Personal Injury Orthopedic And Pain Management Hand-Book For Attorneys, Paralagelas And Case Managers How to manage, defend and win! A handbook to help understand and defend your client’s treatments
By: Pejman Eli Shirazy M.D.
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Personal Injury Orthopedic And Pain Management Hand-Book For Attorneys, Paralagelas And Case Managers 1st EDITION 2021 By: Pejman Eli Shirazy M.D.
CONTAINING USEFULL REFERENCE AND INFORMATION TO BETTER MANAGE AND DEFEND YOUR PERSONAL INNURY CLIENTS’ RIGHTS, INJURIES AND ORTHOPEDIC PAIN MANAGEMENT TREATMENTS
“TAKE CARE OF THE PATIENT AND EVERYTHING ELSE WILL FOLLOW” THOMAS FRIST. M.D
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Preface After 18 years of practice in the field of Orthopedic and Pain Management, what fuels me and keeps me going, is the satisfaction of helping patients in pain. Their gratitude, their smiles, and the simple thank you gestures are enough to encourage me to continue and help those who suffer from orthopedic conditions, and the pain and suffering that is associated with it. This applies more than anything to my personal injury patients, who I see suffer from injuries on daily basis. These patients are the ones who are always under treated, either because of physicians who doubt their patients’ pain, or due to insurance companies who set boundaries on treatments, and limit patients’ access to appropriate medical care, and when they do receive the care, they designate their treatments as unnecessary, unreasonable, and overtreated. These types of statements are heard on daily basis by law firms’ personnel and treating physicians. And it is up to the legal representatives, paralegals, case managers and treating physicians to make sure that their client’s/patient’s rights to receive proper medical treatments are defended and paid for by the defendants. This handbook is dedicated to all my injured patients that I have treated, and fought for over the years, with the goal of helping other injured patients and clients by educating their legal representatives to fight for their rights.
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CHIROPRACTIC AND PHYSICAL THERAPY What are the similarities between physical therapy and chiropractic care? Physical therapists and chiropractors have similar goals in mind for patients, but they may go about achieving these goals in different ways. Some of the similarities they share include the following: • Both focus on managing pain and discomfort using noninvasive and nonsurgical techniques. • Both may use manual or hands-on therapy to treat a specific condition. • Both may treat, or co-treat, the same conditions. • Both may focus on wellness plans for their patients beyond what they can do during a session. • Both evaluate your symptoms by taking your health history, examining you, and even ordering certain tests. • Both physical therapists and chiropractors are licensed health professionals with years of education and training. Physical therapy/ physiotherapy
Chiropractic care
Pain-free movement is one of the key primary goals.
Pain relief and alignment of the spine are key primary goals.
Focuses on how the body moves and functions as a whole.
Focuses mostly on issues related to back pain, neck pain, joint pain in the arms or legs, and headaches.
Physical therapists help you perform stretches and exercises, as well as performing some manipulations for certain conditions, to improve your mobility.
Chiropractors perform manipulations and adjustments to help your body heal itself.
Physical therapists work in just about any healthcare environment, as well as your home.
Chiropractors usually need specialized spaces and equipment to perform adjustments and manipulations.
HOW MANY SESSIONS OF THERAPY IS APPROPRIATE? Most research studies and guidelines state 12 sessions of therapy per diagnosis is appropriate. So, if the patient has neck and back pain treatment can be up to 24 sessions. However, the severity of the condition and continued documentation of patient’s progress and improvement by the therapist or chiropractor can justify additional treatment.
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MEDICATION USE IN PERSOANL INJURY The use of medication is often overlooked by physicians when treating personal injury patients. The lack of use is most of the time interpreted by the defense as lack of pain. Appropriate use of medication is an important part together with the therapy for patient’s recovery. Therefore, an INITIAL MD EVALUATION is important in the management of patient for appropriate medication prescription and rehabilitation recommendations.
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ANTI-INFLAMMATORIES: i.e Ibuprofen, Naproxen, Diclofenac…….
Are important in the initial phase of injury, and a course of at least 14 days is important prior to recommending pain management injections (this is a guideline requirement).
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Important to properly manage patient’s pain and quality of life, as well as ability to participate in therapy.
• MUSCLE RELAXANTS (prescription only) i.e Soma, Flexeril…..
Are important throughout the first 4-6 weeks to assist with recovery and improved function and sleep.
ANELGESICS (PAIN KILLERS): i.e Tylenol with Codein, Tramadol, Norco
SLEEP AID: i.e Ambien, Restoril, clonazepam…
Important in establishing affect of patient’s pain on quality of life, as sleep is a basic requirement for proper function.
