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!