All right, I think we're going to get started. Thank you everyone for being here. We're going to sort of this last talk of the Spine and Pain Focus Day is a really uplifting one. It's on billing and coding. I was just thinking as I walked in, it must be something I said because the room is very, very not full like it was just 15 minutes ago. But I think this is an incredibly important sort of topic area for those of us who practice in the spine and pain arena. We're going to sort of divide this talk up between the three of us. I think we've got some updates for you on billing and coding. We've got some conversations about sort of the pathway to reimbursement. And it's not all doom and gloom. I tried to get them to, this is sort of a tired joke on my part, but I've tried to get them to put like buckets of Xanax near the doors because we're talking about billing and coding. But there is some good news. There have been some victories. There's some things to celebrate as well. So we'll talk about those as well. So on the panel with myself, I'm Mehul Desai. I'm in private practice in Washington, D.C. Sort of a private edemics sort of setup where we do a lot of private practice, focused practice, but also train a lot of medical students, residents, and fellows, and also do a bunch of clinical trials. We're sort of, at any one time, we're doing anywhere from five to 10 clinical trials. Hemant Kalia is in Rochester, New York, and he's going to be coming up in a moment here. And then Gene Techmeister is out here on the West Coast at USC. So we've got sort of a breadth of experience, but all three of us are very much involved in legislative policy, reimbursement policy. We've all worked at the society level and also at the sort of state and national level with whether it's with Medicare or the FDA or with private payers on sort of helping with the reimbursement pathway for the kinds of things that we all do. So I'll turn it over to Dr. Kalia for the first talk. Thank you, Dr. Desai. I actually have the most easiest section of this entire talk today. And I hope I can make this a little more interesting for you guys. How many of you actually know the whole process of introducing a new therapy in the market? And what is the lifecycle and what stages it go through to get an actual reimbursement with a show of hands? Perfect. So let's understand the entire process and we'll start with a hypothetical example. So let's say you come up with a novel innovative therapy and you want to prove that it's efficacious and get a pathway for reimbursement. The first thing you need to do is you need to prove that it is safe and effective. And there are multiple stages of regulatory compliance in this entire journey you will have to go through. The first process you will have to meet with FDA. FDA will oversee your process of the study and the trial, which you will do to gather the data to prove the effectiveness and safety of your therapy or device. They're only interested in two things. They're interested in safety of the device or therapy, or they're interested in efficacy of the device or therapy. There are two pathways to get that study done. So you have a 510K pathway or an IDE pathway. IDE pathway is the Investigational Device Exemption. If you have a device, you want to bring it to the market, and it's completely investigational. It's a completely novel thing you have come up with. And by the way, there are disclaimer, there's a small line in the end of this presentation. If you guys come up with any new idea during this talk, I get a share of it, just kidding. So if you do get that device, which is completely new from ground up, you have to get the IDE which is exemption to do the study. Another pathway is if there is already some device in the market which predicates your hardware and there is similar safety profile, you can get an exemption and you can expedite that whole pathway through what is known as 510K, where your product will get expedited approval through FDA to start the study. And you will still have to prove the safety and the efficacy of that specific device through a clinical trial. So once you have conducted a trial, you have proven its efficacy, you have proven its safety, the next step is to get into the pathway of reimbursement. Because if it's not reimbursed, there is no point in, you know, getting this entire new therapy into the market. That's where the role of AMA comes into play. How many of you have attended or know of AMA CPT and AMA RUC? Okay. So there are three specific codes with CPT and every therapy or the treatments which we do on a daily basis can be categorized into one of these three categories. In fact, most of the treatments which we do on a daily basis, which have a delineated path of reimbursement fall into category one. These are treatments or therapies which have already gone through the process of data collection and have proven the efficacy and safety and they have a sustainable path for reimbursement already set up. So all those therapies and treatments fall into category one. A new therapy or a new treatment generally starts at what we call a category three code. So category three code, as you can see, is a temporary code for emerging technologies which is designed to gather the post-market data on that specific treatment of therapy. How many of you actually did or do mild procedure? Generally invasive lumbar decompression procedure? Okay. So that's a procedure which has been practiced for almost half a decade. It had a T-code or a category three code for almost six years. This therapy was introduced into the market in that T-code about six years ago and just recently, a few months ago, it got graduated from category three to category one. What it means is when they have a category three code, the pathway for reimbursement is very limited. You have to do negotiation with your insurance companies or your contracts in your region or directly with Medicare to have a pathway for reimbursement for category three codes. Otherwise those therapies are not regularly reimbursed by private payers. Category two codes are basically just tracking codes for performance measurement. These are codes, you must have heard of the term value-based contracting or VBC. Medicare has been pushing towards VBC for quite some time and there