachusetts. And there I was primarily just doing orthopedic diagnostic EMGs or carpal tunnel, plexopathies, you know, drop foot, things like that. And then I was also doing a lot of spasticity management, consisting of a lot of different things consisting of botulinum toxin, a lot of back up and pumps and peripheral fenal nerve blocks as well. And that was more in the Boston area. And then I kind of merged them all together in the university orthopedic setting. A university orthopedics is, by the way, the orthopedic department for Brown University. And then I'm also at Tufts Medical Center in Boston, where I'm for faculty for teaching a lot of our residents. And I really enjoy doing that. By the time they're done with their residency, I have them filling pumps and doing Botox injections. I see some of you are here today and old residents too. It's nice to see you guys. Let me, next slide, please. First, let me give a couple of disclosures. I do work as a speaker for companies who I really view as allies to help me spread awareness for spasticity management. You know, for every one patient who gets treatment for spasticity, there's gotta be 10 who don't, more or less. You know, there's so many patients out there who needed spasticity treatment when Jimmy Carter was president, you know, and they've been living for years and years and years, you know, like this, when they don't have to be living like that. And we can really help them. And also, you know, kind of paradoxical to tell, you know, the thing that really prevents burnout in my mind, in my career, is that I really love the patients, known them for years. I really enjoy taking care of them. I enjoy being really good at what I'm doing. I'm kind of being a leader in the field and in my geographic area. I enjoy working with these patients and helping them through a difficult time in their lives. And I view industry as a friend in really helping me to spread the gospel. Of course, I know, like I'm not naive, I know that they're in it for the money and this is a for-profit healthcare system, I get it, but at least they're helping raise awareness for a really sadly under-treated patient population. And so the company that I've worked with have been PADV, which is Botox, Medtronic and Paramount Critical Care, which makes Gablafent to the back of the pump. And I'm also on the Corporate Relations Committee for the American Academy of Physical Medicine Rehabilitation. My talk is gonna be primarily, I didn't really wanna talk about my path because I know that Dr. Mehta and Dr. Patel and Christina, they all, sorry, I forgot your last name, they all kind of have their own paths. And I don't wanna just kind of talk about my path because it's kind of similar to some of theirs. So instead, I kind of wanna talk about where the path has led, which is really to getting good at coding and billing. And there's gonna be a lot of information here. Please feel free to take photographs. And feel free to reach out to me and email me down the road as well. My email is zwbohart at gmail.com. But I have learned a lot in private practice about billing properly. Why is it important? Clinics of all stripes have to be financially viable or they will get shut down. You know, you're shut down if you're in an academic setting, they'll get shut down if you're in private practice, they'll get shut down if you're in a group setting. You know, we really have to be financially viable. And that means at least breaking even. We can't be losing tons and tons of money every year, year after year. Particularly because the medications we use, Botox, you know, the Botox, ZM and Dysport, Gablifen, Muracil, so the Botulinum toxins and medication goes in the back of the pump. These are very, very expensive medications. And if we don't bill for them properly, if we don't get prior authorization properly, we are literally going to lose thousands of dollars in a day. I mean, there are days where I'll use, you know, 10, $20,000 of medications in a day for these patients. And if I, you know, don't get prior authorization or don't bill properly for a quarter of them, well, then I'm going to lose five grand in a day. That's frankly money out of my pocket and it's going to impair my ability to really properly care for my patients. So we really have to be well-versed in prior authorizations and help people with that. And we have to be well-versed in billing and coding. And we also have to have a follow-up process to make sure that the practice was reimbursed properly and I'll go into that as well. Next slide, please. Next slide. Here we are. So there's really two ways to get your medications. One of them is buying and billing and the other one is specialty pharmacy. So buying and billing is basically when we purchase the medication directly from the pharmaceutical company and we bill the patient's insurance for it. Just be