Phorest & Trees 11/2020

 

Phorest & Trees Sharing the things I’m reading but not eating

COVID infection: Not recommended based on recent anecdotal evidence I meant to send this email out 2 weeks ago (around thanksgiving) but me and my family were afflicted with COVID-19. We are all fine now. Thank you for the many people who reached out with kind wishes.

Brachial Neuritis in the news Thanks to Dr. Bitterman for the link. I would recommend minimally knowing what is in this article because it is being read by your patients.

The Biphasic SNAP

For those of you I have taught some volume conduction theory concepts, I typically admit defeat about the biphasic SNAP. Theoretically it should be triphasic with an initial positive deflection. So I asked Dr. Dumitru to explain it and I finally do. This is not for the faint of heart. Actually it’s really not for anyone except true geeks. So I recommend you not click on this.

Fraud and Abuse

Are you at risk for penalty by the OIG for the talks you’re giving? AANEM advocated for Bipartisan H.R. 8780 which addresses quality in EDx medicine. The bill addresses “ongoing problems with EDX fraud and abuse, as well as poor quality EDX testing, by unqualified providers, many of whom are using substandard EDX equipment.” It was modeled after the approach taken by mammography and sleep labs who faced similar battles. See the attachment for details. Click here for AANEM advocacy.

More about Coding 2021

There was some confusion about the modifiers 25 and 26. I asked the coding expert at AANEM and this is what she shared (along with a great attachment explaining why insurance companies should pay us for same day EMG and E&M) “Modifier 26 is typically used in a hospital setting. Each code is made up of three components:  a professional component (physician work), a technical component (supplies, equipment, etc.) and liability. For physicians who work in a hospital system, the hospital needs to bill for the technical portion of the code and the physician bills for the physician work part of the code.  Modifier 26 is what the physician would use to do this and the TC modifier is what the hospital would use.        Modifier 25 is used to establish that there was an identifiably separate E/M performed on the same day as a procedure. This is done because inherent within each procedure code is time to perform a basic evaluation and management. There are many instances where it is appropriate to bill for an E/M on the same day, but modifier 25 needs to be used with the appropriate E/M code in those instances.  I have attached AANEM’s position statement Billing for Same Day Evaluation and Management and Electrodiagnostic Testing which details some common scenarios where it is OK to bill for an E/M on the same day as an EDX procedure.” Thanks to Ethan Colliver for this link. ·         One of our graduates at a large non-VA institution who frequently lectures on coding had this to offer (which I agree with): “My very simplified impression of the new coding rules is that the MDM rules are basically the same, the level of service was always really determined by MDM, now they more explicitly state the HPI and bullet points in the PE don’t matter (thank goodness).   If you do a procedure same day as the visit it gets a -25 modifier. If you are doing a test (EMG) then you can't double dip by reviewing it in an E+M visit the same day. AANEM has very strict criteria as to what denotes medical necessity for doing an E+M visit on top of the EDx visit. I rarely bill a f/u visit if i am doing EDx (or a new patient for that matter) , and if i did the medical decision making is not explaining the EDx (that gets reimbursed with the EDx codes) its ordering medication, discussing other problems, ordering PT and having a discussion about planning and other treatment options not related to the usual counselling expected from an EDx visit.  Don't be fooled by the new rules...if we don't continue to have robust H+P we will see denials go up for advanced imaging and procedures.  (Which i am already seeing and others have mentioned too). I don't expect my average LOS to change a whole lot, hopefully documentation will be quicker. My new plan is to shrink my notes significantly..especially since patients will be able to read them more easily. I fear every word I write will be scrutinized by certain patients and it's just not worth the time. I will template more things to ensure studies and procedures get covered.”

Revenge of PMR Poster Boy

This is the universe getting back at me for the last one. Ugh. I should have sent a newer picture.