are a lot of performance metrics which are reported either by the hospital or bigger groups or organized entities. And all those metrics generally kind of fall into this category two code. Everyone with me so far? Okay. Let's move on. So next is the role of the category three codes. We already kind of went through some of the broader concepts of category three codes. So there are three main pathways or constructs for category three. One is obviously, as I mentioned, data collection. The second is the support for clinical trials. So when the mild therapy was first introduced into the market, interestingly enough, Medicare sponsored it. Medicare was one of the sponsors for mild therapy and they created a pathway for reimbursement under a clinical trial. So all patients who had straight Medicare or Medicare Advantage plans could get this treatment done. So over the last six, seven years, every single patient who got a mild procedure, which was a category three code, was either straight Medicare or Medicare Advantage plan. Now that they have a category one code, it will open up this procedure to commercial pairs and the access to this therapy will be increased significantly. And third, obviously, the reimbursement pathway. And classic example as I'm bringing this example again and again of mild procedure because it's a classic example of how a therapy is introduced into the market and goes through that entire process of getting fee schedules assigned to it. Let's jump onto the next phase of reimbursement, which is the RUC. So you had an idea, you got the study done, you prove the efficacy and the safety of your device or your treatment. You went through this AMA process and you got the category three code. And now the category three code was there for maybe a year, two years, and you were able to gather the post-market data and now you feel comfortable to request AMA to evaluate your product to graduate it to category one. Once a code is graduated to category one, it has to go through the process of RUC. RUC is a separate committee in AMA which is responsible for assigning work relative value units to that specific CPT code. In simple words, what it means is they look at the entire operation of giving that therapy in your clinic or in the hospital, which includes your physician fee, physician work, it includes your malpractice, it includes your geographical region where you're doing the procedure, and all the other operational costs which are associated in giving that therapy. So all those things are combined and the process of RUC is through a survey. So you probably, either through APMR or some other societies, have received a survey where if a new code comes on, then you're asked to evaluate that based on the survey and comparing it to other established therapies. So the goal is to assign a work relative value unit to this new category one code so that a value can be assigned and a dollar value can be assigned to that CPT code through Medicare. So that's the whole process of RUC which solidifies the pathway for reimbursement. Once your device or your treatment goes through the RUC process and the RUC committee has assigned a work relative value unit to your CPT code, that code now goes to Medicare because Medicare is the single biggest, largest insurer in our country. Once a CPT code with the work RVU assigned is sent to Medicare, Medicare now looks at it from a completely different perspective. They are looking at not only the efficacy and the safety of the product, they're also looking at the cost effectiveness. They're also looking at patient impact and the quality of life parameters. And they're also looking at the competitive effectiveness to existing therapies. So all those factors go into play when a new therapy with a category one code goes to Medicare to assign a reimbursement pathway for the therapy. And Medicare generally what it does, it either will come up with what is known as NCD, which is National Coverage Determinant, which is a coverage policy for the entire country. NCD trumps all local coverage determinants. So if you have NCD for a therapy, that will trump all other policies. LCD on the other hand is determined by the local MACs. The entire country can be divided into six regions and each region has their Medicare contractor or known as MAC. The following presentations will kind of go into some of these MACs and how they work. If there is no NCD for a specific treatment or a therapy from Medicare, then these MACs have the ability to come up with their own LCD, which is a local coverage determinant. And this is the entire process of a new, novel, innovative therapy or treatment getting a pathway for sustainable reimbursement down the road. You will see that this process can break down at multiple steps. And there are a lot of different stages where it will require either legislative or regulatory advocacy efforts if you have to make any changes in the coverage determinants of the therapies or expansion of certain therapies along the spectrum. So I hope I was able to kind of give you a 36,000 view of how this whole process works. It is a convoluted process and it can take a few years to go through that process and have that innovative treatment launch into the market. And we're going to, yep. All right, thank you, Dr. Kalia. I'm going to go next here. And I was sort of jokingly earlier saying that I sort of get to deliver much of the bad news, which is always, I sort of seem to relish in it. So I'm going to really lean into the bad news here. So it's not all bad news, but there's certainly some. And that's always sort of the process when it comes to reimbursement, right? So I think Dr. Kalia did a really fantastic job sort of walking us through the steps of a code and sort of a new product and the evaluation that goes on to sort of get it to a place where there's a code and also where there's value associated with that code. But that doesn't actually ensure that that code is reimbursed. I mean, it may be reimbursed by Medicare, but it may never get reimbursed by commercial payers every single day. I mean, probably we can get a show of hands. How many of you guys have done a prior authorization or done a call for a peer to peer in the last couple of, like, let's say two weeks? It's pretty much everyone, right? And it's