Dry Needling

[Guest guest]

Hi Friends,

Does anyone know if Dry Needling is within scope of practice for PTs in

Michigan?

 

Warm wishes,

 

 

SAILESH  SATPATHY, PT

[Guest guest]

Hi everyone,

Still think billing the same way as physicians makes the most sense:

different levels of evaluation ranging from brief to extensive, different

standard flat rate office visit charges which cover all costs for basic care

and then the ability to add procedure codes for things that need separate

billing. PT could retain procedure or other E & M codes, and make new ones

to accurately reflect the knowledge and training of the PT, that all agree

need the specialized skill and training of the PT. The rest would covered

in the office visit charge. Dry needling would be one of those " specialized

skills " . Plus those specialized skills would be only done by the PT. For

those wanting to use support personnel like a physician (incident-to), you

could (if the law allowed it) and all those things like monitoring exercise

programs, counting reps etc would be covered in the office visit charge.

So the basic billing would be a type of office visit (depending on length

and category of basic treatment) plus specialized procedures. Would be much

simpler and allow the PT to delegate treatment tasks where legal and still

get paid at a basic level for all that goes into an " office visit " .

Of course this leads to the concern that this would lead to quantity billing

of multiple procedures but that list of procedures would be small and finite

and the need for those procedures would still have to be justified.

This also would only work if quality measures would be used as well to

either increase or decrease reimbursement based on whether the clinic doing

quality care.

Just my opinion.

Tom

thowell@...

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From: PTManager [mailto:PTManager ] On Behalf

Of Rick Gawenda

Sent: Tuesday, August 23, 2011 3:16 PM

To: ptmanager

Subject: Dry Needling

This topic has been discussed several times on this list serv and I believe

it is an important discussion. Here is a policy from CareFirst BCBS in

land stating dry needling is not covered as it is considered

experimental/investigational. At least one of the studies reviewed was done

by a member of APTA.

With that said, would a payment system based on the severity of the

condition and intensity of services required and provided be a better form

of reimbursement instead of per CPT code or per visit without rationale for

why insurances reimburse what they reimburse? Let the therapist decide what

interventions are best for their patients and who is best to provide that

intervention all while under the responsibility of the evaluating therapist.

http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/60e726

1c3db2eed1852576d9004f7291?OpenDocument

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

[Guest guest]

Insurance companies are quite fascinating when they express opinions about

issues they clearly are not familiar with. There are indeed several insurance

companies with specific policies against dry needling. Since in 1997 I

introduced dry needling courses to PTs and other healthcare providers in the

USA, I have initiated several discussions with insurance carriers in different

states. I have an insurance-free PT-owned practice in Bethesda, MD, but still

get involved when my patients are faced with denials of payment. Some of the

letters I have prepared are in response to denial letters from insurance

carriers, including BC/BS of land, Guardian, and others. Every insurance

carrier reversed its opinion and covered all charges for the PT services which

included dry needling.

I do no plan to start a discussion about the validity of trigger point

treatments, dry needling, or myofascial pain, but only want to illustrate that

insurance companies are very good at denying anything they want in spite of

overwhelming evidence to the contrary.

The BC/BC of land policy about dry needling is pretty standard.

Interestingly, not a single insurance carrier has ever consulted me or other

specialists in this field. The insurance folks managed to find a few obscure

papers to support their probably preconceived notion not to cover dry needling.

In my letters to carriers, I present many scientific papers illustrating why

denying trigger point treatments will lead to prolonged and ineffective

treatments and therefore, to greater financial liabilities. I make the argument

that dry needling is in fact the most specific and effective treatment option

currently available within the context of manual physical therapy.

