For the integrated practice, injection therapies are well worth adding to the services you offer to patients.

By Marc H. Sencer, MD

One of the great advantages of owning an integrated practice is your ability to add and be reimbursed for medical services that you are not able to perform as a doctor of chiropractic. Injection therapies are a good example.

The easiest injections to add are trigger points. A trigger point is a special kind of myofascial pain. These are discreet areas on a muscle that when palpated produce pain. Sometimes this pain is referred to other parts of the muscle or even more distant sites.

Typically, trigger points are injected with a local anesthetic such as lidocaine or marcaine. Some practitioners use a mix of a steroid and an anesthetic.

The indications for all injections, including trigger points, are the same. If the patient has failed at least four weeks of conservative care such as physical therapy, chiropractic, nonsteroidal anti-inflammatory drugs (NSAIDs), or is not a candidate for these, then you can try more aggressive treatments such as injections.

Your physical exam and history should clearly document any palpable trigger points and their location. In addition, your documentation should demonstrate medical necessity as described above.

All injections should be documented with a detailed procedure note. This note includes the sterile prepping of the injection site, the gauge and length of the needle used, the amounts and substances injected, any complications encountered, and the time the patient was observed in the office for any complications and whatever response or benefit the patient received.

In addition to the procedure note, you will need to have the patient sign a proper informed-consent form. Be sure to give the patient a chance to discuss the treatment and answer all of his or her questions. Again, this applies to all injections, not just trigger points.

It is useful to have an informational handout that you can give patients prior to giving an injection, and another one that describes aftercare, common reactions, and what to do about them including when to call the doctor or go to the ER.

Trigger point injections are very safe but, just in case, some MDs will want to have a crash cart on site in the event of serious complications.

You do not need a physiatrist or other specialist to perform trigger point injections; many primary care doctors know how to do them, and the skill is easy to learn. There are seminars and online courses available, too. Some nurse practitioners and physician assistants can also do these injections (or be taught to do them).

You used to be able to bill trigger point injections as multiple procedures, but now the code is bundled. This means you can only bill one injection per patient encounter. You can, however, do other injections in addition to the trigger point.

Medicare’s National Correct Coding Initiative (NCCI) lists injection pairs that cannot be billed together, and private insurance companies have their own guidelines.

In addition to trigger points, muscle tendons can also be injected. This procedure is also relatively easy for an MD to learn. You can usually be reimbursed for multiple tendon injections if you demonstrate medical necessity for them.

Caution: Do not bill an injection with an office visit. That will usually result in a flagged claim that is rejected or denied. Therefore, injections should be done on separate encounters from initial and re-evaluation visits.

Joint injections are reimbursed and coded as small, medium, or large; again, many primary care doctors do these so you may not need a specialist. Also, nurse practitioners and physician assistants can do them (or be trained to do them). Look for a physician extender with orthopedic experience.

Nerve-blocking injections are more complex and usually require someone with specialized training such as a neurologist or physiatrist. Some primary care doctors do these and, here also, courses and training seminars are available.

The most common nerve blocks given in the office setting are occipital nerve blocks for tension headaches, and blocks for peripheral neuropathies such as carpal tunnel, ulnar, and other entrapment syndromes, or polyneuropathy. Typically, an anesthetic such as lidocaine is injected. These injections may be repeated as necessary.

Nerve blocks, tendon, joint, and trigger point injections may be done with ultrasound guidance for more precise placement of the needle. If done this way, you can bill for an ultrasound diagnostic study, a needle guidance procedure, as well as the actual injection.

Courses are available to teach MDs and physician extenders how to perform ultrasound studies, as many primary care doctors may not be familiar with the procedure.

There are more complex injections that require the use of fluoroscopy for guidance and may require the use of anesthesia because they can be painful. These include epidural nerve block, facet injections (which now require fluoroscopy for reimbursement), sacroiliac joint injection, and special injections such as prolotherapy and platelet-enriched plasma.

Injection therapy can be a blessing for patients who are not responding to more conservative treatment, and it is an important source of revenue for integrated practices.

If you are integrated, you should consider offering these therapies to your patients. If you are thinking about becoming an integrated practice, add these procedures to your business plan.

Marc H. Sencer, MD, is the president of MDs for DCs, which provides intensive one-on-one training, medical staffing, and ongoing practice management support to chiropractic integrated practices. He can be reached at 800-916-1462 or through www.mdsfordcs.com.