because there's a whole host of things that have a partial sort of pathway to reimbursement, but not a full pathway. Just because something's approved by the FDA and covered by Medicare doesn't actually mean that any other payer is obligated to cover it. And all of us run into this situation nearly all the time, probably on a weekly basis, where the insurance or commercial payer tells our patient that the product or the procedure we've recommended is investigational, right? And it's sort of this very deliberate use of the word investigational, which always sort of undermines the confidence the patient has in the procedure we've recommended, because they come back and they say, well, you didn't tell me this was investigational. And so then you have to sort of parse out what that word means in that situation. So, you know, we're going to talk sort of in big picture generalities during my talk. This is my, these are my disclosures, none of which are relevant to our conversation today. And I'm going to, sort of the objectives of my talk are to discuss the overarching reimbursement changes in the United States and to talk about some of the new codes and changes introduced over the past year. I think Dr. Techmeister is also going to cover some of this, so we'll try to not be redundant whenever possible. So sort of starting with the big sort of gorilla, CMS or Medicare, they typically have a proposed fee schedule, sort of the midpoint of the year, June, July timeframe typically. And then there's a comment period, and then they sort of have a final rule. And so the payment schedule for physicians, ASCs, and HOPDs, these are the rules that govern that. So the rule proposes to cut the conversion factor by 2.8 percent to $32.36 in calendar year 2025 as compared to $33.29 in the last year. So this cut reflects both an expiration of the 2.93 statutory payment increase for 2024, a 0 percent conversion factor update, and a 0.5 percent budget neutrality adjustment. The final rule just came out, and I think it's a 2.93 percent cut that's been put into place. So there's certainly a lot of work currently occurring to sort of see if that can be addressed, overturned, or there can be some other legislation passed to solve some of these problems that continue to address us. Because when you look at a 2.9 or 2.8 percent cut, on the surface that seems like a relatively small, relatively arbitrary number. But really, the reality is that when you take into account inflation, and this is just one example of that. I'm primarily going to skip this slide and go over to here. But when you look at inflation, the reimbursement from a Medicare perspective is not nearly keeping up. So this is sort of a publicly available slide from CMS, actually from the AMA, pardon me. And you can see that sort of the cumulative change since 2021 is pretty graphically startling, right? So you can see that physician fees have essentially stayed stable or slight increases, whereas fees that are being paid to skilled nursing facilities, outpatient hospitals, certainly inpatient hospitals have continued to go up stratospherically, right? So nearly 60 to 65 percent increases in those fees. And the cost of doing business continues to go up. So for those of us in private practice, but even those who are employed, the practice costs continue to go up and are reflected by that gray line that shows sort of almost a 40 percent increase in the cost of doing business from 2001 to 2021. So pretty startling and meaningful. If you look at Medicare updates compared to inflation and practice costs, which is just another way of looking at this, you see again that the practice cost inflation has gone up nearly 60 percent or 55 percent since 2001. And even in the physician fees are basically relatively static. They're certainly not accounting for practice cost inflation. So I think the impact of a fee reduction is not just the sort of individual fee reduction itself, but the sort of downstream effects it has both on our reimbursement, but also as we compare it to what's happening from an inflation perspective in the United States. So here's some of the things that are also occurring. There's been some proposals to add codes. So these are codes like there's some new codes such as G2211, which is an add-on code per visit complexity. So it's intended to be used in some instances when you've got sort of a problem that you're sort of wholly responsible for managing and are taking responsibility for managing that entire problem, not for like a single acute instance of an issue, but one where you're sort of taking care of the entire patient for that episode. So this description is a visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and or medical care services that are part of ongoing care related to a patient's single serious condition or a complex condition. This is an add-on. It's listed separately in addition to your E&M code whether it's a new or established visit. There's some uncertainty whether you can ever use it with Modifier 25. Some sources say you can, others say you can't. I think generally speaking, we're not necessarily here to give you advice on how to code these things, but I would be reluctant to use it in a Modifier 25 situation until we have a little more guidance with time. So again, this was a code that was made available and was payable beginning January 1st, 2024. Just out of curiosity, how many people were familiar with this code coming into today? Show of hands. Okay. A couple. So has anyone used it and seen any? Okay, great. So again, it's an add-on code when you're the focal point of taking care of that patient for all the healthcare services around that incident. And it's sort of determined based on the relationship between the patient and the physician, which is kind of how to determine when you use it. You should not use it, however, when your relationship with the patient is for a discreet routine or time-limited nature. If you see someone for an acute concern, you should not be using this code in addition. And if you've not taken sort of full responsibility or assumed responsibility for the patient's ongoing care with regards to that sort of long-term issue, then it shouldn't be used. So on the other side of this is that ambulatory surgical center rates have seen an increase in 