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How to Boost Your Bottom Line with an Office Procedure -- Family

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How to Boost Your Bottom Line with an Office Procedure -- Family HOW TO Boost Your Bottom Line WITH AN OFFICE PROCEDURE Adding joint and soft-tissue injection to your practice can pay off in more ways than one. William D. Martz, MD Dr. Martz is medical director s practices’ expenses of the family practice office continue to grow at the University of Arizona at a faster pace Health Sciences Center. He has facilitated lectures and than revenues, workshops on joint injection Aphysicians are under greater technique. Conflicts of interest: pressure to do more with none reported. less. While working harder and seeing increasing num- bers of patients each day is an option, finding methods to work smarter is becoming an attractive alternative. One viable strategy for your practice is to increase charges per unit of time. Performing more proce- dures is a simple and suc- cessful way to achieve this goal. category of procedures well worth your time As you are probably aware, not all pro- and effort – joint and soft-tissue injections. cedures are created equal. Some procedures Here are some of the benefits of adding (e.g., flexible sigmoidoscopy) are reimbursed joint and soft-tissue injections to your clini- very poorly considering the time they cal armamentarium: require. Other procedures (e.g., skin biopsy • Patients appreciate their primary care and excisions, colposcopy/biopsy and exer- physicians offering services that traditionally cise treadmill testing), though reimbursed require a referral to a specialist. more handsomely, may require significant • Patients avoid treatment delays. amounts of physician and nursing time, • Physicians’ satisfaction improves when significant up-front costs to the practice and a variety of procedures are integrated into extensive training. However, there is another their daily schedules. ILLUSTRATION BY STUART BRADFORD Downloaded from the Family Practice Management Web site at www.aafp.org/fpm. Copyright © 2003 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. ® • Practice revenues can improve signifi - KEY POINTS SPEEDBAR cantly. Joint injection reimbursement will match or beat any other offi ce-based proce- • Performing simple offi ce procedures, such as joint dure on the basis of charge per unit of time and soft-tissue injections, is an effective way to ➤ ➤ (see “Comparing offi ce-based procedures,” increase your revenue, improve patient satisfac- With practice expenses page 40). tion and maintain your enthusiasm for medicine. increasing more rapidly • To learn injection techniques, select a course or than revenues, physi- Joint injections 101 workshop that includes adequate time for obser- cians are struggling To many physicians, breaking out of the vation and practice. to increase their comfort zone of current practice patterns is • When fi rst learning to administer injections, reimbursement. diffi cult. The motivation to learn a new pro- begin with less diffi cult sites, which is where cedure can be maintained only by deriving patients most often present with complaints. some genuine satisfaction from performing the procedure regularly. Although perform- ing joint injections will benefi t your patients the course and the sponsoring institution. ➤ ➤ and your wallet, remember that keeping I highly recommend seeking a course where One effective way to yourself engaged and excited in your prac- at least a portion of the time is dedicated to boost reimbursement tice of medicine is just as vital. observing and practicing the actual injection is to add an offi ce- If you’re willing to embark on this new techniques for each of the areas covered. You based procedure, such challenge, the fi rst step will need to learn the indi- as joint and soft-tissue is to learn the procedure. cations, contraindications, injections, to your cur- Attending a workshop or Performing joint injections preparation and aftercare rent practice services. short course that focuses will benefi t your patients for each of the most com- on joint and soft-tissue mon injection sites. injection techniques can and your wallet. Even after you com- provide you with the nec- plete a course, profi ciency essary training. (Also see with these techniques will ➤ ➤ “Suggested reading,” page 40, for additional require practice. Optimally, you’ll be able to When compared with resources on joint injection.) You can gain some experience in a supervised setting, other offi ce-based contact your local AAFP chapter to inquire with a physician who is competent in per- procedures, joint injec- about courses offered in your region. forming these procedures. The number of tions will equal or beat The content of these courses will vary supervised procedures necessary to achieve their charges per unit depending on the instructor, the length of competency will certainly vary, but most of time. WHAT THE LITERATURE SAYS Signifi cant studies have shown that