aware that if you do this, you are on the hook for these medications. And if you don't get reimbursed for your, let's say your botulinum toxin injection, then you're going to lose out on not only on the physician's fee for injecting it, which might be, you know, 150, 200, 300 bucks, depending on what the assurance is and what you're doing, but also the thousands of dollars that it costs for the medication. So you really have to be careful. So that's buying and billing. There are benefits to doing buying and billing. Another way to get the medications is specialty pharmacy, which I think Prasneeta talked about. And that's when we procure the medication from a specialty pharmacy, which is used by the patient's insurance companies, like Blue Cross will have their own, Medicaid will have their own, Aetna will have their own, for example, and it's mailed to our office. When we are going through specialty pharmacy, you're not on the hook, but there's no profit either because we're not providing the medication. My approach, and this is something that works for me and me and being in Massachusetts and Rhode Island, but really it is state by state different. For botulinum toxins, I only buy and bill if a patient has Medicare with a supplemental or just Medicare, I should say. Why? Because Medicare is, you know, in my experience, it's not really in the business of making a profit off of us. You know, it's a government program. They're not trying to make a profit off of us. They're not finding reasons A through Z to basically underpay us or undercompensate us or rip us off or say we're not doing this or that properly. But for commercial insurers, there's obviously a profit margin there. Even if they're not for profit, you know, they have to pay their executives. They have to, you know, sort of support their business model, you know. So for them, I always use specialty pharmacy unless mandated otherwise. Every once in a while, Blue Cross will say, you know, you have to go through a buy and bill for this patient insurance and I do it, but I really prefer to do specialty pharmacy because then I'm not on the hook. I also do specialty pharmacy for Medicaid because very often Medicaid will, I'll get the prioritization. They'll say, yes, we'll pay, we'll reimburse you for the Botox, but then for some reason they don't. And then once they don't, it's really hard to go after them again. So I really prefer going through specialty pharmacy. The reason why I like to go through specialty pharmacy when it's non-Medicare is because the profit in toxins is really minimal. You only get, you know, one, 2% more than the actual cost of the medication. So in my humble opinion, you know, the physician fee to inject is more, but the profit you're getting off the Botox is really very little. So it's really not worth the risk for me for buying and billing for an insurance company when there's a high risk or even a moderate risk of it being rejected. So with toxins, I buy and bill for Medicare, but for everybody else, I do specialty pharmacy. For Baclofen though, I always buy and bill. And the reason why is that the risk benefit ratio is a little bit better there. There is significant profit in intrathecal Baclofen. It is considerable, but the physician fee for administering the med is really quite low. Whereas with botulinum toxins, when you're injecting with the EMG and ultrasound guidance and eStem, you do get paid more for the actual injection. But with Baclofen, the actual injection itself really doesn't pay that much, but there is significant profit in the medication. So I don't really wanna miss out on that profit if you're not buying and billing. Next slide. And if anyone has any questions, please let me know. So let me go over some of the CPT and J codes for the Baclofen pump. The biggest one you have to know is 62370. That is to fill the Baclofen pump. If you change the dose, it's 62368. And if you're interrogating the pump without a dose change, or for example, somebody just comes in and you want to know when the pump has to be changed by, the medication has to be filled by, then that's 62367. The J code for Baclofen is J0475. But please remember that you must bill for the number of units used. This is so basic, but it is so true, and you will go broke if you don't do this. Because Baclofen, Gablofen, Oral-V or Oracel, they're expensive. It costs, depending on the price you negotiate and you're getting it through, it costs between 150 bucks and 200 bucks per unit. And a Baclofen pump has up to eight units. So if you don't bill properly, you could lose 12, 13, $1,400 on refill easily. And this is basically how you determine what a unit is. So pumps can either be 20 cc's or 40 cc's. So one unit is the concentration of Baclofen being 500 mics per mil times 20 cc's. That's one unit. And then you just do the math. So if it's 1,000 mics per mil times 22 cc's, that's two units and then so forth. 