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IMAGING: X-RAYS, CT, MRI X-RAYS: Indicated for acute injury, mainly helpful for: •
Fractures
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Dislocations
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Evaluation of spine prior to chiropractic manipulation (adjustments)
CT SCANS: •
Primarily useful in acute injury, mainly helpful for:
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More accurate evaluation of bones for fractures or disclocations
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Evaluations of Brain for bleeding post head trauma
MAGNETIC RESENANCE IMAGING (MRI): •
Normally, not a first imaging in acute injury. For spine injuries usually appropriate at or after 6 weeks, since if soft tissue injury is suspected they must resolve at 6 weeks. Spinal pain beyond 6 weeks may signal structural damage, therefore an MRI may be justified.
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Exceptions: Significant neurological symptoms and exam findings. In this case MRI may be ordered earlier.
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Primarily useful for: structural damage to spinal discs, nerves, muscles, ligaments and others soft tissue.
TYPES OF DISC DAMAGE How important is the radiologist report and description of bulge/protrusion/ herniation etc? VERY IMPORTANT • Bulge- No contact with the outer 1/3 of the disc annulus NO PAIN • Herniation/Protrusion- outer 1/3 contact produces pain • Rupture disc- produces pain • Sequestered disc- produces pain
Disc Abnormalities Bulging
Herniated Raptured
Sequestered or Fragmented
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Disc protrusion, disc herniations and extrusions produce disc pain because they reach the outer layer of the disc as the image below demonstrates:
The Disc Internal Anatomy
How To Defend And Justify Epidural Injections
Evidence Based Medicine
• Settlement offered: $ 20K only • Reason: • “ The epidural injections were not necessary” • “There was no evidence of facet joint damage on MRI, so the facet injections and radiofrequency were not necessary” • Defense Expert: • “Patient has no neurological involvement (no radiculopathy, no sciatic pain, no radiating pain in arms or legs, no numbness and tingling). Therefore injections were not medically necessary. • “Dr. Shirazy over treated the patient, his pain management procedures, and bills were unreasonable. Physical therapy would have been adequate. “
• ”Cook book” guidelines set by accepted organizations as to when it is appropriate to perform pain management procedures. • North American Spine Society • American Academy of Pain Management • Medicare Guidelines • As long as we adhere to these guidelines, you should be able to justify the treatments performed in our centers.
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The guidelines for pain management spine procedures • Pain level of at least 6/10 on the pain scale • Failure of 6 weeks of physiotherapy (Chiro or PT) • Imaging studies suggestive of discogenic or neurogenic pain ( for epidurals) • Failure of at least 2 weeks antiinflammatory oral medications • No need for Radiculopathy, sciatica, neurological findings or nerve compression on MRI • No indication based on size of disc protrusion
What the guidelines DO NOT SAY: • • • • • •
No need for: Radiculopathy, sciatica, neurological findings or nerve compression on MRI No need for facet imaging findings(for facet injections) • No indication based on size of disc protrusion
Frequency of Epidural Injections per guidelines: • Up to 3 epidural injections in a 6-month period is medically justified; as long as improvement is documented. • There is no set time between injections. Generally, at least 2 weeks. • One level of epidural injection is accepted at one time (for example 1.4-L5 epidural injection, not 1.4,15 and L3-L4)
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NORMAL MRI OF THE SPINE BUT CLIENT/ PATIENT STILL IN PAIN The Origin of Pain – Facet Diagnosis • Patients with normal spine MRI in pain after failing conservative therapy treatment should consider facet pain as source of their pain. • Many of these cases are commonly determined as a soft tissue case mistakenly, because the doctor didn’t diagnose the patient correctly. • The “Gold Standard” in the diagnosis of a facet pain is the actual facet block injection. If consequent to the injection there is an improvement of the pain of 50% or more, then you will proceed to the second injection.
The Origin of Pain – Facet Joints
Facet joints have nerves- Medial Branch N.
• Pain May last > 6 weeks • May have radiation to shoulders, buttocks, etc. • Trigger point injections are not helpful. • Patients pain increases with extension of the spine. • No imaging proves facet pain.
Facet Block Injections For facet origin of pain
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Frequency of Facet Injections Per Guidelines: • Up to 2 facet injections every 6 months are indicated. • No more than 2 bilateral facet injections are indicated (for example Bilateral L4-L5 and L5-S1 facet injections are ok. If L3- L4 facet added, it is not indicated) can not perform together with epidural. • After the first facet block, an improvement of 50% or more must be documented to proceed.
FACET RADIOFREQUENCY / RHIZOTOMHY Indication for Rhyzotomy/ Radio- Frequency • Must have had facet blocks that provided over 50% of improvement. • The period of improvement is not a factor (1 day, 1 week or months) • Rhizotomy could be performed over 2 sessions if bilateral. • The levels of Rhizotomy must correspond to levels of successful facet blocks.
Frequency of Facet Injections Per Guidelines: • • Up to 2 facet injections every 6 months • are indicated. • • No more than 2 bilateral facet injections are indicated (for example Bilateral L4-L5 and L5-S1 facet injections are ok. If L3- L4 facet added, it is not indicated) can not perform together with epidural. • After the first facet block, an improvement of 50% or more must be documented to proceed.
