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A CMS emergency regulation, issued Nov. 4, requires COVID-19 vaccination for staff at healthcare facilities participating in Medicare and Medicaid programs.

The legislation covers more than 17 million workers at more than healthcare 76,000 facilities in the U.S., including ASCs, hospitals, nursing homes, dialysis facilities, home health agencies and long-term care facilities. 

The rule applies to clinical and nonclinical employees and includes students, trainees and volunteers who work at a Medicare or Medicaid-funded facility, as well as those who provide treatment or other services for the facility under contract or other arrangements. According to the Ambulatory Surgery Center Association, there are about 5,700 Medicare-certified ASCs in the U.S.

CMS is requiring the facilities covered in the regulation to ensure eligible staff have received at least one vaccine dose prior to providing any treatment or service by Dec. 5.

CGS has released its final policy for epidural injections for pain management.

This will be effective December 5, 2021. Please check your individual MACs.
  
While this is a nationwide policy, we are seeing some discrepancies with the various policies. Some have a limit of four (4) epidurals per region and others are stating a limit of four (4) for all regions. We will clarify this soon, but it appears to be four (4) per region.
 
However, it also says that after the first treatment, a patient must have 3 months of ≥ 50% relief. If that is not achieved, a second procedure may be performed after 14 days using a different approach after appropriate documentation, which is very difficult.
 
Diagnostic codes do not include disc displacement and disc degeneration. All in all, the policy is extremely difficult to live with, not only for diagnostic coding, but for limitation of procedures limited to 4 per year for all regions combined.
 
Other issues also include in reference to documentation of at least 2 fluoroscopic views, pre and post pain levels each time.
 
There are some changes as per the request of ASIPP and other societies in reference to the definition of inclusion criteria:
 
  • This now includes radicular pain, severe degenerative disc disease, and post laminectomy syndrome.
  • An objective pain scale or functional assessment must be performed at baseline and repeated at each follow-up for assessment of response.
  • Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care.
  • Only one spinal region may be treated per session.

ASIPP is hosting a webinar, New LCDs for Epidural and Facet Joint Interventions: An Algorithmic Approach to Documentation of Medical Necessity and Indications, to provide an in-depth explanation of the changes within these LCDs. Dr. Laxmaiah Manchikanti will give the 90-minute presentation, which will be followed by a 30-minute Q&A with panelist, Amol Soin, MD; Sairam Atluri, MD; Annu Navani, MD; and Chris Gharibo, MD. The cost of the webinar is $175 and will provide you with 2 AMA PRA Category 1 CreditsTM 
 
LCDs Released Are:
Additional Information:
The NYU Grossman School of Medicine is surveying pain medicine fellowship graduates' perception of their training and level of preparedness for entering the practice of pain medicine. The survey committee is comprised of Christopher Gharibo, MD; Krupali Chokshi, MD; Gopal Desai, MD; and Lisa Doan, MD. Their goal is to publish information on which areas fellowship graduates feel most prepared and where needs are unmet that can provide constructive feedback to fellowship programs and ACGME. IRB approval has been obtained for the survey and all responses will be completely anonymous.

The survey will take only 5-10 minutes to complete and we greatly appreciate your input. Click here to take the survey

New Orleans-based court says COVID-19 vaccination and testing rules raise grave legal issues

A federal appeals court on Saturday temporarily blocked the Biden administration’s new rules that require many employers to ensure that their workers are vaccinated or tested weekly for COVID-19.

A three-judge panel on the New Orleans-based Fifth U.S. Circuit Court of Appeals granted an emergency stay prohibiting enforcement of the rules for now, saying they raise “grave statutory and constitutional issues.”


Drug company plans to seek FDA authorization of treatment for patients with a mild to moderate form of the illness

Pfizer Inc. said a preliminary look at study results found that its experimental pill was highly effective at preventing people at high risk of severe COVID-19 from needing hospitalization or dying, the latest encouraging performance for an early virus treatment.

The company’s drug cut the risk of hospitalization or death in study subjects with mild to moderate COVID-19 by about 89% if they took the pill within three days of diagnosis, Pfizer said Friday. The drug, called Paxlovid, was also found to be generally safe and well-tolerated.



"We're changing the way we address overdoses," says HHS secretary


The Department of Health and Human Services (HHS) launched a new plan to curb drug overdoses that promises more federal backing for harm reduction techniques.

