So, if you're not excited after listening to Jason, I mean, my practice was procedurally mostly shoulder practice, but the number one diagnosis in the practice was knee osteoarthritis. So I saw more knee osteoarthritics that I wound up not operating on, and so it is a tremendous burden. And so the market here is, I've seen data saying anywhere between 5 and 15 billion. It's growing at an amazing rate every year, and it's global, right, all these different paradigms. And you know, the opportunity is twofold. You know, when we have about 50 million osteoarthritics now, it's almost going to double in the next 20 years. We do about 2 million total joints a year now. That's going to double in the next 10 years. And when you combine that with the fact that, you know, we're seeing a significant decrease in our procedural, you know, reimbursement, this is also a way that we can repair our incomes with some new treatment modalities. So I think it's a really exciting aspect of orthopedics now that's really, you know, along with the increase in procedural volumes that we're going to see because of the aging of the population. It's really one of the things that's going to drive the orthopedic space for the next 10 years. So some really simple things to consider about the billing, you know, the nuts and bolts of the billing. So you have to consider three things. Is it a governmental payer or a private payer, commercial? Are you in the office or the operating room? And is it a standalone procedure or done in conjunction with a CPT code generated procedure? These are the three things you need to keep in mind when you're doing billing. And so if you're in the office, only inter-articular corticosteroids and hyaluronic acid have J-codes. So they're the only things that you can bill J-codes for. PRP and microfragmented fat have T-codes. They're tracking codes. So these are codes that the AMA puts out that actually track procedures but don't have any RVU value in them. So when you bill them, the RVU value is zero. Really the coverage for these is carrier-dependent and it's dynamic, so you need to keep up on this and have your staff continue to query the payers as to their coverage for these type of services. If they're not covered, you can bill them fee-for-service. To do so, though, especially for Medicare patients, you need to have them sign an advanced beneficiary notification. This is essential for Medicare, and I would suggest that you should do it for commercial carriers also. You need to consult their policies, as I said before, but it's always good to have these things done anyway so that you can document it in the treatment chart. This is what the ABN looks like, and you can get these online. If you're in the OR, it's considered inclusive. If you're doing a rotator cuff repair and you do BMAC injection, by CMS, it's considered inclusive. It varies depending on the payer, so you need to consult their policies. If it's not covered or deemed experimental, then you can bill for it as long as there's a waiver or an ABN. You really have to have an informed consent discussion with the patient to make sure that they know that they're getting something that they're going to have to pay for. You need to document these things, too, so you need to have informed consent, an explanation of the investigational nature of the procedure, the reason why it's not covered, a reference to your ABN, if you have one, or your waiver, and then, of course, a detailed procedural note. These guardrails will help you keep safe on the procedural side. There's tons of information about this on the internet. All the payers have their policies online. There's also good information, CMS, actually. Their website is full of some good information here, so I would suggest you go there, too. The Biologic Association, which we're part of, their website is full of all sorts of great information about these procedures, so I'd recommend you go there. This study was done in 2018 at Rush, and on the billing side, it's still current, so this is a good reference, too, in regards to how you actually would bill for these things in your office and the operatories. I think the people that have adopted this technology the best are the ones who have really established it as sort of a separate service line. This is a business. You set it up as a business, and you track it as such. It's an ancillary service, right? The people who are the most successful with it, too, also may incorporate a hematology lab so they can actually characterize the components of the product that you're giving to the patients. This is really a high-level way to do this. You know, we had a designated room for injections with a chair that was very comfortable, and patients could incline, recline, and things like that. And you can market this, but you really need to be careful in the way that you market it. You know, these are not stem cells. This is not regenerative medicine. This is really ways to decrease pain and inflammation at this point in time, right? So as long as you characterize it as such, I think you're not going to get into trouble, but if you characterize it, as some have done, as a regenerative or restorative process, then the FDA will come after you for that. So what about specifically? How do we code for each individual orthobiologic? I consider VSCO an orthobiologic. I put it in this category. It's covered by CMS, but many carriers do not cover it. The ones that do usually require some type of pre-certification, so you need to be aware of that. And your billing is, you know, you bill an injection code or the musculoskeletal ultrasound injection code. If you do significant E&M work before the injection, then you can bill for that as long as you use a 25 modifier. Don't do it for the subsequent injections. The evaluation of the patient is included in that injection code, believe it or not. The injection codes actually have pre-service time, intra-service time, and post-service time, just like a rotator cuff repair. So you know, subsequent injections or if you really haven't done, if you call the patient up and say, you know, your HA is here, come on in, I wouldn't bill an E&M for that either because that's included. And then you bill your J code, and you know, there's a J code for each of these different HA components. How about PRP? Not covered by CMS. Covered by some insurance carriers, and a lot of workers' compensation in states will be covered. In New York, it's covered, so you don't have to get approval for it, but it's covered. I did a survey last year on, you know, the price that people charge throughout the United States, and it varies anywhere from $400 to $1,000. You bill the 0232T code, that's the tracking code, and that's inclusive of the PRP, the harvesting, the image guidance, and the preparation. So all of that stuff is included in that 0232T code, so you can't charge for that. And once again, if you do significant E&M work, I suggest that you code for that with a 25 modifier. And you know, this is really specific only to PRP. Some people use this 0232T code for all different biologics. It's not correct. This is only for PRP. And you know, this is a study out of Rush, interesting study, where they looked at cost effectiveness of PRP and compared it to other modalities and the cost thereof. And they came up with the, to the conclusion that PRP was worth about $1,200. So imagine that. So it's sort of in the ballpark of what we're talking about. So for PRP, you code the 0232T code and you have an advanced ABN. In the operating room, the same, but make sure that the hospital is not going to double bill the patient in your ASC or your hospital, because if you don't do that, then the patient gets two bills. They can get really frosted by that. So you really have to make sure that that protocol is in place. If you do it on a CMS patient, it's included and you can't bill for it. Once again, remember the CPT code rules are that if it's done with a CPT code procedure, then it's for Medicare, it's, it's bumbled in there. About microfragmented fat, well, this is really, I think if you listen to Jason's talk, this is a really exciting orthobiologic. It's not covered by CMS or commercial carriers yet. And the charges are anywhere from $3,000 to $4,500 from the sites that I saw that were doing this. So it's a major league investment for the patient. You code the 0565T code. You can do it, and there's an ultrasound guided code too, that's 0566T. And once again, you bill E&M if you did significant work. In the office, all it is is the 0565T and the advanced beneficiary notification. In the operating room, the same, but once again, just like PRP, you make sure that the patient's not going to get doubly billed for this procedure by you and the hospital. How about BMAC? Once again, not covered by CMS or commercial carriers, fee anywhere from $2,200 to $5,000 from the survey that I did. And I've seen any one of these codes on the right being used for this, right? And they're not, it's not appropriate, really. This is a unlisted code. This is a 20999 code, ABN, same thing in the OR, and once again, make sure that the hospital or the ASC is not going to double bill the patient. So in summary, you know, this is a really exciting part of medicine. It's an unmet need. I mean, you all in this room know that patients do not want to have total joints, and they will go to great lengths to avoid having a total joint. If you can offer them an array of treatments and they understand their economic responsibility, then I think that, you know, that you can offer them other opportunities to improve their symptoms and their condition. So you've got to know the rules, especially for coding and the FDA, as this is an area ripe for regulatory burden. And you know, so be transparent with your patients, document appropriately, and I would recommend that if you're not using these, that you do consider adopting them, as certainly it represented a very important part of my practice. Thank you very much. All right.

orthopedic treatments

knee osteoarthritis

income increase

treatment modalities

billing for orthobiologics