New TPI restrictions?

[Multimodal]

well CMS is at it again! making our jobs harder with every new LCD update. this time trigger point injections are coming under fire. you know, because a $50 reimbursement is really breaking their bank. Anyway, the part that has me most concerned is this line about limitations below. it looks like they are only allowing TPI with local anesthetics. while not specifically calling out steroids, "Any other injectate" seems very vague and could include steroids in my opinion which sucks because in some cases I genuinely find they help TPI last much longer.

"Limitations: A TPI involves the use of local anesthetic and does not include injections of biologicals (e.g., platelet richplasma, stem cells, amniotic fluid, etc.) and/or any other injectates."


What do you all think ?

here is the link to the updated LCD: LCD - Trigger Point Injections (TPI) (L36859)

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[cowboydoc]

Having read only the above, it sounds like they are trying to block the people trying to get paid for non-covered procedures.

 

[Agast]

They’re saying stop billing Medicare for your cash pay stem cells

 

[Ducttape]

first, Agast is right.

second, there is very little data that suggests steroids really provide any benefit over local alone, and there is potential risk for complications when adding them.

 

[Multimodal]

They’re saying stop billing Medicare for your cash pay stem cells

woa woa woa, wallet biopsies are my #1 procedure!

that's the impression that I get too but our billing people are freaking out about this now. I don't do it for all patients but those with clear very symptomatic trigger points do seem to get much longer relief with steroids vs LA alone. contrast this to the more widely distributed myofascial pain, those patients arent going to respond with or without steroids.

 

[clubdeac]

we just quit offering TPIs a few months ago b/c of this. I never did many of them anyway.

 

[Multimodal]

we just quit offering TPIs a few months ago b/c of this. I never did many of them anyway.

honestly probably what I'm going to have to do as well. just another chip out of the crumbling block that is procedural based pain management. I thought universal healthcare would be the nail in the coffin of our profession but now I think the insurance companies are going to beat them too it.

getting pretty tired of being punished for doing nothing wrong.

 

[Laryngospasm]

Well in their defense while we may only get 35$ before taxes the hospital charges the patients 800$ or so. I have some patients that do well with these.
I’ve been saying they will deny these soon.. with many insurances requiring prior auths for these now. I realize not everyone is HOPD but that’s been my experience.

 

[Agast]

Steve must be busy. He is very anti steroid in trigger point injections 🙃

 

[Dr. Ice]

Just use toradol instead

 

[bedrock]

I agree steroids are not good idea in TPI.

However for patients without contraindications, I add 30 of Toradol which can be quite helpful.

 

[Multimodal]

Just use toradol instead

cant use toradol either. new LCD only allows for local anesthetic. next LCD update will probably say they're experimental

 

[nvrsumr]

I haven’t done a tpi in years but mainly because the PTs love dry needling everything and doesn’t pay.

I also didn’t use steroid but who cares. The level of micromanagement of drs medical decision making is unsettling.

I’m glad im on the back 9 of my career.

 

[SSdoc33]

what is this BS?

so do i have to get prior auth for a TPI now? i cant just do it on a new patient eval?

also, no need for steroids anyway

 

[Laryngospasm]

If you actually read it good luck meeting those guidelines completely…. Impairment in adls, 50% improvement for 6 weeks, functional assessment before and after injection.. it will cost you more to do one that you get paid. If they ever audit you there’s no way you’re meeting all the requirements. They are simply legislating out of existence so many procedures through through red tape it’s going to be impossible to get anything done.