The Overdose Prevention Strategy "breaks new ground" with coordinated federal support for efforts such as needle exchanges, and distribution of test strips to check for fentanyl in street drugs. In the past, such services were generally done by grassroots groups.

"We're changing the way we address overdoses," said HHS Secretary Xavier Becerra, in a press release. "Our new strategy focuses on people -- putting the very individuals who have struggled with addiction in positions of power. And thanks to the American Rescue Plan, we can address what so many people have seen in recent years: a rise in overdoses that can risk a person's life -- and affect their entire family."




We can prevent patients from falling down the rabbit hole


It starts innocently enough. Perhaps a sports injury, an accident, surgery, or a work-related incident. The physician prescribes pain medication, and for the majority of people, it ends there. The patient takes it as needed and discontinues it when they get better.

But for those with a genetic predisposition for substance use disorders (SUD), stopping may not be an option. They can't. And thus begins a dangerous descent down the slippery slope of prescription pain medication misuse. Worse yet, because of the cost and difficulty in acquiring pills, some may turn to street drugs, which can increase the risk of overdose.

With all the recent federal and state laws restricting the prescribing and dispensing of controlled substances, it's clear we have an epidemic of overprescribing. And while physicians certainly don't intend to get their patients hooked on pain pills, it can be difficult to know who is at risk of developing a SUD and who is not. In their attempt to help patients, physicians may unknowingly lead them down the path toward the life-altering disease of addiction. Because addiction doesn't discriminate, you can't identify a potential SUD risk based on how someone looks, their job, how much money they make, or their lifestyle.

Pain Medicine Case Reports (PMCR) and Editor-in-Chief Alaa Abd-Elsayed, MD, PhD would like to invite you to submit case reports and case series to the PMCR journal. Your article will be published free of charge.

Open access journals are freely available online for immediate worldwide open access to the full text of published articles. There is no subscription fee for open access journals. Open access journals are no different from traditional subscription-based journals: they undergo the same peer-review and quality control as any other scholarly journal.

Interested in becoming a member of the PMCR Editorial Board?
Editorial board members are asked to review 2-6 manuscripts per year. Please submit your most up-to-date CV to sgold@asipp.org for consideration.

For more information or to submit your articles, click here.
| CASE REPORT |


Maho Jinno, MD, Yasuyuki Shibata, MD, PhD, and
Kimitoshi Nishiwaki, MD, PhD

Abstract
Background: Pulsed radiofrequency (PRF) is widely used as a safe and effective method against chronic pain. However, the detailed description showing a reliable effect on intractable chronic peripheral neuralgia is not clear.

Case Report: We experienced 3 cases of chronic intractable peripheral neuralgia, in which long-term pain relief of 2 months was obtained. This relief was achieved by performing PRF at a position (target point) where the sensory nerve stimulation from the needle tip coincided with the painful area.

Conclusions: This report suggests that a nerve block at the target point may be important in PRF for peripheral nerves. From our experience, there was a dermatome-like distribution map of the skin in the peripheral nerves, and it was presumed that PRF was effective at the target point.

Key words: Pulsed radiofrequency, peripheral nerve, chronic pain, sensory test, target point, dermatome
| RANDOMIZED CONTROLLED TRIAL |


Dina Abdelhameed Elsadek Salem, MD, Sara Mohamed Abdel Nabi, MD, Sherif A. Alagamy, MD, and Alshaimaa Abdel Fattah Kamel, MD

Abstract
Background: Intraarticular bupivacaine produces sufficient analgesia after arthroscopic knee surgery, but its analgesic duration is short. There is a need to search for an adjuvant with a longer duration of analgesia.

Objectives: This study aimed to compare the duration of analgesia, total rescue analgesic consumptions, pain intensity, adverse effects, and patient satisfaction of dexmedetomidine and fentanyl as adjuvants to intraarticular bupivacaine for analgesia after knee arthroscopy.

Study Design: A prospective double-blind randomized controlled study.

Setting: Zagazig University Hospitals.

Methods: After ending arthroscopy and 15 minutes before deflation of the tourniquet, 45 patients were randomly allocated into 3 equal groups: Group B (n = 15) received an intraarticular injection of 50 mg (20 mL) bupivacaine 0.25% plus 1 mL saline; group BD (n = 15): received an intraarticular injection of 20 mL bupivacaine 0.25% plus 100 µg (1 mL) dexmedetomidine; and group BF (n = 15) received an intraarticular injection of 20 mL bupivacaine 0.25% plus 50 µg (1 mL) fentanyl.

