How to Boost Your Bottom Line With an Office Procedure

November/December 2003 Table of Contents

Adding joint and soft-tissue injection to your practice can pay off in more ways than one.

William D. Martz, MD

Covered in FPM Quiz

KEY POINTS

Performing simple office procedures, such as joint and soft-tissue injections, is an effective way to increase your revenue, improve patient satisfaction and maintain your enthusiasm for medicine.
To learn injection techniques, select a course or workshop that includes adequate time for observation and practice.
When first learning to administer injections, begin with less difficult sites, which is where patients most often present with complaints.

As practices' expenses continue to growat a faster pacethan revenues, physicians are under greater pressure to do more with less. While working harder and seeing increasing numbers 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 procedures is a simple and successful way to achieve this goal.

As you are probably aware, not all procedures are created equal. Some procedures (e.g., flexible sigmoidoscopy) are reimbursed very poorly considering the time they require. Other procedures (e.g., skin biopsy and excisions, colposcopy/biopsy and exercise treadmill testing), though reimbursed more handsomely, may require significant amounts of physician and nursing time, significant up-front costs to the practice and extensive training. However, there is another category of procedures well worth your time and effort - joint and soft-tissue injections.

Here are some of the benefits of adding joint and soft-tissue injections to your clinical armamentarium:

Patients appreciate their primary care physicians offering services that traditionally require a referral to a specialist.
Patients avoid treatment delays.
Physicians' satisfaction improves when a variety of procedures are integrated into their daily schedules.
Practice revenues can improve significantly. Joint injection reimbursement will match or beat any other office-based procedure on the basis of charge per unit of time (see "Comparing office-based procedures").

Joint injections 101

To many physicians, breaking out of the comfort zone of current practice patterns is difficult. The motivation to learn a new procedure can be maintained only by deriving some genuine satisfaction from performing the procedure regularly. Although performing joint injections will benefit your patients and your wallet, remember that keeping yourself engaged and excited in your practice of medicine is just as vital.

WHAT THE LITERATURE SAYS

Significant 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 common despite the paucity of evidence demonstrating their efficacy for various painful arthropathies and periarthropathies. In recent years, however, several controlled studies have been conducted to measure the effectiveness of corticosteroid injections.

Though some studies have demonstrated only short-term benefits from steroid injections, several others have demonstrated long-term benefits, including decreased pain, increased range of motion and improved joint function.2,3,4 In particular, studies have demonstrated the efficacy of corticosteroids for patients with chronic subacromial impingement syndrome and for early disease control in patients with rheumatoid arthritis.3,4

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.
McColl GJ, Dolezal H, Eizenberg N. Common corticosteroid injections: an anatomical and evidence-based review. Aust Fam Physician. 2000;29:922-926.
Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am. 1996;78(11):1685-1689.
Hunter JA, Blyth TH. A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders. Drug Safety. 1999;21:353-365.

If you're willing to embark on this new challenge, the first step is to learn the procedure. Attending a workshop or short course that focuses on joint and soft-tissue injection techniques can provide you with the necessary training. (Also see "Suggested reading" for additional resources on joint injection.) You can contact your local AAFP chapter to inquire about courses offered in your region.The content of these courses will vary depending on the instructor, the length of the course and the sponsoring institution.I highly recommend seeking a course where at least a portion of the time is dedicated to observing and practicing the actual injection techniques for each of the areas covered. You will need to learn the indications, contraindications, preparation and aftercare for each of the most common injection sites.

Even after you complete a course, proficiency with these techniques will require practice. Optimally, you'll be able to gain some experience in a supervised setting, with a physician who is competent in performing these procedures. The number of supervised procedures necessary to achieve competency will certainly vary, but most physicians should feel comfortable after three to five injections at any given site.

SUGGESTED READING

The Clinics Atlas of Office Procedures: Joint Injection Techniques. Pfenninger JL, ed. Philadelphia, Pa: W.B. Saunders Company; 2002.

"Physiatric Injection Procedures." Dreyer S, Dreyfuss P, Cole AJ, Windsor R. In: The Low Back Pain Handbook: A Practical Guide for the Primary Care Clinician. 2nd ed. Cole AJ, Herring SA, eds. Hagerstown, Md: Lippincott Williams & Wilkins; 2002.

Office Orthopedics for Primary Care. Anderson BC. Philadelphia, Pa: W.B. Saunders Company; 1999.

Essentials of Musculoskeletal Care. 2nd ed. Snider RK, ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997.

If you are learning injection techniques for the first time, it would be beneficial to master two or three areas before moving on to sites requiring greater technical skills. Initial injection sites include the subacromial bursa of the shoulder, the knee joint and the lateral epicondyle of the elbow. Not only are injections at these sites technically less difficult than others, but when patients present with clinical complaints that may require an injection, these sites are the ones that most often need attention. The anatomy of these areas is relatively straightforward to learn, which makes these injections the easiest to master.

COMPARING OFFICE-BASED PROCEDURES

Procedure	CPT code	Medicare reimbursement*	Estimated physician time (minutes)	Initial cost of equipment	Reimbursement per hour (not including nursing 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 (e.g., finger, toe)	20600***	$50	5	Supplies only	$600
Joint injection, medium joint (e.g., elbow, wrist)	20605***	$55	5	Supplies only	$660
Joint injection, large joint (e.g., shoulder, knee, hip)	20610***	$67	5	Supplies only	$804

*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.

Reaping the benefits

Learning a new procedure can be aworthwhile investment for you and your practice. Joint and soft-tissue corticosteroid injections have been well studied withpositive results. Take a little time to practice the techniques, and your satisfied patients and increased revenue will make youglad you did.

Send comments to fpmedit@aafp.org.

Dr. Martz is medical director of the family practice office at the University of Arizona Health Sciences Center. He has facilitated lectures and workshops on joint injection technique. Conflicts of interest: none reported.

Copyright © 2003 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.