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PAIN BLOCKS Blood Patch >50 LESI's Hardware Block 5 Epidurogram Fluoroscopy Intradural/Intrathecal Injection-At Least 3Mo

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PAIN BLOCKS Blood Patch >50 LESI's Hardware Block 5 Epidurogram Fluoroscopy Intradural/Intrathecal Injection-At Least 3Mo BAYLOR SCOTT & WHITE TEXAS SPINE & JOINT HOSPITAL Initial Appointment / Reappointment / Update (Circle One) NAME: CRITERIA HAS PRIVILEGE REQUESTED REQUIRED DONE APPROVED DENIED PAIN BLOCKS Blood PatCh >50 LESI's Hardware BloCk 5 Epidurogram FluorosCopy Intradural/Intrathecal InJection-At least 3mo. ACGME pain fellowship 10 Manipulation of Spine, any level, w/sedation BC/BE Anesthesia only CERVICAL PAIN BLOCKS DisCogram - CerviCal 30L, 5T, 5C* Epidural Steroid Injection - CerviCal 20 HypertoniC Saline InJeCtion - CerviCal 10 Medial BranCh BloCk - CerviCal 5 FaCet Joint - CerviCal 10 Selective Epidural - CerviCal 20 Selective Nerve Block - CerviCal 20 SuprasCapular Nerve Block 10 THORACIC PAIN BLOCKS DisCogram - ThoraCiC 30 L then 5 T Epidural Steroid Injection - ThoraciC 10 HypertoniC Saline InJeCtion - ThoraCiC 20 L then 2T Medial BranCh BloCk - ThoraCiC 10 FaCet Joint - ThoraCiC 10 Selective Epidural - ThoraciC 10 Selective Nerve Block - ThoraciC 10 LUMBAR PAIN BLOCKS DisCogram - Lumbar 30 Epidural, Steroid Injection - Lumbar 50 Epidural NeurolytiC Block - Lumbar 5 InJection for Lysis of adhesion - Lumbar 20 Medial BranCh BloCk - Lumbar 10 FaCet Joint - Lumbar 25 Selective Epidural - Lumbar 25-L1-L5 & 25 S1 Selective Nerve Block - Lumbar 25-L1-L5 & 25 S1 10 w/cath 10 w/o Epidural, Continuous, Caudal (Sacral) cath 10 w/cath 10 w/o Epidural, Steroid Injection - Caudal cath InJection for Lysis of adhesion - Caudal 5 Sacroiliac Joint Injection 15 Genicular NB 5 Opturator NB 5 CoCCyx 2 SPECIALTY PAIN BLOCKS IDET *see note below 50 disco's + course DisCtrode *see note below 50 disco's + course NeuCleoplasty *see note below 50 disco's + course Dekompressor *see note below 50 disco's + course Verterbralplasty or Kyphoplasty 50 disco's + course MILD / VERTOS 50 disco's + course *NOTE For those that Currently have privileges for lumbar epidurals, lumbar faCets and or saCroiliaC Joint inJeCtions you will need to do at least 50 lumbar disCograms and Complete a Certified Cadaveric Course for IDETs, DisCtrodes and NeuCleoplasties. For those who do not Currently have privileges for lumbar epidurals, lumbar facets and or sacroiliac Joint injections you will need to do at least 100 lumbar disCograms and complete a certified cadaveric course for IDETs, Disctrodes and Neucleoplasties. *NOTE *MUST BE PROFICIENT IN LUMBAR DISCOGRAPHY BEFORE STARTING CERVICAL DISCOGRAPHY **NOTE For all who have Completed an Anesthesia, PM&R, Radiology, Neurology or OrthopediC residenCies you must Complete 100 lumbar proCedures before training for CerviCal or thoraciC procedures. For those that do not meet the above Criteria you must Complete 500 lumbar procedures and have at least six months experience doing lumbar procedures prior to learning CerviCal or thoraciC procedures. For all new physicians coming into Pain Management at BSWTSJH you must be board eligible or certified before privileges will be granted. HAS PRIVILEGE REQUESTED REQUIRED DONE APPROVED DENIED IV Infusion IV Infustion-Regitine/Lidocaine 2 TransdisCal same as idet Epidural Catheter w/ External Reservoir w/o laminectomy 3 mth. Pain+10 Lumbar Drain same as above Neurotomy/ Rhizotomy - Lumbar 10 Neurotomy/ Rhizotomy - CerviCal LRF+5 cases Neurotomy/ Rhizotomy - ThoraCiC T-MBB+LRF Neurotomy/ Rhizotomy - Dorsal Root Ganglion CRF+C-sel Neurotomy / Rhizotomy - GeniCular RF Neurotomy / Rhizotomy - Opturator RF Neurotomy/ Rhizotomy - Trigeminal trigeminal+5 Neurotomy/ Rhizotomy - Sphenopalatine Ganglia sphenopalatine+5 Neurotomy/ Rhizotomy - SympathetiC - CerviCal Neurotomy/ Rhizotomy - SympathetiC - Lumbar 5 Neurotomy/ Rhizotomy - SympathetiC - ThoraCiC symp blk + L-RF Radio-FrequenCy - Caudal/Stellate Ganglion/SympatheCtomy Stellate Ganglion Block 10 SympathetiC Block -CerviCal 10 SympathetiC Block -Lumbar 5 completion of L-SYmp T-disco SympathetiC Block -ThoraciC or T-sele SympathetiC Neurolysis - CerviCal SympathetiC Neurolysis - Lumbar 5 SympathetiC Neurolysis - ThoraciC Sympathectomy - ThoraciC SplanchniC Block 10 SplanchniC Neurolysis 10 splan. Blks + 5 HypogastriC Plexus