“

1. Coverage Guidance​

   Coverage Indications, Limitations, and/or Medical Necessity
   Initial Trigger Point Injection
   Trigger point injections (TPI) will be considered medically reasonable and necessary to treat myofascial pain caused by trigger points when all the following requirements are met:
   1. There is a focal area of pain in the skeletal muscle.
   2. There is clinical evidence of a trigger point defined as pain in a skeletal muscle that is associated with at least 2 of the following findings: the presence of a hyperirritable spot and/or taut band identified by palpation and possible referred pain AND
   3. The physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber harder than normal consistency with or without a local twitch response and referred pain AND
   4. Non-invasive conservative therapy is not successful as first line treatment OR movement of a joint or limb is limited or blocked OR the TPI is necessary for diagnostic confirmation.
   Subsequent TPI
   Repeat Trigger point injections previously injected trigger points will be considered medically reasonable and necessary to treat myofascial pain syndrome when all of the following requirements are met:
   1. There is a positive pain response from the most recent TPI defined as providing consistent minimum of 50% relief of primary (index) pain after the TPI measured by the SAME pain scale* at baseline and post-injection AND
   2. Consistent pain relief from the most recent previous TPI lasting at least 6 weeks1 AND
   3. The myofascial pain has reoccurred and is causing objective functional limitations measured by a functional scale obtained at baseline and after TPI which demonstrated at least 50% improvement from the previous TPI.
   *NOTE: The scales used to measure pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.
   Limitations: No more than three (3) TPI sessions will be reimbursed per rolling 12 months.
   Requirements:
   1. Patients should be part of an ongoing conservative treatment program and documentation to support the patient is actively participating in a rehabilitation program, home exercise program or functional restoration program is in the medical record.
   2. Trigger point primary index pain must be measured prior to the injection at the beginning of the session.
   3. The post procedure pain level must be measured after the TPI at the conclusion of the session u sing the same scale* utilized at baseline.
   4. When documenting the percentage of pain relief from the primary (index) pain compared to the post-injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of the duration of pain relief. The documentation should include a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection and the specific dates the measurements were obtained using the SAME pain scale* used at baseline.
   5. When documenting the ability to perform previously painful movements and activities of daily living (ADLs) it is insufficient to provide a vague or nonspecific statement regarding the improvement of previously painful movements and activities of daily living (ADLs). The documentation should include a functional assessment to show clinically meaningful improvement with painful movements and ADLs, if this metric is used to justify the efficacy of the TPI Provider should use established and measurable goals and objective scales to assess functionality and ADLs measures.
   Limitations:
   1. A TPI involves the use of local anesthetic and does not include injections of biologicals (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other injectates.
   2. It is not considered medically reasonable and necessary to perform TPI into multiple muscle groups in different anatomical regions during the same session.
   3. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, etc.) during the same session as TPI.
   4. Trigger point injections for treatment of headache, neck pain or low back pain in absence of actual trigger points, diffuse muscle pain, a chronic pain syndrome, lumbosacral canal stenosis, fibromyalgia, non-malignant multifocal musculoskeletal pain, complex regional pain syndrome, sexual dysfunction/pelvic pain, whiplash, neuropathic pain, and hemiplegic should pain are considered investigational and therefore are not considered medically reasonable and necessary.
   5. Use of fluoroscopy or MRI guidance for performance of TPI is not considered reasonable and necessary.
   6. The use of ultrasound guidance for the performance of TPI is considered investigational.
   7. Trigger point injections used on a routine basis, e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes are not considered medically necessary.

 

[lobelsteve]

Steve must be busy. He is very anti steroid in trigger point injections 🙃

Any idiot who puts steroids in a tpi is not a pain physician. Wasting a steroid dose when literature clearly shows no benefit in an unproven finding (trigger point) is not the practice of medicine.

 

[oneforfighting]

well CMS is at it again! making our jobs harder with every new LCD update. this time trigger point injections are coming under fire. you know, because a $50 reimbursement is really breaking their bank. Anyway, the part that has me most concerned is this line about limitations below. it looks like they are only allowing TPI with local anesthetics. while not specifically calling out steroids, "Any other injectate" seems very vague and could include steroids in my opinion which sucks because in some cases I genuinely find they help TPI last much longer.

"Limitations: A TPI involves the use of local anesthetic and does not include injections of biologicals (e.g., platelet richplasma, stem cells, amniotic fluid, etc.) and/or any other injectates."


What do you all think ?

here is the link to the updated LCD: LCD - Trigger Point Injections (TPI) (L36859)

Do you get updates on CMS changes?

 

[drrosenrosen]

I'd like to do cash pay for these, but medicare won't let you charge for a covered service, even if they don't pay enough to justify doing it. I have been sending more pts to a local PT who does good dry needling

 

[pmrmd]

I will inject the facet capsule with dex/marcaine if people have bad RF neuritis and call it a TPI.

Oh well.

 

[callmeanesthesia]

I will inject the facet capsule with dex/marcaine if people have bad RF neuritis and call it a TPI.

Oh well.

Same. I guess I’ll just do a steroid shot during an office visit, and only bill for the office visit…

 

[Laryngospasm]

Same. I guess I’ll just do a steroid shot during an office visit, and only bill for the office visit…

I thought Medicare considered it fraud to do some and not bill for it?

 

[callmeanesthesia]

I thought Medicare considered it fraud to do some and not bill for it?

I guess I’d bill it, but with modifier GZ? As far as I know that causes an automatic denial on Medicare’s end but will not result in a bill to the patient because no ABN was issued.

 

[powermd]

I've been charging $100 cash for US guidance on most of my soft tissue injections for a year now (if ins won't pay 76942). For the odd fluoro-guided TP, I'll do the same for that. My TPs are not true trigger points anyway, it's fascia plane hydrodissection. I can't remember the last time I palpated a "taut band". So if I start billing for the US and a visit, while doing the block for free, I'm not breaking MDCs rules since I'm not doing a covered procedure. And F them for that list of rules. Insane.