intra-articular and soft-tissue injection therapies play an important role ➤ ➤ in the diagnosis and management of degenerative joint disease, rheumatoid arthritis, crystalline arthritis, bursitis, tendinopathies and entrapment neuropathies.1 For several decades, intra-articular steroid injections were Patients will appreciate common despite the paucity of evidence demonstrating their effi cacy for various painful arthropathies and your performing these periarthropathies. In recent years, however, several controlled studies have been conducted to measure the procedures, as it will effectiveness of corticosteroid injections. save them a trip to a specialist, thus avoid- Though some studies have demonstrated only short-term benefi ts from steroid injections, several others have ing treatment delays. demonstrated long-term benefi ts, including decreased pain, increased range of motion and improved joint function.2,3,4 In particular, studies have demonstrated the effi cacy of corticosteroids for patients with chronic subacromial impingement syndrome and for early disease control in patients with rheumatoid arthritis.3,4 1. Kim PS. Role of injection therapy: review of indications for trigger point injections, regional blocks, facet joint injections, and intra-articular injections. Curr Opin Rheumatol. 2002;14:52-57. 2. McColl GJ, Dolezal H, Eizenberg N. Common corticosteroid injections: an anatomical and evidence-based review. Aust Fam Physician. 2000;29:922-926. 3. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Effi cacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am. 1996;78(11):1685-1689. 4. Hunter JA, Blyth TH. A risk-benefi t assessment of intra-articular corticosteroids in rheumatic disorders. Drug Safety. 1999;21: 353-365. November/December 2003 ■ www.aafp.org /fpm ■ FAMILY PRACTICE MANAGEMENT ■ 39 ® SPEEDBAR physicians should feel comfort- SUGGESTED READING able after three to fi ve injec- tions at any given site. The Clinics Atlas of Offi ce Procedures: Joint Injection ➤ ➤ If you are learning injection Techniques. Pfenninger JL, ed. Philadelphia, Pa: W.B. Saunders techniques for the fi rst time, it Company; 2002. Learning joint injections would be benefi cial to master requires attending a “Physiatric Injection Procedures.” Dreyer S, Dreyfuss P, Cole AJ, two or three areas before mov- short course or work- Windsor R. In: The Low Back Pain Handbook: A Practical Guide ing on to sites requiring greater shop that will allow you for the Primary Care Clinician. 2nd ed. Cole AJ, Herring SA, eds. technical skills. Initial injection to observe techniques Hagerstown, Md: Lippincott Williams & Wilkins; 2002. sites include the subacromial and practice them bursa of the shoulder, the knee Offi ce Orthopedics for Primary Care. Anderson BC. Philadelphia, under supervision. joint and the lateral epicondyle Pa: W.B. Saunders Company; 1999. of the elbow. Not only are injec- Essentials of Musculoskeletal Care. 2nd ed. Snider RK, ed. Rosemont, tions at these sites technically Ill: American Academy of Orthopaedic Surgeons; 1997. ➤ ➤ less diffi cult than others, but when patients present with clin- Concentrate on master- ical complaints that may require worthwhile investment for you and your ing less technical injec- an injection, these sites are the ones that most practice. Joint and soft-tissue corticosteroid tion sites fi rst, such as often need attention. The anatomy of these injections have been well studied with the knee joint, before areas is relatively straightforward to learn, positive results. Take a little time to practice moving on to more which makes these injections the easiest the techniques, and your satisfi ed patients complicated sites. to master. and increased revenue will make you glad you did. Reaping the benefi ts Learning a new procedure can be a Send comments to [email protected]. COMPARING OFFICE-BASED PROCEDURES Medicare Reimbursement per hour reimburse- Estimated physician Initial cost (not including nursing Procedure CPT code ment* time (minutes) of equipment or overhead costs) Flexible sigmoidoscopy 45330 $103 20-30** $3,000-$7,000 $206-$309 Colposcopy 57452 $120 20-25** $3,000-$5,000 $288-$360 Colposcopy with biopsy 57455 $148 25-30** $3,000-$5,000 $296-$355 Exercise treadmill 93015 $103 20-30** $5,000-$10,000 $206-$309 Epidermal shave biopsy ≤ 0.5 cm 11300 $55 10-15 Supplies only $220-$330 Excisional biopsy ≤ 0.5 cm 11400 $108 20-30** Supplies only $216-$324 Joint injection, small joint 20600*** $50 5 Supplies only $600 (e.g., fi nger, toe) Joint injection, medium joint 20605*** $55 5 Supplies only $660 (e.g., elbow, wrist) Joint injection, large joint 20610*** $67 5 Supplies only $804 (e.g., shoulder, knee, hip) *Based on Arizona carrier data. **Usually requires nursing time in addition to physician time. ***Combine with J3301, triamcinolone acetonide (Kenalog) injection. Medicare will reimburse $1.60 per 10 mg of Kenalog; most injections require 20-40 mg. 40 ■ FAMILY PRACTICE MANAGEMENT ■ www.aafp.org /fpm ■ November/December 2003.
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