Trees

To my brain injury folks. Using music to awaken the mind. If you watch, please do so to the end. Next time you’re on Netflix, look up Crip Camp: A Disability Revolution. Why we don’t use sterile water with our botox?...cuz it hoitz! When you’re at the VA, check out the Atlas of orthoses and Assistive devices. (Link likely won’t work outside the VA.) thanks dr. edmond. Also of interest is the Atlas of common pain syndromes (Attendings may like the Atlas of Uncommon Pain Syndromes) A patient of mine wanted a referral for “TMR” to address pain; I am quite familiar with its use in prosthetic control but not pain. If anyone has experience with this, please contact me. TMR consists of a nerve transfer of residual peripheral nerves to otherwise redundant target muscle motor nerves. When TMR is performed on an amputee, the residual peripheral nerve is mobilized and any neuroma is excised. The native motor nerve of the target muscle is then located through nerve stimulators and transected near the muscle. Lastly, the residual peripheral nerve is coapted to the motor nerve, close to its point of entry into the muscle. New knowledge of specific chemo induced CNS neurotoxicity: CD19-directed immunotherapies are clinically effective for treating B cell malignancies but also cause a high incidence of neurotoxicity. The result is that a subset of patients treated with chimeric antigen receptor (CAR) T cells or bispecific T cell engager (BiTE) antibodies display severe neurotoxicity, including fatal cerebral edema associated with T cell infiltration into the brain. Swimming benefits autonomic responses.

Phorest and Trees early November 2020

 

Phorest & Trees Sharing the things I’m reading (big or small) Many more trees this time. Enjoy!

CODING 2021

See attached for my long awaited summary of the upcoming coding changes. Admit it you’ve been waiting with baited breath.

Ground Round Discussion

There was some recent controversy surrounding the role of the Ground Electrode. I have attached Larry Robinson’s articles on the ground electrode as well as the forum discussion involving dr. Dumitru and Robinson. (I almost spat my lunch out on the screen while reading the last of dr. robinson’s hilarious posts.)

Who says VA aint GQ?

The NJ VA’s very own Dr. Rex Ma is the poster boy for AAP and VA/ECU attending Dr. John Norbury is the same for AANEM. Who says we VA docs can’t be GQ?

Is it ethical to test the asymptomatic limb?

I found the answer by Dr. Stalberg to this question to be all encompassing on the AANEM forum. If you find this stimulating, I encourage you to lurk on the forum and read our gods and demigods discuss practical stuff. Enjoy:   I think that there are often indications for bilateral studies, also with unilateral symptoms. As you indicated, for a side-comparison with age,height,temperature (BMI) matched values.( In our lab we have all reference values normalized for age, height, and keep control of temperature and distance, but still often make bilateral testing for neurography.) We find that absolut bilateral values may be within refernce limits, but the side difference is outside (lab ref values), It may be essential to rule out generalized EDX abnormalities, in spite of unilateral symptoms. (mononeuritis multiplex/pnp, CTS, ulnar entrapment…). Particular for neurography. If the patient has bilateral symmetrical symptoms, unilateral study may be enough to assess type of pathology. For EMG, the situation may be more tricky. Requires usually quantitation. Examples of recommended bilateral studies: MND question in a patients with one-sided symptoms, atypical radiculopathy and more…... As you see, I give different suggestions for neurography (CAMP ampl, and latency, F-latency and persistence, sensory amplitudes) and EMG. You asked if it ethical to make bilateral studies in unilateral symptoms. One can also ask if it “ethical” of professional to make just local studies and miss important subclinical information. Usually very easy to explain the strategy to the patient.

CRS Socket Design

No it doesn’t stand for “can’t remember s%$t” in this case. Attached is my summary of an atypical socket design that uses alternating pressure and release built into the casting process to allow for more efficient motion. The original article lightly touches on the physics but I thought it was very well written and easy to understand. I am in the midst of discussions with prosthetists who have actually (Thanks to Dr. Shenoy for the reference!).

Diabetes stuff

My deeper interest owing to my own diagnosis Reinforcement that speaking conversationally (I personally even go colloquially) with patients may improve outcomes.  Mismatches between oral glucose tolerance testing and A1c. False positives? Gila monster venom: Exenatide, (Byetta or Bydureon) CGM gets easier to obtain from the VA and DoD

Trees

Why we don’t use sterile water with our botox?...cuz it hoitz! Hi-tech bandage for wound care for my SCI friends When you’re at the VA, check out the Atlas of orthoses and Assistive devices. (Link likely won’t work outside the VA.) thanks dr. edmond. Also of interest is the Atlas of common pain syndromes (Attendings may like the Atlas of Uncommon Pain Syndromes) A patient of mine wanted a referral for “TMR” to address pain; I am quite familiar with its use in prosthetic control but not pain. If anyone has experience with this, please contact me. TMR consists of a nerve transfer of residual peripheral nerves to otherwise redundant target muscle motor nerves. When TMR is performed on an amputee, the residual peripheral nerve is mobilized and any neuroma is excised. The native motor nerve of the target muscle is then located through nerve stimulators and transected near the muscle. Lastly, the residual peripheral nerve is coapted to the motor nerve, close to its point of entry into the muscle. New knowledge of specific chemo induced CNS neurotoxicity: CD19-directed immunotherapies are clinically effective for treating B cell malignancies but also cause a high incidence of neurotoxicity. The result is that a subset of patients treated with chimeric antigen receptor (CAR) T cells or bispecific T cell engager (BiTE) antibodies display severe neurotoxicity, including fatal cerebral edema associated with T cell infiltration into the brain. Vocab: STRUT ACDC is back!