2,000 mics per mil times 40 cc's is eight units. So the point is, if you're putting in eight units of Baclofen, you have to bill for eight units of Baclofen. Otherwise you're just gonna get paid for one, and then you're over $1,000 out the window, basically. And then please also remember to use the NDC code. The NDC code is always written on every medications we inject. Use the NDC code if the patient has Medicaid primary or secondary. Otherwise, if it's secondary, you're gonna lose out on 20% of the full cost of the medication, which is more than what we're getting reimbursed to actually inject it. And if it's Medicaid primary, then we're gonna lose out on 100%. So please do remember to use the NDC code. Next slide. Dr. Bohart, before we go on to the next slide, we did have a question. Are you doing nerve blocks with phenol or alcohol? If no, why not? I am doing my phenol nerve blocks with phenol. Phenol nerve blocks with phenol. And I get it from a pharmacy in Florida called Anaseo. Anaseo, why not? I don't understand the why not part. I guess I can also answer. So I do not do phenol nerve blocks right now because I find that first of all, my hospital pharmacy is very confused about how to obtain it. And so it was requiring a lot of work to get them to understand how to obtain the med. And then second of all, that in my practice, it was so rarely being used. I felt like I can get where I needed to get with toxin. So the less you do it, the worse they are at both procuring something and billing for it. So- Yeah, I agree. I agree. Yeah. I agree. In my private practice, I use phenol a fair amount because I just order it from that pharmacy that I was telling you about in Florida and Tampa, Anaseo, and it shows up the next day. And I usually order it if I'm getting compounded baclofen for some reason, like if a patient was really far away and I don't want them to come back so often for refills. But yeah, but when I'm actually at Tufts Medical Center in Boston, then there are like a million hoops to jump through and it's really difficult to get. And in my private practice, there's just so much more freedom. I can basically do whatever I want to do. So yeah, I do do a fair amount of phenol there. And the reason why I do phenol is because it enables me to really spare baclofen and it can really be more effective in certain instances. But instead of, sorry, Botox, instead of injecting 200 units or 300 units of Botox in the elbow flexors, I can just do a phenol block musculotaneous nerve, and then I'll be able to put the Botox or botulinum toxin elsewhere. Next slide. So here's the CPT and J codes for botulinum toxins. For Botox, it's J0585. For Dysport, it's six. And for Xeomin, it is J0588. And now there's a couple of tips here. I see a question there, I'll get that in a second. 64642 is for injecting one to four muscles. Let's say you're injecting three muscles in one limb, you do 64642. If you're adding another limb, you do 64643. Then if you're doing five or more muscles, it's 64644, 64645. An important point here is that if you inject two limbs and you do five muscles in one and three muscles in the other, you wanna build the primary code, you want it to be the more highly reimbursed code. So you would do 64643, sorry, 64644 and 64643 instead of 64642 and 64645, because the primary code being 64644 reimburses more than 64642. Next slide. And sorry, just, there was the question. Did you wanna read that one or? Yeah, you can read it, it's all right. Okay, yeah. Is anyone using Iovera cryo... Sorry, this is gonna be a tough one for me. Cryoneurolysis for spasticity pain and are you getting reimbursed for it? I think Dr. Patel answered. I saw Dr. Patel answer that. Yeah, I can just talk to that a little bit. I'm just starting to use it. I've been doing it mainly as a research tool and currently I'm just setting it up by getting samples and stuff like that. But I know some people have been using it and charging it as a pain code. I'm having a little trouble with that. And that brings up another really good point. As a community, as physiatrists, as physicians, let's always use the correct codes and stuff and call it what it is. For example, don't call neck pain, that's not cervical dystonia, cervical dystonia. Because in the short term, you get away with it. In the long term, we all get punished. So that's the same reason I'm not using those codes because I am truly treating spasticity, not treating pain secondary to spasticity. Yeah, you can get away with that, but I think we need better codes. So we need to, as a group, put effort and get a new code. So that's the way I'm working on it. And in the meantime, I'm charging patients and figuring out other ways to do it by not having a huge burden on the patients and at the same time, not losing money on my end. But we can talk more about that. But yes, I think this is gonna be the future. And also when it comes to phenol injections, I think of the cryo-neurolysis as a cleaner way of doing a phenol slash alcohol injections without denaturing the surrounding tissue. Thanks. So just a few more CBT codes. 