Manipulation Under Anesthesia: Possible Revenue Source for Orthopedic ASCs

ASCs continuously search for new service lines to generate additional revenue for their centers. Orthopedic and pain management ASCs often look to spine surgery to provide that new revenue, but they often overlook a procedure they can add with no capital investment and no implant costs — manipulation under anesthesia.

Manipulation under anesthesia is a non-invasive pain management technique that involves stretching and deep massage of soft and built-up scar tissue as well as some joint manipulation, performed while a patient is under anesthesia. According to Bruce Fischer, DC, CCSP, manipulation under anesthesia is usually performed by a team consisting of a chiropractic physician, and an MD or DO. All physicians involved must have had a minimum of 32 hours of post-graduate training in MUA. These courses are sponsored by several accredited chiropractic schools.

"For ASCs, it can be financially rewarding to have an MUA program. Chiropractic physicians and their patients are a virtually untapped market in this setting," Dr. Fischer says. "ASCs can increase revenues without increasing costs because MUA is a non-invasive technique that is done manually without instrumentation."

Who requires MUA?
Patients that are not responding to typical, conservative treatment are good candidates for MUA, according to Dr. Fischer. He says, "These are patients who have tried regular chiropractic treatment, physical therapy, serial epidural injections and even surgery. Failed back surgery syndrome responds extremely well to MUA, due to the breaking up of the adhesions/scar tissue that often forms post-surgically. It is not uncommon to have spine surgeons working with MUA physicians to treat these candidates, with often predictable positive outcomes of decreased pain and increased function."

MUA can also be an alternative to surgery for some patients. Dr. Fischer says, "It can be highly effective for patients who have tried everything else."

What is required in MUA procedures?
Typical MUA patients will undergo a three-day procedure. "This is standard, as it can take that long to change scar tissue in the soft tissue and joint to normal tissue," Dr. Fischer says.

Dr. Fischer says MUA consists of 80 percent stretching and deep muscle massage and 20 percent joint manipulation. Most of the MUA patients have multiple injury sites such as the lumbar spine, pelvis and hips, which are all separately billed. A typical MUA procedure lasts between 10 and 15 minutes. "In a usual morning we can perform 15-20 MUA procedures before 11 a.m.," he says.

Each MUA procedure will require an anesthesiologist, an OR nurse, a medical physician, for pre-op clearance and assisting in the procedure, and a chiropractic physician, who typically does most of the joint manipulations.
Propofol is the drug of choice, due to its muscle relaxation effects. This allows the patient to be stretched without any resistance or spasm, which is what can make MUA successful where most conservative therapies have failed, according to Dr. Fischer.

What should ASCs know about billing for MUA?
Dr. Fischer says most insurance companies will reimburse for the procedure only if the patient has exhausted the usual treatments and the referring physician thoroughly documents failure of prior care, proper diagnostic testing and any specialist consultations. Medical necessity must be established, and patients must undergo a screening process prior to scheduling.

There are many financial advantages to starting an MUA program at your center. For every MUA patient, there are three billable dates of service and usually multiple billable regions performed. Another financial advantage of MUA billing is that each region performed is separately reimbursable. "The typical MUA patient has multiple area of complaint," Dr. Fischer says.

Continued studies on effectiveness and new training programs for physicians in MUA have helped to grow the market and payor understanding of these procedures.

For more information on how to start an MUA program in your center, please call Dr. Fischer at (561) 347-6682.