 

Phorest & Trees 2020-10

Phorest & Trees Sharing the things I’m reading (for better or worse) Hope you enjoy the new look!

AANEM Guidance on the upcoming 2021 CODING CHANGES

Some of you are probably already aware of the upcoming changes to E&M office visit coding. If you’re interested in their take on it, there is a comment by them from earlier this month and this recent Q&A by AANEM. That article led me to this link at the AMA. I plan to do a summary of the new coding in the future but for now, if you’re wondering how it will affect your electrodiagnostic coding, heeeeere’s Carrie!

Physiatrist’s Coding Cheat Sheet

And even though the timing couldn’t be worse (see above), I’ve finally completed a coding cheat sheet that I’ve been slowly putting together. It’s weird because the front is bifold and the back is trifold. So you will have to pick how many folds are important to you. Also, it’s not super easy to understand without some explanation but I offer it anyway. See attached

Pulley my Finger

I know everyone gets jazzed about seeing things on ultrasound, but how cool is it when you can see things intra-operatively… Attached are pictures of the A1 pulley (often attributed to triggering) and the tendon after release. Just for fun.

Goodbye Dr. Weinberger

Those of you who have rotated at the VA may remember Dr. Larry Weinberger, neuropsychologist who performed many of the comprehensive TBI evaluations. He’s been a close friend of us physicians and we are going to miss him as he leaves for retirement. Attached are a few pictures of us (temporarily removing our masks) posing for pictures.

Injectology stuff

This study of PRP + HA is making the Doximity rounds. I really liked what they measured and found but can’t say I totally agree with the conclusions   This study on PRP for RTC disease did not show superiority to corticosteroid injections. It’s always interesting to me that most of these studies have some form of “steroids don’t offer long-term benefit.” I personally never expect them to do so but rather use them as a way of offering temporary relief so that the patient can fully enroll themselves in the therapy which will actually address the underlying issues. We already know that muscle, tendon, and even ligament will remodel if forces are applied through them. I suppose the advocates of “PRP vs steroid” want to kickstart that process.

MILESTONES & BOARD Scores

I remember when my good friend/mentor, Susan Garstang was tasked with coming up with milestones as mandated by the ACGME. Personally, I thought it was an upgrade from what we had before. A recent publication by some reputable names in our field tell us that they do have some predictive value for board scores.

AANEM Meeting 2020

it was fantastic. They set a high bar for what a virtual meeting can be. Residents were asking for the link where is here. I believe you have till the 9th or you can purchase 3 years of access to the lectures. Devin Rubin’s “You make the call” series has everything you need to know about needle emg. I attended a session with Larry Robinson where I directly got to ask him questions that are going to change my practice. (Ben Levy, let’s talk about inching again!)

MUSCLE ULTRASOUND

Other than MSK, there is a lot of research into muscle in various conditions. Attached is an early look at a review from Muscle and Nerve

Natural Medicines

After watching a 1 hour info session on this, the bottom line is this website.

Trees

Burn pit exposure gets some attention. Unfortunately many of my veterans express consternation with this so I found it a good read. An attempt to offer objective benefit of Cupping. Doesn’t matter if you don’t address the underlying issue. DMARD switching and mood disorders Recently a book came out on mental health in musicians reviewed in Mix magazine. I attached a screenshot of that article. Are you stuck in Act1 of your life, or are you ready to take the red pill? The residents shared the cute attachment on the etymology of well-known candy bars.

 

Phorest & Trees 2020-09 B

 

HI all,

Hope everyone is doing well. If you are on Spotify, enjoy some music from my band.  Otherwise, here’s what I’ve been reading.  Hope you enjoy.