2.6%. Specifically when it comes to epidurals, intercostal nerve blocks, sacroiliac joint injections and spinal cord stimulation, there's been a 3.7% increase, a 2.5% increase for radiofrequency neurotomy procedures, and a 1.5% increase for transpharyngeal injections and facet joint injections. So this does not include a 2% continuous sequester cut. There's a whole host of new codes. I mean, certainly this is something that's available online. You're welcome to take a picture of it. There's a whole set of codes that are sort of looking to further delineate some of the codes that we currently have available, particularly around the degenerative disc sort of diagnosis. So whether that's discogenic pain or discogenic pain with leg pain, you can see that these are on here further defined, more so than they were previously. There's also a whole host of codes that sort of, again, really go into sort of these specific diagnoses related to degenerative disc disease, and they're just sort of are replacing some of the older codes as they migrate more things over to the ICD-10 sort of criteria. The one that I wanted to highlight here is that this is the new code that's being recommended for use when you're diagnosing a patient with multifidus dysfunction. So for a long time, we were using codes like spinal atrophy or muscle atrophy, but really we should be using, or not should, we all should be using M62.85, which is specific to dysfunction of the multifidus muscle in the lumbar region. And the really important thing about using this code is that it allows us to track utilization more appropriately. So when we use codes that are not quite right for the issue, you may get lucky and get a patient approved, but it really doesn't arm either us, the societies, the physicians individually or in aggregate, or industry to really fight these battles to make sure that coverage is achieved for our patients. And this is a code that became effective just a month ago. The last slide I'll talk about is telehealth. I think this is something that comes up all the time. Everyone's pretty concerned about telehealth and whether telehealth services will be continued to be covered. So the Telehealth Modernization Act of 2024, which is a bipartisan act, which was including the following extension of certain telehealth flexibilities, removing geographic requirements and expanding origination sites for telehealth services, and extending them through December 31st, 2026. And it also allows and extends audio-only telehealth services. So I think this has been, you know, most of our practices have seen a significant change in the number of patients both requesting telehealth appointments, but also clinician desire to do telehealth. In our practice, it's really interesting. I do zero telehealth appointments and everybody else in my practice, the other four people do anywhere from 25% to 50% telehealth appointments. So it's a pretty popular sort of vehicle to be able to continue to provide care. And relatively speaking, I think a low-cost option for patients to get continued check-in points for their ongoing care. With that, I'm going to pass it over to Dr. Teichmeister. Thank you, everybody, for sticking out with us for 3 o'clock in the afternoon on a Saturday. On a doom and gloom note, we're going to continue a little bit of some bad news, but I promise there's going to be some good news at the end. So we just got to get over that little bit of a hump and then we can figure out what we could actually do. People or patients are not innately familiar with what it takes to actually provide care in terms of cost in this country. And there have been multiple studies that were done that if people actually know, they would actually choose different services. So be free to discuss that with patients in order for them to acknowledge how difficult it is. So maybe at some point, we can get critical mass and get buy-in from the population that we actually treat, not just from myself and everybody else that is here in the audience caring for these patients. Just a little summary slide. Just a little summary slide of healthcare transactions with HMOs and pharmacy benefit management and the complexity of billing and collections and HOPD and ASC and category 1 and category 2 and category 3 codes. I'm not sure if it was by design to be this complicated, but it is the system that we currently have and are living with. So I don't have any direct relevant financial disclosures. I do sit on a couple of health policy and advocacy committees for different organizations. I do have a little magazine piece about how I believe that advocacy should be a medical competency because we do not do enough to advocate for ourselves. We are patient advocates and we advocate for their care. We fight in order to provide what we think is the necessity for them to be able to do what we need to do, but we don't advocate enough for ourselves. So I do think that's an important note to make. So we're going to talk about the current landscape, a little bit of review with Dr. Desai just to look at some key issues and really pivot on what can we do about it. I'll give you some experiences there as well. This was very similar to the slide that Dr. Desai showed where the convergence factor if adjusted for ablation would be the orange line where it's currently the blue line. And like everything else in the world, prices are going up except what we get paid for it. So there's an overall 10% reduction in that conversion factor from 1998, but at the same time, there's been an increase in goods and services by upwards of 80%. So not only is providing care not giving us extra income and reimbursement, but it's also creating a significant barrier to continue to practice. Especially in private practice. I was in private practice for six years. Now I'm in academics. Part of the reason was I just did not want to deal with the administrative burden of trying to run a practice. When I left in 2019, it was right before COVID and I moved into Los Angeles in 2020. A lot of the partners in my practice that I left had to take a pay cut because they weren't able to meet payroll. And they did it in a way in order to ensure that their employees are getting paid and they continue to pay rent. But they themselves were not making any money just because