 

[MitchLevi]

TPI do not require US (ever).
Do not use steroid in a TPI.
Occasionally drop a little Toradol in there but don’t bill for the Toradol.
TPI are effective and should be used on occasion.

 

[Agast]

TPI do not require US (ever).

I had to use ultrasound in order to get it approved by workers compensation

 

[CleanUp]

I find it quite incredible most physicians will accept this BS ruling and try to do such creative workarounds and then not even bill a 99214 for a mbb follow up.

 

[callmeanesthesia]

I find it quite incredible most physicians will accept this BS ruling and try to do such creative workarounds and then not even bill a 99214 for a mbb follow up.

I was thinking the same thing. But where were our specialty societies on this issue?

 

[SSdoc33]

Again, do I have to now get a prior auth for TPIs?

So stupid

 

[soccrwz]

TPI do not require US (ever).
Do not use steroid in a TPI.
Occasionally drop a little Toradol in there but don’t bill for the Toradol.
TPI are effective and should be used on occasion.

otherwise agree, but doing a TPI if near the lung is extremely reasonable, even if they have a lot of fat to know your in the muscle and not the adipose layer, its one of the most common lawsuits associated with Pain management practices due to PTX

 

[powermd]

TPI do not require US (ever).
Do not use steroid in a TPI.
Occasionally drop a little Toradol in there but don’t bill for the Toradol.
TPI are effective and should be used on occasion.

If you're just blindly stabbing the muscle, I would agree. I do fascia plane hydrodissection, which needs US to do it well. Does it work?

Well, last August I went biking 14 miles which was apparently beyond my conditioning level. I began having pain in my left gastroc that wouldn't go away. It started to stiffen. Running and biking became impossible because it would flare up. Six weeks into this I went for a little nothing hike with the kids and spent the next two days hobbling around the house with the thing in spasm. So what did I do? That Monday I examined the achilles with my US. It looked fine, and the pain was at the musculotendinous junction. I did a gastroc fascia plane hydrodissection with 10 mL of 1/8% bupi. No immediate change, but over the next five days it settled down and I tried running again. No problemo. Biking- fine. Pushed the pace on running- it kept getting better. And then it happened on the right. I didn't wait this time. Same block, it got better and stayed better. This mirrors the experience of a lot of my patients with the same procedure on different tendons. The smart businessmen among us are probably thinking "I could bottle and sell that as PRP" for $1000 and the patient wouldn't be the wiser. Yup.

 

[bedrock]

I haven’t done a tpi in years but mainly because the PTs love dry needling everything and doesn’t pay.

I also didn’t use steroid but who cares. The level of micromanagement of drs medical decision making is unsettling.

I’m glad im on the back 9 of my career.

honestly probably what I'm going to have to do as well. just another chip out of the crumbling block that is procedural based pain management. I thought universal healthcare would be the nail in the coffin of our profession but now I think the insurance companies are going to beat them too it.

getting pretty tired of being punished for doing nothing wrong.

I will inject the facet capsule with dex/marcaine if people have bad RF neuritis and call it a TPI.

Oh well.

This is just ridiculous. Agree with nvrsumr and multimodal that this micromanagement of physicians is beyond riculous. Between this type of BS and payments getting cut every year, it is no surprise that pain fellowships are not as competitive as they used to be.

I too have feared that universal health care would finally destroy our profession, but insurance companies just beat them to it, by chipping away at virtually everything that we do. I'm just crossing my fingers that I can get through 6.5 years and retire before there is a major change that destroys US healthcare. I certainly can't recommend med school to current college kids.

One significant concern is that i know that many well meaning docs on this board will do a procedure (that should pay them much more) and just bill it as a TPI just to help a patient out.

Looks like that option is going away. So if someone is denied for virtually anything, the patients options will be to just deal with it or pay full cash price for the denied procedure.

 

[DesertDoc16]

I find trigger point injections to be one of the more beneficial treatments we have. I have so many patients that receive long-term relief with simple local anesthetic TPI under ultrasound into the muscle and fascial plains. I know it’s anecdotal, but it is one of the few procedures where I’m always impressed with the durability of relief. Don’t discount the power of the trigger point injection!

 

[RaceCanyon]

TPI do not require US (ever).

How about the 100 lb fibro patient with tiny traps and rhomboids? You're easily in lung with 1 inch of the needle.

 

[MitchLevi]

Get better at doing TPI, and one day you’ll learn not to inject fibro pts. TPI don’t help them, and often they’ll tell you it made them worse.

 

[oreosandsake]

TPI = blind stabbing places that hurt and loculates medication in muscle

Fascia dissection with US and maybe toradol is actually a combination of nerve block as well…. Work much better

 

[Status Sciaticus]

I'd like to do cash pay for these, but medicare won't let you charge for a covered service, even if they don't pay enough to justify doing it. I have been sending more pts to a local PT who does good dry needling

Can you charge patients cash for a covered service if it doesnt meet the LCD? Say TPI helps for 4 weeks instead of 6 weeks. Despite TPI being covered by medicare, it wont be covered in that particular patient.