95874 is the CBT code for EMG guidance. When we do EMG guidance, you have to buy the actual needle. So there is a cost there for ultrasound guidance. The CBT code is written there, 76942. For now, Medicare reimburses for both. Most insurance companies don't. I mean, we have to do one or the other, I think. But Medicare does reimburse for both, at least where I live. But I believe that may change in the near future. I know there's some changes coming down the road, possibly with Medicare. But again, please remember to add the NDC code if the patient has Medicaid primary or secondary or you're really going to lose out on a ton of lost income, which is really money out of your pocket. What was that question? I'm sorry. Yeah, the question was if you have to bill for waste-diffusing Dysport. And the answer is yes, you have to bill for waste with each one of them. And these are the kind of nuances that your traditional coders and billers are not going to understand. Right. So, while it seems like minutiae, if you want to be successful and not be called and told how much money you're losing, you want to know this information and then you want to make sure it's reflected in your coding and billing. Because I know like some of ours, that we had the issue where our billing system was not actually set up for all of these sort of modifiers. And so there was months that we had to go back and fix it. Yeah, I couldn't agree with you more. I recently found that at Tufts that we can't, that they couldn't put in a lot of the modifiers for waste or no waste, and it really is very difficult. And they're using Epic, and they're relatively new with Epic. It's been really a big problem. And I believe it is, it's JZ and JW for Dysport as well, correct? It is, yeah, those are universal waste codes. Yeah, so to talk about this, billing for waste, if a patient has Medicare, and where I am Blue Cross Blue Shield as well, but it varies from state to state, you have to bill for a waste, and that's a modifier which is JW, and no waste is the JZ modifier. To remember that, just think that JZ leaves nothing on the floor, you know, JZ. So JZ is no waste. I'm from Brooklyn, sorry. So for example, if you inject 300 units of Botox with no waste, and they have Medicare, then you do 300 times J0585 with JZ, which is no waste. However, if you inject 250 units, you dispose of the 50, and then you do 250 times J0585, and then 50 times J0585 with the JW modifier. You'll get reimbursed the same, but that is a Medicare mandate, so you do have to know how to do that. Next slide. I'll just add one thing to that to everyone. Make sure you document that in your clinic note. Not only in your billing, but in your clinic note, you need to have a separate line saying X number of units wasted. Right, yeah, intentionally wasted. Yeah, yeah, yeah. Dr. Patel, and I believe that we also have to bill JZ for backfill and pump fills, and I found that out recently. Do you, have you seen that? No, I haven't. I think, I mean, we just use up the entire amount. There usually is never waste because it's a pump site. No, there's never waste, but I was told recently that we do have to do that, and I need to verify that. Yeah, I don't know if we do that or not, but my billing people might be adding that. I don't know. I can't find it. Okay, and every once in a while, there'll be an insurance company where I put in one of those modifiers, and then they reject the whole thing because they don't recognize that modifier. So that's another problem. I think UnitedHealthcare just doesn't have that modifier at all, and if you mistakenly put it in, then they reject the whole thing, you know, so then you're just out of luck. Here are the commonly used ICD-10 codes for spasticity. These are the ones that I use the most. Obviously, there's more, but I, again, couldn't agree more with Dr. Patel, who's really been a good mentor for me. You know, we really want to bill properly. We want to code properly. We want to use the correct ICD-10 code and not, you know, call something what it's not because sooner or later, you're going to get audited. You're going to, you know, it's going to be difficult. It's going to get more and more difficult for our, you know, what we do to get approved. So we really do owe it to the field and to our patients to really use the correct ICD-10 codes. For TBI, I use two spastic hemiparesis, left and right, and that's been working so far. So I don't use one or the other. Next slide. So billing companies, in private practice, you know, we can all, look, if you're in academic medicine or if you're in big group