of how difficult it is to, from month to month and week to week, especially with the delays and the predatory practices of some insurance companies, very difficult to collect on that. So it's not just a physician problem. These are patient reporting serious problems, spending on paperwork or disputes. And try to get patient buy-in, especially for new procedures. But it is very difficult from our own perspective, what we need to do as physicians, how much time and effort it takes from our staff, how much time and effort it takes from the patient in order to actually get somebody. And we're talking about 30, 40 percent think this is a serious problem that needs to be addressed, or the 25 percent of adults and patients. So not only is it low reimbursement, but it's also very difficult. So not only is it low reimbursement, but greater expense. We need to hire more staff, we need to spend more time between prior authorizations and completing denials and submitting denials in a timely fashion and crossing the T's and dot the I's. So the third grader that's reading our note actually come across in terms of what we were trying to describe or convey. But the Tony Antler practice per physician cost is pretty significant with an increase in time, and other reimbursements are not going anywhere. And healthcare is not really that unique in terms of a service industry, but I think we can and should borrow some ideas and concepts from billing and reimbursement from the other service sectors. Attorneys, for example. If you send an email to an attorney or if they take a phone call from you, they will bill you for every 15 minutes. Mayo is starting to charge for portal messages, and I think there are some other institutions that are going to start charging for portal messages for patients. But we have to figure out a way in order to properly compensate not just the physicians, but all the supporting and ancillary staff that comes along with running a practice to provide appropriate and proper care. So just a couple of numbers from thought. This is a couple of years ago from Nanos Internal Medicine, but an 18-minute office visit takes 52 minutes of patient time, involves eight people. During a four-day hospital stay, patients interact with a staff that's 160 times, and at least 25% of our overhead is really billing and insurance-related. So not only are we spending quite a bit of time caring for patients and administratively burdened, but we're also spending a lot of time interacting, and that needs to be factored in to how we provide care. And UnitedHealthcare isn't helping. This is a flowchart of the UnitedHealthcare group, and the physicians are being an agent of the insurance company instead of being an agent for the patient. And if you look at how many thousands and tens of thousands of employed physicians actually work for Optum, this is what Kaiser did on a much bigger and much greater scale in order for UnitedHealthcare to be the most profitable company in the world, or one of the most profitable companies. I mean, I think they're making $100 million a day or something in profit. We're talking about billions of dollars per year for what? Just providing care within barriers and administrative costs. Imagine if we just take the amount of money we spend on administrative burden from UnitedHealthcare and actually put that back into the system and provide care using that funds, how much healthier of a society we would be. And then the lifestyle lecture that we just talked, maybe hopefully will be mute because everybody is going to be able to get some sleep and have less stress because we're actually putting that money and investing into healthcare and appropriate patient care. So the E&M code, the CPT codes, it encourages procedures. Recent changes have incorporated some cognitive diagnoses and cognitive thinking and reasoning where if you're not familiar with that, the change I believe in 2021 was not only a time-based assessment, but we're looking at medical decision-making complexity as a source of billing. So you don't have to have a physical exam. You don't have to have social history and family history in order to bill for a level 4 visit. And unlike through Desai, I'm about 30, 40% on telehealth. Why? Because we can save some money for patients not having to pay for gas and coming down 30, 40 minutes to see me. But I could still medically conduct a complex level 4 visit without laying hands on the patient because if we have all the necessary tools and information, we can actually make a decision. And this is a little bit of off topic, but AAPMNR has a white paper that we published last year looking at telehealth services. And at least for spine and pain procedures, there's significantly high-level evidence that a formulated treatment plan via telehealth visit is as accurate and can lead to as good a benefit and successes as an in-person visit. So just take a look back on your level 4 and what that actually involves in terms of the components, not just the physical exam, review of systems, and their family history, but we're actually starting to go into that medical complexity decision-making model for reimbursement, which I think is a step in the right direction. The $150 billion a year administrative health care cost was from 13 years ago. That number has doubled by now. So how do we actually reduce costs and provide better care? The U.S. is nowhere near on that list, but that's the percentage of physicians reporting financial incentives for targeted care and meeting goals. Now, obviously, you have to get patient buy-in. We can't be solely responsible for how our patients act, but I think it should be a component of how we are paid and reimbursed. How that is done, I don't have a good answer for you. Hopefully, somebody smarter than me can figure that out. But with the rising overhead, the decreased reimbursement, this forced shift to value-based care and bundled payments without due diligence on its effects and how it's actually going to lead to improved care, the complex billing coding system, utilization of prior authorization practices, delayed, denied payments, these are the scope of the problem. And this is what we have to face. So how do we do that? Well, we have to use advocacy to influence policy. People are making decisions and people