I am the author of nearly 40 chapters in medical textbooks, including the

prestigious Bonica's Management of Pain. Be assured that the editors of the

Bonica textbook would not have included a chapter about myofascial pain, trigger

points and indeed, dry needling, if there were no scientific evidence of the

concept and the interventions. In addition, I prepare a quarterly review article

on myofascial pain for the Journal of Musculoskeletal Pain. It is interesting

that pain management experts in different countries do acknowledge the value of

myofascial pain and indeed of the most specific treatment option currently

available. Clinicians agree. Just today, I received an email from one of my

course participants:

I wanted to express my sincere thanks for the amazing information and techniques

that were shared by you at the AAOP (American Academy of Orofacial Pain - JD)

pre conference course in Las Vegas.

Career changing and epiphany would be descriptors of how it has changed my

practice even after just one course!

At first a little skeptical, I now use intramuscular manual therapy in lieu of

any modalities, prior to stretching, MFR or manipulative techniques.

In just the last 3 months my practice has evolved to the point where requests

from patients for Dry Needling has exceeded the time I have to help all those

seeking to benefit from this amazingly powerful therapeutic intervention.

I understand that such anecdotal testimonials do not carry any weight with folks

who already know that they are not going to pay for a new and innovative

technique, which is better supported by scientific evidence than most other

techniques PTs use in their practices.

There are many problems with how insurance companies make their arbitrary

decisions. Dry needling is just a technique used within the context of manual

physical therapy. There is an overwhelming amount of literature demonstrating

that trigger points are associated with all pain diagnoses. Recent studies even

show that treatment of trigger points in patients with fibromyalgia decreased

not only the patients' local pain, but also reduced their overall pain levels.

If anyone would like to get some of these references, please contact me directly

and I will be happy to provide these.

Many PTs use manual trigger point release techniques and not a single carrier

has expressed that they will not cover such soft tissue techniques.

These services are likely billed under the 97140 CPT code. Manual trigger point

therapies are time-consuming compared to dry needling, which because of its high

point specificity, can accomplish the same release in significantly less time.

There are numerous scientific studies in support of manual trigger point

release.

Insurance carriers are very good in excluding relevant papers. They may quote

papers on injection techniques, but select very specific sections of these

papers. Commonly quoted papers (such as Hong CZ: Lidocaine injection versus dry

needling to myofascial trigger point. The importance of the local twitch

response. Am. J. Phys. Med. Rehabil. 73(4): 256-63, 1994, or Kamanli A, Kaya A,

Ardicoglu O, Ozgocmen S, Zengin FO,Bayik Y: Comparison of lidocaine injection,

botulinum toxin injection, and dry needling to trigger points in myofascial pain

syndrome. Rheumatol. Int. 25(8): 604-11, 2005) are often quoted to deny dry

needling, but both these papers state very clearly that dry needling was very

effective. A Cochrane Review specifically stated that dry needling appears to be

a useful adjunct to other therapies for chronic low back pain.

It is quite amazing that in a recent " discussion " with a carrier, they mentioned

a study by DiLorenzo et al (Dilorenzo L, Traballesi M, Morelli D, Pompa A,

Brunelli S, Buzzi MG,Formisano R: Hemiparetic shoulder pain syndrome treated

with deep dry needling during early rehabilitation: a prospective, open-label,

randomized investigation. J Musculoskeletal Pain 12(2): 25-34, 2004). In this

study, the only variable was dry needling and the results speak for themselves.

CVA patients with a painful shoulder were divided into two groups. All

subjects had the same rehabilitation program. Half got dry needling in

addition. The study showed that dry needling reduced analgesic medication use,

improved sleep and mood and prepared patients better for their rehabilitation

program.

A meta-analysis (Cummings TM, White AR, Needling therapies in the management of

myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 82(7):

986-92, 2001) concluded that “direct needling of myofascial trigger points

appears to be an effective treatment. "

A comparative study of the effectiveness of trigger point injections with

lidocaine and dry needling with solid filament needles showed that the

techniques are equally effective, but the effects of dry needling lasted longer

(Ga H, Choi JH, Park CH, Yoon HJ, Acupuncture needling versus lidocaine

injection of trigger points in myofascial pain syndrome in elderly patients--a

randomised trial. Acupuncture in Medicine: 25(4): 130-6, 2007). Wet needling

or injections are always more expensive than dry needling as physicians will

consider wet needling as a separate CPT code. Dry needling on the other hand is

always part of other manual therapy interventions and do not increase the costs

per treatment session. In other words, dry needling is budget-neutral!