 

[powermd]

Can you charge patients cash for a covered service if it doesnt meet the LCD? Say TPI helps for 4 weeks instead of 6 weeks. Despite TPI being covered by medicare, it wont be covered in that particular patient.

Until now, I just charge for the ultrasound, do the injection (that doesn't meet their ridiculous guidelines anyway) for free, and charge for a visit. Now, that's going to expand to Medicare and by extension Medicaid, since they follow MDC rules. Don't like it? Off to PT you go.

 

[powermd]

On the subject of trigger points- I have a weird one right now. Referred to me for possible "T12 rib syndrome", I did an intercostal block which did nothing. Then I got the guy on the fluoro table, marked his point of maximal tenderness, and found it was located over the tip of the L4 transverse process. I had suspected it might be something like this but it comes up very, very rarely. I injected a small volume of local under fluoro at the tip. 100% relief for 24 hours, then back. Looking over the local fascia anatomy, I tried again with 10 mL bupi 0.25% + dex at the tip, this time with US for added visualization, then an additional 15 mL of 0.125% in what appeared to be the deep ES fascia plane with the QL. Now waiting to see how he does over the 1-2 week timeframe.

Btw, I charged $100 for the fluoro guidance, since no one pays fluoro for a TP.

Any thoughts on this one? The patient and his wife were wondering what ortho would say. I tried not to laugh...

 

[Status Sciaticus]

Until now, I just charge for the ultrasound, do the injection (that doesn't meet their ridiculous guidelines anyway) for free, and charge for a visit. Now, that's going to expand to Medicare and by extension Medicaid, since they follow MDC rules. Don't like it? Off to PT you go.

Right, but now can you just cash price everything together for say, 200-300?

On the subject of trigger points- I have a weird one right now. Referred to me for possible "T12 rib syndrome", I did an intercostal block which did nothing. Then I got the guy on the fluoro table, marked his point of maximal tenderness, and found it was located over the tip of the L4 transverse process. I had suspected it might be something like this but it comes up very, very rarely. I injected a small volume of local under fluoro at the tip. 100% relief for 24 hours, then back. Looking over the local fascia anatomy, I tried again with 10 mL bupi 0.25% + dex at the tip, this time with US for added visualization, then an additional 15 mL of 0.125% in what appeared to be the deep ES fascia plane with the QL. Now waiting to see how he does over the 1-2 week timeframe.

Btw, I charged $100 for the fluoro guidance, since no one pays fluoro for a TP.

Any thoughts on this one? The patient and his wife were wondering what ortho would say. I tried not to laugh...

odd indeed.
I guess ortho can remove the transverse process lol. Wonder what the CPT would be for that lol. /s

 

[powermd]

Right, but now can you just cash price everything together for say, 200-300?

Sadly, I have to factor in what the market will bear. It sickens me that my vet can charge $600 for a BS ultrasound, and people will IMMEDIATELY pull out their card, but try charging a pain patient $200 cash for something and they can't find their wallet.

For services that have a high rate of success, I have no problem charging a fair cash rate and sticking to it. Trigger points, PRP, PRF, etc.. meh.

 

[Laryngospasm]

Sadly, I have to factor in what the market will bear. It sickens me that my vet can charge $600 for a BS ultrasound, and people will IMMEDIATELY pull out their card, but try charging a pain patient $200 cash for something and they can't find their wallet.

For services that have a high rate of success, I have no problem charging a fair cash rate and sticking to it. Trigger points, PRP, PRF, etc.. meh.

That’s a real big rabbit hole you opened..

 

[PinchandBurn]

Sadly, I have to factor in what the market will bear. It sickens me that my vet can charge $600 for a BS ultrasound, and people will IMMEDIATELY pull out their card, but try charging a pain patient $200 cash for something and they can't find their wallet.

For services that have a high rate of success, I have no problem charging a fair cash rate and sticking to it. Trigger points, PRP, PRF, etc.. meh.

Probably just get a ABN and charge $75 to $100. If thye say no. Then do OV.

 

[Ferrismonk]

honestly probably what I'm going to have to do as well. just another chip out of the crumbling block that is procedural based pain management. I thought universal healthcare would be the nail in the coffin of our profession but now I think the insurance companies are going to beat them too it.

getting pretty tired of being punished for doing nothing wrong.

To be fair, this isn't the insurance companies, this is Medicare. The probable best cast scenario for Universal Healthcare in the US.

How about the 100 lb fibro patient with tiny traps and rhomboids

Fibro specifically excluded per the LCD above.