are making policy without due influence from the people that actually have a stake in providing that care. And for most of us, we don't have a gateway to do that. So how do we do that? Well, advocacy leads to policy changes. We've seen that in Washington State with coverage for spinal cord stimulation, for example. We've seen on the West Coast here with Naritian and some certain MAC and LCD determinations more recently, especially for procedures. Comprehensive reform is absolutely needed to address this. This does mark an opportunity because there are resources out there for you to be able to do that. There are currently two bills that are introduced in Congress that would hopefully reduce and reverse some of the cuts and some of the reduction in prior authorization, some of the increase in prior authorization necessities. So just by knowing that that's out there and having the ability to reach out and be able to have a dialogue with the insurer, with the politician in order to improve that, is going to be, unfortunately, on us, not to mention all the other responsibilities we as physicians hold in order to provide care. But we also have to advocate for ourselves in addition to advocating for our patients. So how do we do that? We build relationships. Those in private practice know that there's going to be contracting talks with insurance companies and negotiating contract terms. That's incredibly important. When I was in practice in Connecticut, right before I left, we actually stopped taking UnitedHealthcare because at that point in time they were paying 80 percent of Medicare, and we just could not foresee continuing to run a private practice taking UnitedHealthcare. And then those souls are going to be lost by trying to find care somewhere else. But as a private practice, we just could not afford to see those patients. We would lose money on those patients, and we still have to pay our employees. We still have to cover their insurance. We have to pay rent. We have to make sure that we replace essential sterile supplies, for example. Policy development and how do we get involved in it. The AAPM&R has an incredibly well-designed toolkit for you to be able to do that. When you actually go into the website on AAPM&R, you can look into send a letter to a congressman. This is what we're doing. This is what we need to sign on on. Do it. Take a moment. It doesn't take that much, but it's going to improve things in the future, at least that's my hope. Collecting data and showing what actually really works and not being dogmatic about the treatments that we provide just because we've done something for 20 years does not mean that we have to do it continuously going forward. We have to look back and see what actually works. One of the most interesting statistics that I've seen is that patients that are the most satisfied with their care actually have the poor outcomes because satisfaction is linked to the physician doing what the patient wants and not what the patient needs. So the patient's satisfaction scores actually lead to increase in care, at least in the cost of care. So acknowledging and knowing that can maybe have a difficult conversation because that patient doesn't need X, Y, and Z in order to get better, even though they want it because that's what they saw on TV or somebody told them. But if you want to actually make them better, you have to look at the evidence and practice evidence-based medicine. So this is a Noridian who has public open meetings. Noridian is the Medicare servicer for the West Coast. It includes California, Nevada, Arizona, Hawaii, Guam, and some Northern Mariana Islands as well. And they have open public meetings for their LCDs. The last one I was at was in August of last year. That was for vasovertebral nerve inflation. I was one of two physicians on that call. Now there's 30-something million people in California. Vasovertebral nerve inflation is a pretty good treatment for axial low back pain. It has solid level one clinical evidence. But there were two physicians on the call, including myself, in order to positively impact the coverage determination. We're talking about intervertebral disc repair, Botox injections, minimally invasive arthrothesis of the SI joint, cervical fusions, trigger point injections. All of that is in public comment and public meetings. These are the ones that they have held over the last couple of months. And this is a lot of what we do. If you don't take the time to actually go on and have a voice, then you're not going to be heard, and whoever is on that call is going to make the determination. Because surprisingly, the other people on that call from Noridian actually listen to the people that present. They want people to give them information because they're not on the front lines treating patients. So whatever your local determinant is, whatever your administrator is, go on the website, take a look. If there's a policy that's upcoming that's open for public period, that's something that's going to be integral to developing your practice. So how do we do that? Well, we join professional organizations. We have mass numbers. The more of us that are working towards a positive goal is going to be present in terms of outcomes. Long-term strategies as far as value-based care, stay informed of policy changes. We have a 2.8% reduction in Medicare costs, but there's a law that's been proposed in Congress that's going to undo that plus 1.8%. So that's a 5% swing almost in reimbursement from the negative to the positive. Minus 3 to plus 2. Email a congressman, send them a letter, give them a call, do something. The more they're inundated with those requests, the more they may actually pay attention to those. So what are the takeaways? It really has to be a multipronged effort, not just physicians, but we have to get patients to buy in as well, and we have to be proactive in going out there and really fighting for what we believe in because nobody else is going to do it for us. The public has a very different view of what we do, and in order for us to do what we want to do, we have to get other people to buy into that. And the collaboration is absolutely important between AAPM and our and every other society, AAP and I'm a member of Pacific Spine and Pain Society, Ipsos and NASS, multi-society