practice, it doesn't matter, you know, they take care of it. But, you know, if you're in private practice or if you're in, you know, specialty private practice as well, you know, and you're not in some big academic setting, you really, you know, we have to approach our practices kind of like a CEO, either a mini CEO or a CEO of your own practice or CEO of your department or CEO of just your own clinic. But remember that billing companies are for-profit businesses and they want our business. And the best time to negotiate with them is before you sign on the dotted line. And in general, they make their money by charging a percentage of revenue collected. So really try to negotiate the best possible deal from them. Don't be afraid to play hardball with them. This also includes, you know, pharmaceutical companies we provide medications for if the price is negotiable. Play hardball, you know, don't be afraid to try to negotiate the price down because again, financial viability is really very, very important or we can't take care of our patients. Even, you know, if you can talk them down, a billing company from 6% to 5% and 1% is a lot of money at the end of the year. Because the profit on botulinum toxins is really minimal, what I did with my billing software, which is Athena Health, I negotiated that they not charge on the J codes because otherwise if they did charge, you know, there are several percent on the J codes and if the profit on botulinum toxins is only about 2%, then I would literally be underwater with every botulinum toxin injection that I perform. So they don't charge me on my J codes, which is great. And that's been very helpful for me. If you do use a billing software, make sure you can easily tell if a patient's insurance is reimbursing properly every time and make sure the insurance is valid. So what I do, I use Athena Health, which I really like. There's no software, it's just a login so you can go on any computer. And basically before every injection, I make sure that it was reimbursed, if it's not Medicare, I make sure that, excuse me, that I was reimbursed properly with the previous injection. And if not, then I put a pause on it and I say, come back next week while we figure this out. And I'll give you an example. At the beginning of the year, I noticed there were a few patients who I was not getting reimbursed properly for. And it turned out that they all had Aetna. So I called Aetna, I called provider relations, it took me forever. I was actually on vacation in Florida, called a whole bunch of people. And finally, I got through to somebody who told me that I was decredentialed as a providing physician from Aetna and nobody let me know. I got no email for them, no call, no letter, nothing. So they wound up recredentialing me. They said it was a mistake, whatever. It took about a month to get recredentialed with them. But then in that meantime, I wasn't able to treat all those patients with Aetna. Had I not had the ability to basically look at the reimbursement of the previous injection for my patients coming in, then I may have gone a year or two with treating patients with Aetna and having lost thousands upon thousands of dollars. So for me, Athena Health has really enabled me to kind of tell when I'm getting reimbursed properly or not. If you do use a billing company, I would really recommend meeting with them monthly to really get a report on your questions to make sure, hold their feet to the fire, make sure that you are getting reimbursed what you should be getting. This is an excellent question, actually. There's a good question about using the 25 modifier with a separate eval and treat code of handling other issues beyond toxin and pump. So like bracing medications, hey doc, can you take care of my pain, refill a prescription, whatever. Right. We had a lot of denials when we started doing that. And so I have been very, very hesitant to do it again. I would much prefer making them come back a week later and be with my APP and go over those things. And I just basically tell the patients like, hey, we never know nowadays if I'm gonna write for a wheelchair, we never know they're gonna wanna face-to-face, they want certain things answered, whatever. And so I need to bring you back and make it all in a separate note. And for the most part, I'd say most of the patients, especially now with telehealth options and that, it works a little bit better. You have to have some flexibility in your schedule, but I think that works better than the 25 modifier. I'll refill prescriptions during visits, but the rest of it, I kind of say, you gotta come back. Yeah, I agree. If I, I couldn't agree more. If I am buying and billing 400 units of botulinum toxin at a cost of 2,500 bucks, I don't wanna risk getting reimbursed on the 2,500 bucks so I can make an extra 50, 60, 70, whatever. It's just not worth the risk to me. It