Results: The BF group had a statistically significant longest duration of analgesia (693.3 ± 22.6 minutes) compared to group the BD (505.8 ± 23.5 minutes) and group B (244.1 ± 17.5 minutes) (P < 0.0001). The total meperidine consumption was statistically significantly decreased in group BF (35 ± 12.6 mg) compared to the BD and B groups (60 ± 12.6 mg and 83.3 ± 15.4 mg respectively) (P < 0.0001). Groups BF and BD showed a highly statistically significant lower postoperative static and dynamic pain scores at 30 minutes, 1, 2, 4, and 6 hours compared to group B. However, group BF was comparable to group BD at the same time intervals. Postoperative static and dynamic pain scores showed a highly statistically significant higher values at 4 hours in group B, 8 hours in group BD, and 12 hours in group BF (P < 0.0001). No significant side effects were observed in the groups. The duration of analgesia was the most important parameter that determined patient satisfaction.

Limitations: Small sample size and lack of studies that compare both adjuvants.

Conclusions: Fifty µg of fentanyl as an adjuvant to intraarticular bupivacaine produces effective and safe analgesia after knee arthroscopy as 100 µg of dexmedetomidine and has a longer analgesia duration in the first postoperative 24 hours.

Key word: Dexmedetomidine, fentanyl, intra-articular bupivacaine, postoperative analgesia, knee arthroscopy.

| RANDOMIZED TRIAL |


Omyma Shehata Mohamed, MD, Sara Mohamed Omar, MD,
Alaa Fouli Gaber, MBBCH, Manal Mohamed Hassanien, MD, and
Abd-Elraheem Mahmoud Mohamed, MD

Abstract
Background: Ablation of the genicular nerves (GN) has emerged as a useful alternative therapeutic modality in chronic knee osteoarthritis (OA) specially for high-risk patients. However, in some cases due to the presence of other articular branches or anatomical variability, it may have a poor impact in relieving pain. Ablation of other or additional articular branches might have different outcomes.

Objectives: We aimed to investigate the efficacy and safety of using 3 needles as a new technique in ablation of GN and compare it to the classic single-needle approach.

Study Design: A prospective parallel single-blind randomized study.

Setting: Department of Anesthesia and Intensive Care, Faculty of Medicine, Minia University, Egypt, and Pain Management Unit, Assiut University Hospital, Egypt. 

Methods: Fifty patients with advanced knee OA were involved in this clinical study to be treated with radiofrequency ablation of GN using either: the single-needle technique (SN group [n = 25]) or the 3-needle technique (TN group [no = 25]) and assessed for: pain with the Visual Analog Scale (VAS); knee function and disability with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); and patient satisfaction using global-perceived effect throughout 2 weeks, and 1, 3, and 6 months after the procedure.

Results: Significantly longer and better improvement in perceived pain (VAS), function and disability (WOMAC) with more patients’ satisfaction were recorded in the TN group than the SN group at all follow-up time points without untoward events.

Limitations: Short follow-up time; longer period could permit recognition of long-term outcome.

Conclusions: Compared to the conventional single-needle GN ablation technique, the 3-needle approach appears to be a promising, safe, and more effective ablation technique for patients with chronic knee OA.

Key words: Chronic knee osteoarthritis, radiofrequency, three needles






Since this malpractice insurance program officially launched in November 2018, ASIPP has signed up hundreds of providers with an average savings of 30%. This is professional liability insurance tailored to our specialty and will stand up for us and defend our practices.

Norcal Mutual is 'A' Rated by AM best and is license in all 50 states. To read a few important points to keep in mind about the program, including discounts, administrative defense, cyber coverage, aggressive claims handling, and complimentary award-winning risk management CME activities, click here.

ASIPP® is now offering our members the benefit of a unique revenue cycle management/ billing service. We have received a tremendous amount of interest in the ASIPP® billing and coding program.

Click here to learn more about the negotiated rate for practices and more!

ASIPP® has formed a partnership with Henry Schein and PedsPal, a national GPO that has a successful history of negotiating better prices on medical supplies and creating value-added services for the independent physician. Working with MedAssets, PedsPal provides excellent pricing on products like contrast media that alleviate some of the financial pressures you experience today.

Like and follow ASIPP® on Facebook, Twitter, and LinkedIn for the most
up-to-date news related to you, your practice, and your patients!