letters and multi-society statements actually do go a long way into making positive changes. So today we started off with looking at a leopard in a tree and this one microcosm of what we do in terms of reimbursement and billing and CPT codes, but we really have to take a look at the big picture. You have to fight for your patient. You have to fight for your ability and your right to be able to take care of that patient appropriately. And I want to thank you for your time. We're going to stay up here a little bit. I think we're going to take some questions, and I'll leave it to Dr. Tsai. Thank you, everyone. Thanks, Dr. Techmeister and Dr. Collett. Any questions? We want to give people a chance to ask questions. If not, we'll let everyone get to happy hour. So yes. Did you hear the question? So I think the question was, you covered when CPT codes, sort of what the process is to get them covered. But what happens if they stop being covered or they get downgraded? So I think Mild's another good example of that, where there was a code, then it went, yeah. Yeah, so that's a good scenario. I have not come across the downgradation of a code from a category 1 to category 3. But there are multiple examples where the category 3 assignment to the code has been dropped. One of the examples in contemporary practice which is coming up is the intradiscal biologics. That therapy had a T code for almost six years. And most recently, one of the MACs came up with a non-coverage determinant for the intradiscal biologics. If that goes through, then unfortunately, there will be no sustainable path for any reimbursement for that therapy. And once the Medicare drops their coverage for a T code, then that's a dead therapy. So I think, yeah, thank you for answering that question. Do we have any other questions? Yep, right over here. Are you familiar with that code? So a diagnosis code, ICD-10 code? So I think there's been some adjustments in the chronic pain syndrome code, I think. So you want to answer that? Correct. So this code was introduced actually last year. It became active January 1st this year. This is coordination of services for chronic pain management, specifically for primary care practices. There are multiple codes which were introduced at the primary care level. Preventive medicine codes go back three, four years. And last year, that G code was introduced for coordination of services for a chronic pain patient, because that chronic pain patient does come up with multiple comorbidities and coordination of services between multiple specialties. I have not seen a lot of pain practices or spine practices jumping onto that code, because the work relative value units which has been assigned to the G code is slightly lower than your follow-up code or a new patient evaluation code. So it doesn't make any feasible sense for the specialists to kind of pick up on that specific code. Any other questions? Yes. I guess I may have missed this, but early on, you mentioned that there was some good news to follow along with the bad news. What was that? I'm sorry. We're still searching for it. I think I live in Washington DC, so we're just doom and gloom right now anyway. But I think in general, I think some of the information that Dr. Techmeister talked about with some of the laws being introduced that perhaps would kind of result in a 5% swing is part of the good news. I think there's been some battles that have been won through lobbying that is part of the good news. Do you want to say something more about that? The good news is that we can do something about it. And I don't think that a lot of people really realize that. It's like, oh, well, this is what it is. This is what Medicare is doing. But we have seen a positive, substantial change with lobbying advocacy at the policy level locally and regionally. If we can better group together as physicians as a whole on a national level, there is a pathway for change. But we have to be involved. I agree 100%. It is a Herculean task. It requires crossing the aisles and coordination between all our national and state societies to come together. There are multiple societies on the spine and pain side. And it will require a concerted effort irrespective of what the value propositions are for those individual societies. If all the societies don't come up together to fight for physician voices, patient voices, I think both the insurance industry and the hospital association industry will continue to win by the divide and rule policy of dividing physicians among themselves. Last time I checked, there were 62 pain societies in the United States if you include the state societies. That's not a sustainable thing. And I'll add on to that. We also have, for those of you who are familiar, we've got the multi-specialty pain work group. So that's a collaborative of, I think, about 30 or so societies that jointly often will write letters, sign letters, and are pretty active with regards to pain policy, reimbursement policy. I'm actually the NPW representative for AAPMNR. So every time, different societies take the lead typically on different issues. And then we decide as a society whether we're going to sign on or not depending on the issue at hand. But those letters that have multiple societies signed on are certainly more powerful than those that are led by individual societies because they know that the pain space is so fractured. It is, honestly, if you were really looking to make a big change, like lobbying is a full-time job, right? I mean, there are the AMA, the AHA, the industry partners that we have. They all have full-time government affairs people in DC. There is no pain lobbyist in DC. It's difficult to afford a pain lobbyist because the basic salary level or a fee level for a pain lobbyist in DC is about $150,000 a year. So you'd have to have a situation where either one society came up with that money or multiple societies came together to come up with that money to have someone there for a full-time presence. I was actually one of the first NANS legislative fellows on the Hill, Dr. Leong, who's an anesthesiology pain person at Stanford, and myself. And the level of knowledge and information on Capitol Hill about pain is, I mean, it's all over the map. Some people think all we do is prescribe opioids and do acupuncture. Other