doesn't mean that I'm not gonna prescribe an AFO, I'm not gonna do whatever's required for my patient, but I'm just not gonna bill for that time. Or if it's gonna be more complex, then I'll just have them come back. Sure, but I agree. For me, it's just not worth the risk. I'll just add my two cents to that. This is where efficiency comes in. Just imagine you're doing one kind of a process all day long, and all of a sudden you get a curveball, hey, I need an AFO. That slows you down. Don't do that, number one. If they fell down and have a laceration, yes, take care of it or get them to the right person. But otherwise, my patients are educated. They know, they even ask my staff, can I ask about this question today? And they say, yeah, maybe, but we probably won't answer it because you're here today for your injection or you're here for an ITB refill, unless it's a patient that's coming from a long ways and I know I'm not gonna be able to see them in followup before or after the procedure day. So on procedure days, 95% of the time, it's just procedure. Obviously, if something happens, I do use the Bill 25 modifier. And when I use it, just rarely I haven't had a problem. But you need to definitely document above and beyond the procedure note, otherwise you won't get, and you need to kind of, sometimes it's even just easier to have two separate notes, a procedure note, and then another documentation for followup visit and just make it separate. I wanna piggyback on that. We do have a lot of patients that are coming from several hundred miles away and we do wanna address their concerns if we can, obviously within reason, but then the documentation is key. I think if you document well that this is, no, you're here for procedure, but there was a separate issue and I fully addressed that secondary issue. I think going to 25 modifiers is reasonable. There's a question there for how much, yeah, I think these are all reasonable, but it's how much risk do we wanna assume? How much time do we set aside for the procedure? When I have a resident with me, I'm doing four procedures in an hour. If I don't have a resident with me, I do two or three in an hour. How about you guys? It has evolved. So when I started out, I mean, there's certain patients I would schedule for like 45 minutes and now I've got to a point where I'm running really smoothly with sudden patient. I have got to the point where sudden patients do not even get scheduled. For example, Tuesday afternoon is my easy peasy clinic. Everybody easy. Nobody more than 200 units of botulinum toxin. If it's Botox, nobody with any complicated stuff. So I don't even do that on that Tuesday. It's just fill it up with all the straightforward stuff. Thursday afternoon, all the complicated ones and things like that. I also look at if the patient's gonna come in the morning or afternoon. Spinal cord injury patient is gonna be really tough to show up on time if they're scheduled first thing in the morning. Don't do that. Put them in the afternoon. Those kinds of little, little things all add up. And just let me say, for example, if you're seeing 20 patients in a day and each patient is taking you two extra minutes, that's 40 minutes of your time gone at the end of the day. You don't want that. You wanna be efficient. You wanna spend that 40 extra minutes maybe seeing one more patient or go home early and with all your notes done. Don't wanna be frustrated and burnt out. So we have another question here about how do you approach a patient with focal dystonia? So not cervical dystonia, not Reiter's cramp being denied toxin by the payer. And this gets into, so the payer says it's non-FDA approved diagnosis. So this gets into those unusual diagnoses. I mean, I treat pediatrics in adults. So thoracic spina bifida. It wasn't in that little list you have there. My coding and billing people and I have gone around and about because they just want me to call it that spastic paraplegia. And I say, no, that's not what it is. And I think that the most important thing is we need to decide if we're gonna advocate for those patients and how we're gonna advocate for those patients. I have been starting to really put aside a period of time every week where I'm doing peer to peers for the, where they're questioning my dosing, where they're questioning my diagnosis. I find that once it gets on the chart that they've approved it once, then you're pretty golden from that perspective. And I tell them the same thing. I say, I am tired of practicing medicine below the standard of care. So I am tired of giving substandard doses or not treating certain diagnoses because it's not on your list. And then I basically show the amount of data we have with regards to the patient's clinical condition and response or failure of previous treatments. And usually by the time I get down that list, they've pretty much like, oh, just