-gautam

 

Journal of Bone and Joint Surgery Summaries

4 paragraph Summaries with references to get a quick sense of the current knowledgebase

• Rehab strategies in THA. Is formal PT needed? Does prehabilitation work?
• Adhesive capsulitis Is stretching enough>? Which stretches? Injection?
• CMC OA etc

Injections

• Attached is an editorial critically addressing the role of intra-articular placebo and limitations of existing guidelines in answering the question of whether to inject or not to inject.
• Nothing has really changed in terms of practice based on 20% response rate from 3400 ASSM surveyed: It appears that triamcinolone and methylprednisolone are the most commonly‐used corticosteroids for sports medicine physicians; most physicians use 21‐40mg of corticosteroid for all injections, and lidocaine is the most‐often used local anesthetic; very few use ropivacaine. Over a third of respondents used high‐dose (>40mg triamcinolone or methylprednisolone) for at least one joint or bursa.
• Trigger point injections are safe…aren’t they?
• Degenerated meniscus? Stick some fat in it. Thoughts?
• Did you ever notice that some of these veterans with bone on bone OA have no pain? Well it aint just veterans… residents will benefit from reading the lit review in the background section to understand the long-standing (no pun intended) issues with imaging in OA

Hematoma Risk after Needle EMG with NOAC

Attached is a study looking at risk of Hematoma after newer oral anticoagulant use

 

AANEM STUFF  You guys specifically asked for more AANEM updates. So here they are.

• The 2020 annual meeting is full of interesting stuff, is virtual, and is super affordable this year. Our residents should be able to attend for free. Here are the details of the schedule.
• There is a new ultrasound certification through the AANEM
• I will follow up with things learned at the conference

Evaluation of persons with suspected lumbosacral and cervical radiculopathy part II

• Attached is part 2 of the Dillingham et al Monograph
• See prior emails for part 1

ADA Issues New Guidelines for Pharmaceutical Management of Type 2 Diabetes

This is a quick read and very high yield. Being diabetic myself, I was interested to know what has now become the standard. Us old guys didn’t learn in medical school about SGLT2 inhibitors, GLP-1 Ras, and DPP-4 inhibitors. But these medications have changed the face of diabetes.

 

The Empathy Gap

To some extent this is what we are taught — to compartmentalize and dissociate in order to stay focused on the delivery of care — but is it doing us any favors?

 

Fellowship is popular among physiatrists:  The results of this survey demonstrate that majority of graduating residents are matriculating into fellowship training with pain, spine, and/or sports medicine being among the top choices.

 

Opening for Chief of SCI Position Memphis TN VA: For any further information, please contact Anita R. Patel via email @ Anita.Patel1@va.gov or via phone @ 901-577-7346.

Please send CV/Resumes of interested candidates to L’Keyla.Walker@va.gov.

 

 

 

Gautam Malhotra MD

Physical Medicine & Rehabilitation Service - VANJ Health Care System

Director of Strategic Development

Director of VANJ Polytrauma

NJ Liaison to VA Amputee System of Care

Clinical Associate Professor, Rutgers New Jersey Medical School

Diplomate, American Board of Physical Medicine & Rehabilitation

Certified by American Board of Electrodiagnostic Medicine

Certified in Subspecialty of Neuromuscular Medicine

Certified in Subspecialty of Brain Injury Medicine

Phorest & Trees 2020-09

 

Hope you all had a wonderful labor day weekend.

 

Phorest

 

• Attached are 2 summaries of the VA’s “OWN THE MOMENT” initiative offering seemingly easy but important points to consider as we move through our day.
• Attached is an excellent introduction to peripheral neuropathies by on of the greats (Dyck) for a practical approach to diagnosis and management.
• The AMA has published an update to CPT that includes two new codes associated with the pandemic. See here for the AANEM description.

 

Trees

• The C-Brace is ottobock’s passive hydraulic microprocessor orthosis. Allows any orthosis design as long as the C-brace is attached. It is sealed but no water proof. Contraindicated in >10 deg hip flexion contracture, excessive knee flexion contracture, in ability to translate femur anteriorly. Variable stance and swing. Allows for walking backwards, slopes, descending stairs. Adjustment via app. 225 pound limit.
• At the 2019 AANEM, during a “Challenging Cases” roundtable discussion, the “Neck Tornado Test” was brought up as a supplement to the Spurling maneuver. Attached is my summary of the article describing it (Juyeon Park et al International Journal of Medical Sciences 2017; 14(7): 662-667. doi: 10.7150/ijms.19110)
• Antidiabetics, Statins, and the Risk of Amyotrophic Lateral Sclerosis (ALS) !!