None of the papers that insurance quote include studies, that do demonstrate

that dry needling has very specific effects, including:

1. Shah J, T, Danoff JV, Gerber LH, A novel microanalytical technique

for assaying soft tissue demonstrates significant quantitative biomechanical

differences in 3 clinically distinct groups: normal, latent and active. Arch

Phys Med Rehabil 84: A4, 2003.

2. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, TM, Gerber LH,

Biochemicals associated with pain and inflammation are elevated in sites near to

and remote from active myofascial trigger points. Arch Phys Med Rehabil 89(1):

16-23, 2008.

3. Shah JP, TM, Danoff JV, Gerber LH, An in-vivo microanalytical

technique for measuring the local biochemical milieu of human skeletal muscle. J

Appl Physiol 99: 1977-1984, 2005.

Shah and colleagues are researchers at the US National Institutes of Health in

Bethesda, MD, and through their outstanding micro-dialysis studies they

demonstrated that eliciting a local twitch response via dry

needling immediately normalized the chemical environment of active trigger

points. Clinically, these studies are very relevant. Active - or pain-producing

- trigger points are characterized by the presence of

multiple pain-generating chemical substances, including substance P,

calcitonin-gene-related peptide, multiple interleukins, tumor-necrosing factor

alpha, serotonin, and norepinephrine, among others. Dry

needling is the only known remedy in addition to wet needling, which can

effectively correct the chemical environment of trigger points. Meta-analyses of

the effectiveness of dry needling always fail to include such high-level

studies, but that does not make this NIH research irrelevant.

Lucas and colleagues demonstrated eloquently that latent trigger points have

immediate negative implications for movement patterns. Release of trigger points

via dry needling immediately corrected the

movement dysfunction. Physical therapists are concerned about correcting

movement dysfunction. Dry needling is a very effective treatment technique (see

for example Lucas KR, Polus BI, Rich PS, Latent myofascial trigger points: their

effects on muscle activation and movement efficiency. J Bodyw Mov Ther 8:

160-166, 2004; Lucas KR, Rich PA, Polus BI, Muscle activation patterns in the

scapular positioning muscles during loaded scapular plane elevation: the effects

of latent myofascial trigger points. Clinical Biomechanics 25(8): 765-770,

2010). Latent trigger points are not only important for motor dysfunction, but

they also contribute to central sensitization as has been demonstrated by

numerous recent studies.

In other words, when physical therapists use dry needling as part of their

treatment regimen, they not only correct movement dysfunctions, but they also

contribute to a sharp and immediate reduction of pain.

Central sensitization is one of the most intriguing aspects of myofascial

trigger points.

In summary, I believe there is ample literature supporting the use of dry

needling in the physical therapy treatment of patients with pain and movement

dysfunction. It is important to realize that dry needing is

never a stand-alone therapy, but is always a relatively small part of the manual

physical therapy treatment. I believe that dry needling is a budget-neutral

manual therapy technique.

Insurance carriers assume that physical therapists who include dry needling will

increase costs. Quite to the contrary, considering the long (but still

incomplete) list of references, it is important to realize that dry needling

increases the specificity of the treatments and as such will likely reduce the

total number of treatments required.

Lessons to be learned:

1. When an insurance carriers denies a treatment technique, carefully read their

arguments and reply with excellent scientific research.

2. PTs who want to be autonomous should stand up for our profession.

Irrespective of whether a PT has experience with dry needling or any other

technique, let the science do the talking.

3. I agree with Rick to " Let the therapist decide what interventions are best

for their patients and who is best to provide that intervention all while under

the responsibility of the evaluating therapist. "

Jan Dommerholt, PT, DPT, MPS

Myopain Seminars, LLC

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