people think we do all these sophisticated things. But the general level of knowledge is very, very, very low. And that's on one end, on the congressional side. On the insurance side, they sort of count on us being fractured and fragmented and then not having sort of a response like these guys talked about that's more comprehensive. Any other questions? Yeah. Rehab site would have bankrupted about 70,000. and how little they know exactly what you're saying about just health care and like community, you know, that few rehab hospitals are offloading the burden. Thank you. Well, I think, well, ultimately I think that the issue you're articulating is that they're they're much more organized than we are, right? So well, but part of the reason they have more money is because they're organized and they represent a common voice. If you had every doctor giving, let's say $500 to the AMA, you'd have, you'd have a pretty substantial pot of money, but 30%, maybe less than 50% for sure of physicians actually belong to the AMA. The most powerful lobby in the non-AMA in the, that represents physicians is the orthopedic surgeons who donate about four to $6 million annually, right? So the pain or pain, spine care, physiatry, we don't, we don't approach even remotely those kinds of numbers. Any other orthopedics doesn't seem to be struggling as much as we seem to be struggling at times. If you think about the level of evidence that spine surgery has compared to the level of evidence we have, it's not much different, but have you ever seen a spine surgery complaint about not getting paid? Not very often, right? So as a member of the spine pack, which is a NAS lobbying or political activity organization, a lot easier to get an ear of a representative via NAS than it is via AAPMNR. That goes to the amount of money that is available to NAS versus AAPMNR versus an endocrinology organization or pediatric organization, if you will. I think it's coming. I actually have an arbitration scheduled for Tuesday that our patient was able to set up on their own in order to get coverage for a procedure that's not covered by his local plan, but it's covered by almost every other plan. And unless we get buy-in from outside of the physician realm, we can't do it by ourselves. And to your point, I think patient involvement is going to be key. So we have one question that came in online that I'm going to ask both of you guys, and I can try to answer it as well. Has anyone determined which pain CPT codes were the most frequently denied or required appeal? Do you guys have any comments on those? Maybe you can both take a shot at it. Or I can take a shot at it. I think it's a regional analysis. It will vary from one region of the country to the other. And also, the pair mix in your region, it's going to be really hard to pinpoint the exact distribution of which codes are denied in a higher rate. I can give my example. Where I practice, one Blue Cross Blue Shield third party administrator covers 82% of lives. So we have a PNS, peripheral nerve stimulation non-coverage policy. So almost every single one of our requests for peripheral nerve stimulation, if it's not Medicare Advantage plan, will get denied. So it will vary in my region as opposed to yours. I think to answer that question, I think there's three buckets. There's the documentation bucket, which is probably really the most important, which is that all too often, our documentation doesn't meet the minimum standard for approval of a procedure. So that's like, for example, has the patient done four to six weeks of physical therapy? Or have they done an NSAID before they can get an MRI? That's just one example. In our region, we tend to have these sort of one-offs with intraarticular facet injections as an example, where you get denials or you have to do appeals. Any new procedure, anything that's got a CPT, but sort of coverage is not clear, you might as well prepare the patient for a very long wait. So two examples of that probably are basal vertebral nerve ablation and restorative neuromodulation. If you talk to your patients about that, you just sit them down and say, this is going to be three to six months. And even at the end of that three to six months, you may have a negative answer. And so I think that's, so documentation is key, preparing the patient appropriately for what might be coming is, I think, also an important part of that. Do you have something you wanted to add? I don't know what the most common is, but I've had everything denied from MRIs to lumbar epidurals to facet injections. But on appeal, and like most anybody else, if you actually get on the phone prior authorization, I'm sure the reversal rate's probably upwards of 90% on some of the denials. Some of it could probably be avoided with documentation, like Dr. Desai said, and making sure you hit the bullet points that are able to be read by the third grader who's reading that note. And that's a line that my mentor used a lot, is you just have to make the documentation as simple as possible so the person that's reviewing it can understand what you're trying to say and trying to convey. That would go significantly towards reducing those. But even generic medications have been denied. So it just depends on the policy, depends on the plan, depends on the group, depends on the region, depends on the MAC and the LCD. And there's so many variables that I don't think there's a good answer. Yeah, and I think even now, I mean, I think we could probably all attest to this. And folks who do a lot of neuromodulation, we're starting to actually see a lot of pushback on spinal cord stimulation. There's a bigger delay in terms of getting authorizations for spinal cord stimulator trials and implants, even if they have greater than 50% relief. Even if they've done the psyche valve, you're getting this long period of time after you've done the trial to get Medicare approvals for it. And sometimes they're not getting approved. You have to go back and redo your documentation to get approved. But with that, I think we will thank you guys all for attending. Have a great rest of the conference. And thank you very much.

Billing

Coding

Spine Management

Pain Management

Reimbursement

Regulatory Compliance

FDA Approval

CPT Codes

Policy Advocacy

Healthcare Reform