BloCk HypogastriC Plexus Neurolysis Auxiliary Nerve Block 10 CeliaC Plexus BloCk Trigeminal nerve bloCk 10 Brachial Plexus Block 10 Brachial Plexus Nerve Block 10 OcCipital Nerve Block 5 Peripheral Nerve Block Plexus Block - CerviCal Plexus Block - Lumbar Psoas Compartment Block Inguinal Nerve Block Intercostal Nerve Block (a.k.a. rib block) 5 SupraclaviCular Block 10 HAS REQUESTED PRIVILEGE REQUIRED DONE APPROVED DENIED Random Joint Injection Wrist Joint BloCk 5 Hip InJeCtion 5 Shoulder Injection 5 Knee Injection 10 Ankle Injection 5 Elbow Injection 5 Triggers Trigger Point InJeCtion 5 Bursa Injection 5 Femoral Nerve BloCk 5 Sternal Block 5 Spinal Cord Stimulator (a.k.a. DCS:Dorsal Column Stimulator) Placement of Neuroelectrodes for Trial 3 mth.pain+10 Analysis of Pulse Generator 3 mth.pain+10 CatheterAnalysis ReplaCementof Pulse Generator or Revision w/ reprogramming InJeCtion of SubstanCe or other than 3 mth.pain+10 AnesthetiC (Lioresal) 3 mth.pain+10 Refilling of Pump 3 mth.pain+10 Intrathecal Drug Delivery Pumps (BSWTSJH only) 3 mth.pain+10 Incision & Implant Pulse Generator** Co-Surgeon - must have 5 Cases with proCtor unless anesthesia trained Revise or Remove Stimulator Generator, EleCtrodes, ReCeiver** Insertion or Revision of Intrathecal Drug Delivery Pumps** Insertion Subarachnoid Catheter W / Reservoir w/o Laminectomy** **Indicates needs at least 3 total of any combination with a proctor and letter of Competence from proctor MISCELLANEOUS ConsCious Sedation (see attached request letter) OTHER Acknowledgment of Practitioner I am qualified to perform the privileges I have requested based on mY licensure, education, training, experience and current competence. I certifY that I am able to perform the privileges I have requested. Furthermore, if I am requesting privileges for procedures that I have not previouslY been granted at BaYlor Scott & White Texas Spine & Joint Hospital I have attached education documentation, certificates, licensure, etc.…for the committee to review. A minimum of 100 procedures (accrued over a 24 month period) is required for re-appointment ___________________________________________ Date Practitioner's Signature I, _____________________________________, am requesting privileges to perform conscious sedation at BaYlor Scott & White Texas Spine & Joint Hospital. I am qualified to perform conscious sedation based on mY licensure, education, training, experience and current competence My current ACLS card is attached. Thank You, Approved Denied ________________________________________________ Practitioner's Signature DR. CREDITIALING COUNTS PROCEDURE # OF CASES DONE # OF CASES NEEDED CERVICAL Cervical Interlaminar 20 Cervical Transforminal 20 10 Cervical Facets 5-AO/AA Cervical Medial Branch 5 Cervical RF L-RF + 5 Cervical Stellate / SYmp 10 Cervical Disco 30L, 5T, 5C* Occipital Nerve Block *MUST BE PROFICIENT WITH LUMBAR BEFORE STARTING CERVICAL THORACIC Thoracic Interlaminar 10 Thoracic Transforminal 10 Thoracic Facets 10 Thoracic Medial Branch 10 Thoracic RF TMBB + LFR #'S Thoracic Disco 30 L + 5 T Intercostal Blocks Thoracic SYmpathetic RF Thoracic SYmpathetic LUMBAR Lumbar Interlaminar 50 25 - L1 THRU L5 Lumbar Transforminal 25 - S1 Lumbar Facets 25 10 Lumbar Medial Branch 5 - SACRAL Lumbar RF 10 Caudal Epiduarl w w/o cath 10 W - 10 W/O Lumbar Disco 30 Sacroilliac Joint 15 Hip 5 CoccYx Injection 2 Blood Patch SAME AS LESI Sacral RF 10 Hardware Block 5 Ganglion Impar Lumbar SYmpathetic 10 Lumbar SYmpathetic RF 10 Splanichnic Block / RF * Celiac Plexas Block * ilioinguinal NB * Saphenous NB * *waiting on peer recommendations OTHER INJECTIONS SCS Trial 3 MTS. PAIN + 10 Baclofen Trials SAME AS LESI Morphine Pump Trial SAME AS LESI Pump Check SAME AS LESI Pump Fill Glenohumeral / shoulder 5 Lumbar Puncture 5 Knee Inj 10 Geniculate nerve block 5 Bertolotti / Assim joint injection SAME AS LUMBAR FACET above is an artificial joint created bY the transverse process meeting the iliiac crest Drain / Aspiration 10 Botox Injection 10 Trigger Point Injection 20 Ankle Inj 5 Lysis of Adhesions 5 Supraclavicular Block 5 Bursa inj. 5 Suprascapular NB 5 Supraorbital NB 5 Trigeminal RF 5 SURGERY COUNTS PROCEDURE NUMBER DONE NUMBER NEEDED SCS IMPLANTS 5 SCS EXPLANTS 5 SCS REVISION 5 LD - WOUND 5 Pump Implant 5 Pump Revision 5 Battery Replacement 5 Pump Replacement 5 Pump Removal 5.
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