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STEM CELLS AND PRP Regenerative Medicine PRP: Platelet Rich Plasma • No Live Stem Cells • Less Expensive • Can Help with Recovery • NO Significant Regeneration • Origin: patient’s blood
Platelet Rich Plasma • Stem Cell PRP Therapy is a healing treatment that rapidly stimulates that body’s natural healing process. • Simple Outpatient procedure • Non-painful • No-downtime after procedure
STEM CELL: • Millions of Live Cells • More Costly • Actually Regenerates the Injury • ORIGIN of STEM CELL: 1. SELF • Bone Marrow • Adipose 2. Other Human Species (New Born) • Amniotic Fluid • Umbilical Cord
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PRP (Platelet Rich Plasma) What is Stem Cell PRP? Stem Cell PRP (Platelet Rich Plasma) is a regenerative therapy treabment UU that works with your own platelets found in your blood. Platelets are naturally extremely rich in the connective tissue growth, and are the main component in injury healng Stem Cell PRP treatment has been rising in popularity among professional athletes and highly active individuals. Stem Cell PRP therapy is particularly great for athletic injuries, enabling patients to return to regular activities and competitions faster and with confidence.
Platelet Rich Plasma SPINE Back pain, neck pain or chronic facet syndrome
SHOULDER Rotator cuff injuries, including partial-thickness Shoulder pain and instability
ELBOW Tennis and golfer’s elbow
HAND & WRIST Nerve entrapment syndromes such as Carpal Tunnel Syndrome
HIP Hamstring and hip strains Sacroiliac (SI) joint dysfunction and pain
KNEE Knee sprains and instability Knee, hip, and other joint osteoarthritis
ANKLE Ankle sprains Achilles tendonitis Plantar fasciitis
Which conditions can be treated with PRP?
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Stem Cells in Personal Injury • “I DON’T WANT SURGERY” • Alternative to surgery in cases with lower policy, or • In cases with high policy and patient not consenting to surgical intervention.
Stem Cell- Conditions Treated Conditions That May Be Treated in Personal Injury 1. Discogenic Pain-cervical, lumbar, thoracic. 2. Knee Meniscus Tear, Ligament Partial Tear 3. Shoulder partial RTC Tear 4. Non-Healing Fractures/Wounds 5. Foot/ankle injuries 6. Wrist, elbow and hand injuries 7. Many NON-Orthopedic Conditions (doesn’t apply to PI patients)
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Stem Cell Therapy On Lien • Typical procedure cost is $18-$23K. Inclusive of surgery center cost, physician professional services, and cost of stem cell. One time procedure. • PRP cost $3-5K per area treated. No surgical center needed.
Stem Cell
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DEFENDING YOUR CLIENTS’ BILLS AND CHARGES THE CODING NETWORK (TCN): • A reputable organization in the field of billing and coding that audits bills for doctors’ offices for accuracy and produces a certificate of compliance. You or the treating doctor can use this service as we are in our office to justify coding and billing practices.
FAIR HEALTH(FAIRHEALTH.ORG): • The most authoritative organization in setting fee schedules. It is based on geographical area of practice, and evaluation of millions of charges within the health-care system. Provides a range of fee for a particular medical service. Excellent guide to evaluate medical services fees.
DEFENSE PROOF BILLS • New Defense Trends Towrads Pain Management Services: • • • • •
“Billing codes are wrong” “Charges are unusual and not-customary” “The doctor/ facility is unbundling” “The doctor/ facility is upcoding” “Bill not prepared by a certified medical coder”
Fee Schedule Auditing
CODING AUDIT SERVICE
With over 15 years of experience in the Orthopedic and Orthopedic and Pain Management Industry, our doctors strive to provide the highest quality service to personal injury patients pursuing a thorough recovery to retum to their active lifestyles.
PEMAN ELI SHIRAZY, MD, QME
ARASH YAGHOOBIAN, MD
TOWY LAU, DO, MPH, MSM
DAVID E. ENRIQUEZ
SOHAIL SHAYFER, MD
Offering Orthopedic and Pain Management Services • • • • •
Radio-Frequency Ablation Epidural blocks (cervical/thoracic/ lumbar) Facet blocks (cervicallthoracidlumbar) Medial and lateral branch blocks Orthopedic medicine Orthopedic spinal surgeries
OFFICE LOCATIONS ENCINO
16952 Ventura Bivd., Encino, CA 91316
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Centers Sacroiliac joint injections Intra-articular joint injections Platelet Rich PlasmalUmbilical Cord Stem Cells (FDA Regulated) Joint Commission-accredited surgery — All Locations
LOS ANGELES
431 S. Hewitt St., Unit B, Los Angeles, CA 90013
818-290-5949 RANCHO CUCAMONGA
8599 Haven Ave., Ste. 103-104 Rancho Cucamonga, CA 91730