stop talking. You can have it. But really honestly, like these kinds of things like focal dystonia, dystonia is like such a problematic word, even though patients have dystonia because they either think, oh, you meant cervical dystonia or you meant writer's cramp, or you can't have a generalized dystonia that's not a torsional dystonia and all that kind of stuff. And so we really need to educate them and use the proper terminology. And the FDA approved diagnoses, if you look at the FDA approved diagnoses, you have to look at the etiology. If the patient has a focal dystonia coming from a traumatic brain injury, then from my perspective, they're the same as somebody with a hemiplegia from a neurologic insult, whether it be stroke or brain injury. So we just have to be able to tell the story to get them to understand it. I don't know if what other people's response, I just have decided I'm willing to talk to medical directors, cause I'm just tired of being told what to do all the time. So. Go ahead. I'll add a couple of points real quick. One point, number one, yes. Talk to the medical directors. Don't be shy. That's the thing. You have to educate them and be blunt. Ask them what kind of practice did they do before they became a medical director and then explain to them. Then I just use their example. If they say they're an orthopedic surgeon, I say, so as an orthopedic surgeon, how comfortable are you making decisions about neurological conditions? And educate them and tell them. And so that's worked really well. The second thing is literature. Even writer's cramp is not FDA approved. There are no, okay. So, but what do you do? You use, for example, April, 2016 guidelines from AAN, first line treatment for dystonia botulinum toxin. So you show them that. Things like that. And there are codes for other dystonias too. So you could use that and you can say for dystonia, the first line treatment is this. And then the other treatments cause other problems. So if you have a head injured patient, and if I was to give them medications that are oral medications that will impact upon their function and then educate them that way. So that's what I do. And it seems to work. Yeah, I agree. I kind of look forward to having a conversation with a medical director from an insurance company because yeah, frequently it'll be like a family medicine doc or an OB or a psychiatrist, someone who has no knowledge about what we do. And then once we, I take it as an example to kind of educate. Yeah. And that's number one. And then number two, I also find that once you get someone on the phone and you explain, well, look, this isn't, not to be cynical, but this isn't like a pain patient. This is a patient with multiple sclerosis who can't walk. Like once you say something like that, they kind of chill out a little bit. Have you experienced that? Absolutely. I give them, I tell them this patient's story. I say, yeah, this patient's got to go home and cry. You know, there's going to be so much pain. This isn't just somebody with back pain. Yeah. Yeah. And then they approve it. Yeah. And I also tell them this, look, I tell them this. I say, you're collecting data on me. You have everything on me. You know how much I cost every patient. Just follow this. If I'm costing you more than saving you money, stop it. Don't pay me and don't approve it. But if I'm saving you money, approve it. Yeah. Yeah. Which is probably a good reason to not, as you were saying before, to not, you know, use inappropriate diagnostic codes. Exactly. Because then they'll kind of catch on to you. Yeah. Whereas if you're just treating spasticity, just treating somebody with upper motor neuron lesions, I think that they're going to trust us a little. Right. I just wanted to acknowledge that we are over the hour. We still do have a lot of folks on the line. So if I can't remember, Dr. Bohart, how many more slides you have? I think I'm done. Can you go to the next one to remind me? I think I'm done. Yeah. Yeah. So basically, just to kind of reiterate, I really, I love treating spasticity. It stops me from getting burnt out because I really love the patients. I feel like I'm like a primary care doctor. These patients have been coming back to see me for years and I really care about them. A huge shortage of physicians. You can really do very well for yourself very quickly because unfortunately, you're right. The standard of care is really very low. And we can really make a tremendous difference out there. And physiatrists do it better than anybody else. We do it better than neurologists. We do it better than anybody because we understand function. But please definitely understand the business side of this, not to milk the cow, but to make sure that your clinic can stay viable so we can keep treating our patients who do not have their own voice frequently. And I would echo that to