Nate Clements, MD

@dromarselod I’m also using Heidi and have loved it so far. Some tweaks to templates and it is certainly helping with efficiency and accuracy of history reporting.

Who is using AI to scribe in their offices and how is it going?

Today, a physician working at the same productivity level is stuck with $32.36 per RVU—which means, adjusted for inflation, they’re effectively making HALF of what they used to. Think about that: same work, half the pay. Meanwhile: Hospitals get sweetheart site-of-service fees. Private equity buys up independent practices at fire-sale prices. @CMSgov @droz @hhsgov @seckennedy keeps slashing physician reimbursement. Bureaucrats rake in raises while doctors get the shaft. In 1992, the Medicare conversion factor was $31.00. Today? $32.36. That’s a $1.36 total increase in 33 YEARS. If it had just kept up with inflation, it would be over $64.00 today. Instead, it’s more than 50% below where it should be. A doc today has to see twice the patients, do twice the procedures, and grind twice as hard just to keep up. And what does Congress do? No doc fix in the latest CR. No relief. No respect. Just another reminder that the system values hospitals and middlemen over the people actually delivering care. Physicians aren’t just underpaid. They’re being systematically devalued. @WaysandMeansGOP @GOPDoctors Not #healthcare

@BoMcNally So bad

Ridiculous flags in favor of Mahomes. Getting to levels of insanity.

@DrKalava Would love to hear how he does and your approach. I have a patient I’m working with right now with the same issues.

Phrenic Nerve Peripheral Nerve Stimulation ⚡️⚡️ 70-year-old male with chronic hiccups for eight years. Hiccups can start randomly but almost always start after eating or drinking. He reports throwing up after every single meal from the intensity and has lost 100 pounds. The only way to stop the hiccups are to force two fingers down his throat and throw up all the food that is in the stomach. He went to Mayo clinic in Minnesota in 2016 was prescribed every medication possible and all of them didnot helped. He reported all standard treatments testing and imaging that were normal. Acupuncture = 3 days of relief EGD = 7 days of relief Right Stellate ganglion block = No relief Let’s see if PNS can help🤔.. Time will tell #hiccups #neuromodulation #gastroenterology #medX #MedTwitter

Referred by neurosurgery^

Any #painmedicine, interventional alone or spine surgery colleagues have literature or experience on treating non osteoporotic traumatic fractures with augmentation? I know it’s not Medicare guidelines. @dougbeall @darthglader @JayKarriMD @Ryan_S_DSouzaMD @eckmann_max

@JayKarriMD Love the deep oblique. Do you routinely do this AND a lateral or one vs the other?

Lumbar RFA pearls: A "deep" ipsilateral-oblique view (~55deg) is critical to: 1) ensure needle is outside the foramen (in obese patients where lateral views are challenging) 2) optimize needle depth past the MAL 3) refine cephalad angulation towards SAP/TP interface

@cronair So painful to watch.

Ludwig is the best OC we’ve ever had, but I think it’s time to retire. He’s been cooked this whole season.

@DrAmitSharmaMD @JayKarriMD @doctdeer @drdesaimd @Ryan_S_DSouzaMD @jonhagedornmd @Sympathy4TheDr Absolutely, but my case discussions don’t help with their official CME.

@NDClementsMD @JayKarriMD @doctdeer @drdesaimd @Ryan_S_DSouzaMD @jonhagedornmd @Sympathy4TheDr Cheeky answer...but no one can beat your case discussions with them 😀 l

Question for my #painmedicine and interventional spine colleagues and friends. Does anyone have recommendations on high yield conferences for nurse practitioners and PA’s? @JayKarriMD @doctdeer @drdesaimd @Ryan_S_DSouzaMD @jonhagedornmd @Sympathy4TheDr

@danmckeeMD @MDAndersonNews Congrats Dan!

Matched at @MDAndersonNews for pain fellowship yesterday and I couldn’t be more excited! Houston here we come!

