1. Future Medical Cost Projections
Module 4
Common Treatments, Part 2

2. Common Treatment Modalities
Overview
Discusses common treatment modalities for pain pumps, medications, surgeries
Objectives
Be able to list at least 5 categories of medications
Be able to name the 3 major categories of orthopedic surgery
Be able to determine types of laboratory most often required
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Common Treatments
Medical
Injections
Spinal cord stimulator
Pain Pump
Medications
Laboratory
Diagnostics
Surgery
Therapy
Equipment
Physician
Home Care
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Pain Pump
not as commonly encountered since SCS used more frequently
Multiple medications typically prescribed
Combination of medications used for both nociceptive and neuropathic pain
Costs associated with pain pump
Installation
Replacement units
Monthly refills
Office visits
Very/very expensive
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Medications
Significant lifetime cost exposure
Clients provide current list of medications
Spell name, read off bottles
Verify, if able, through medical records
Retail pricing: goodrx.com/CVS pharmacy
Use generic if available
Compounded drugs
Try contacting dispensing pharmacy or supplier
Reluctant to provide information
Allowance of $300 per month if unable to obtain pricing
Actual cost can be as high as $1800 per month
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Common concerns
Off label use
Patent expiration
Pre-existing conditions: prior medications
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Typical categories
Anti-inflammatories (NSAIDS)
Analgesics
Narcotics
Muscle relaxers
Sleep aids
Psychotropic ED
Topical
Inhaled
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Laboratory
CBC, CMP, venipuncture (liver and kidney function)
1-5 prescriptions: 1 draw per year
5+ prescriptions: 2 draws per year
Endocrine testing as needed
Therapeutic levels of certain medications
Klonopin
Coumadin, heparin
Anti-seizure meds
Urine drug screening: 4 per year allowance
Blood studies are monitored by family practice, include visits corresponding with draws
Urine testing is monitored by pain management physician
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Diagnostics
MRI, CT, xrays
Frequency
Factors
Severity of injury
Prior surgery
Degenerative condition
Multiple sites of injury
Projection
Every 5 years for conservative cases
Annually for more complex cases
Lifetime allowance
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10. Professional Component
Every diagnostic procedure has a professional component for interpretation
CPT modifier -26 denotes professional component
Include both the CPT code for the diagnostic procedure and the CPT code/-26 for the interpretation
Example:
Xray of knee, 4 views CPT $39.00
Professional component CPT $17.00
Total cost $56.00
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Surgery
Arthroscopy: used to visualize, diagnose, or treat, most often joints of the shoulder, hip, knee, ankle, wrist
Arthroplasty: reconstruction or replacement of a joint, most often joints of the shoulder, hip, knee, ankle
Arthrodesis: immobilization of joint by fusing adjacent bones, most often the spine or ankle
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Shoulder
Shoulder
Ball and socket joint
3 parts of the replacement: lining, ball, pin
Partial or full replacement or revision
Lasts approximately years
Also reverse shoulder replacement which limit range of motion
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Hip
Hip
Shallow ball and socket joint
3 parts: lining, ball, pin
Dislocation a common complication
Lasts about years
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Knee
Knee
Hinge type joint
Extensive physical therapy following replacement
Lasts years dependent on level of activity
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Ankle
Ankle
Limits motion and function
Contributes to gait derangement
Leads to back pain
Not commonly performed
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Spine Surgery
Laminectomy, Laminotomy
Relieves radicular pain
Excision of disc material only
Most often followed with fusion type surgery
Fusion
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Laminectomy-otomy
Lumbar stenosis
Open decompression
Provides unrestricted neural pathway
Reduces pain, leg weakness, neurological symptoms
--otomy: incision into lamina
--ectomy: removal of lamina
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Fusion
Arthrodesis
Installation of hardware to stabilize adjacent vertebrae
Considerations in cost projections
Hardware in/hardware out
Future fusion at adjacent levels
Implanted hardware, caution for MRI
Approaches
Posterior: lumbar spine
Anterior: cervical spine
Swallowing difficulty, hoarseness
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Homework
Compile a list of replacement scheduling for all major joint replacements, create cheat sheet
Create cheat sheet for CBC, CMP, venipuncture CPT coding and mid-range cost using usual/customary fee schedule
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Contact Information
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