understand the coding and billing and the business of it, whether or not you're working in a private practice situation or academic situation. The reason why the hospital brought us in from private practice to academic was we are very good at what we do. And we were allowed to bring what we did to manage the business side of it to the hospital side. And so that is something that now I am making sure that is gonna continue to happen. And we should all ask those questions about coding and billing. I mean, I identified that there were differences between the way they were coding spasticity injections in neurology and in PM&R. And so my question was, hey, how are you coding them differently? Why is their documentation different? And then lo and behold, I identified that they were not being on the neurology side being as specific with regards to hand dominance in those codes. That leads to denials, that leads to lost money for the hospital. So if we know this area, we can be leaders in this area. And I think we do a very good job of understanding the business of it. Thank you. Right on. Does anybody else have any other questions? We would love if anybody else has other questions. We also love to engage you in the spasticity forum. This is a hot topic. There's potential for some pretty significant changes on the Medicare side. And don't read any of this stuff before you go to bed because you'll get depressed. But we need to start advocating for ourselves as physiatrists and the APM&R is helping lead our voice in this. So that spasticity physic forum is going to be one of the places where we're coming together to make sure we can all advocate for these things. Oh, TMJ, I love getting this covered. Well, it's beautiful for botulinum toxin. Any luck getting it covered? I've never gotten it covered before and actually paid myself to have it done. And I'm gonna tell you, it was the greatest thing ever. But yeah, it's not a covered diagnosis at this time and really hard to get justified. Maybe workers comp. Yeah, to kind of talk a little more just for a quick second about what Dr. Kwasniewski was talking about. Medicare is talking about decreasing the amount of botulinum toxin we can use and keeping it to strictly on label. This is against the standard of care. This is gonna be extremely harmful towards our patients. And they're talking about doing that right now. I'm personally meeting up with my local congressman in about a week about this. Medicare is having an open forum tomorrow from 12 to two, I believe. Please feel free to reach out to our friends at AAPMR for the link, but we have to put up a stink. For example, with Botox, they're talking about decreasing the maximum amount used to 360 units instead of 600 units. That's gonna really affect our patients and what we can do for them. So if there's a time to get mobilized, I think that now is pretty much it. Yeah, I'll just add to that, that it's extremely important we all stick together, and it's not only short-term solutions, but long-term solutions too. Look, guys, we don't know where healthcare's gonna end up, but the patients are gonna be there and providers are gonna be there. And the best way we can think of taking care of these people eventually will be doing the right thing. Look, it's happened. It's history, right? There were times when they wouldn't even approve any therapy, and then they realize now, okay, it does make a difference and we get therapy for different conditions. I remember when I was doing spasticity 10, 15 years ago, the Humana would say, yeah, they approve the botulinum toxin, but they won't approve any therapy. And I called them up and I said, look, what's the point? It's like doing brain surgery, but not closing the head. I mean, you can't do that. So there's no point doing it. So we have to fight together for the short-term solutions, but also long-term. And that's why we come together through this forum and the community, through the PhysForm community for spasticity, we can really collectively do a lot more. And I also want to just thank everybody. I was just amazed how many people showed up today. So this is great. It's so exciting that finally, we're all getting excited about this and getting more people interested in this area. Thanks, everybody. Hi, everybody. Anything else I need to do, Carolyn? Am I missing anything? No, this is great. Thank you all so much. And thanks to everyone who joined. Feel free to reach out to us using the email on the screen right now, if you have any additional questions that we missed. Thank you so much. One last thing to say is, let people know if there are other areas you wanted us to talk about in the future. Happy to do it. Yeah, you will receive a survey from us and we will be asking for that feedback, absolutely. So thank you and feel free to email it too.

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