@Ryan_S_DSouzaMD These are awesome. Thanks for sharing. I’m 💯 in on the US guided intercostal blocks.

Check out this new graphic🩻 This is a fun nerve block to perform - ultrasound-guided intercostal nerve block. This graphic shows the important landmarks, muscle layers, and position of the intercostal nerve, artery, and vein.🧵🧵🧵

@JSinghMD @JayKarriMD Thanks y’all. That is how I understand the Medicare lcd as well.

Here’s a quick guide for CPT and ICD-10 codes for facet joint interventions, as determined by CMS. This covers codes I use >99% of the time in practice. Not exhaustive, but highly practical! Details and specifics below. go.cms.gov/4dHM3QU #painmedicine #billingandcoding

@JayKarriMD Are you doing any intra-articular facet injections? If so, how do you bill/justify based on the Medicare LCD?

Treating L4/L5 and L5/S1 (3 total nerve targets)? 2 joints Treating L3/L4 and L5/S1 (4 total nerve targets)? Technically 2 joints

@JayKarriMD I have started using spot fluoro trying to reduce my radiation exposure. If I have a hard time visualizing the spread or anything atypical I’ll go live.

Do you typically use live (“continuous”) fluoroscopy when performing lumbar interlaminar injections? Why or why not? #painmedicine #proceduraltechnique *rephrased for clarity

@JayKarriMD I’ve seen this a couple of times and questioned the spread. I noticed the contrast followed more of a straight line rather than truly spreading along the curve medial pedicle.

#teachingimages The epidural space is likely contiguous with surrounding fascial planes! Shown here is spinal needle placement outside the L5/S1 neuroforamen, but presumably in erector spinal plane, yielding epidural contrast spread.

@JayKarriMD I use it all the time simply because I like it. But I no longer code it other then some commercial plans.

@NDClementsMD For thoracic area TPIs, especially in smaller patients, I use US but don’t code it. You?

#billingandcoding Trigger point injections! How I do it, upon review of CMS criteria 🧵 *salient points and documentation pearls CPT 20552 (1-2 muscles) CPT 20553 (≥3 muscles) ICD M79.10 (myalgia, unspecified site)

@cronair We will be there that week too! Following for all the recs

Alright, 4 weeks out from a Boston trip with my wife… what else should we do and where should we eat?

@DrJesseMorse @Snowboard_dad Care to share which products you find most successful and supporting literature?

@Snowboard_dad I tell people 1 month out from injection you’re feeling better 3 months out about 50% better 6 months out 75% 1 year later you won’t think about it anymore This is if the correct product was injected in the right location with the correct volume

Surgeries for torn meniscus What does the data show? Meniscectomy (Trimming of meniscus) ▪75% decrease in contract area following medial trimming ▪This lead to 2x+ increase in peak contact pressure ▪This higher load on articular cartilage lead to disruption of the proteoglycan matrix leading to swelling & inflammation throughout joint ▪The increased hydration & catabolic state causes collagen matrix to breakdown & accelerate normal wear & tear within the joint ▪Patients undergoing total vs. partial meniscectomy showed significantly higher risk of developed OA ▪Data to support even a 20% resection of meniscus causes a detrimental increase in forces which leads to OA  ▪A 65% partial meniscectomy causes maximum shear stress on articular cartilage ▪Worse outcomes with lateral meniscectomy due to convex lateral condyle of the femur rolls on a flat/convex lateral tibial condyle  ▪Much higher functional deterioration & decreased stability in patients undergoing lateral vs. medial  Meniscus Repair  ▪63% of red-white zone healed close to normal at 10 years ▪68% of white-white zone at 4 year follow up ▪83% were considered clinically healed with no sx/surgery ▪Age , Gender, Chronicity of Injury, Involved tibiofemoral compartment & concomitant ACL reconstruction not found to adversely affect healing rates  I discuss them all here ⬇️ #KneeInjury