Massachusetts General Hospital Handbook of Pain Management Lippinott 2002; 350:382 In most cases of neck and back pain the anatomic and physiologic

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1 HISTORY OF PF-NCS

2 Massachusetts General Hospital Handbook of Pain Management Lippinott 2002; 350:382 In most cases of neck and back pain the anatomic and physiologic diagnosis remains unclear.

3 EMG/NCV has not changed since the early 1960s State-Of-The-Art-Review EVALUATING RADICULOAPTHY: HOW USEFUL IS ELECTRODIAGNOSTIC TESTING? 1999 Page 251: In chronic cases, particularly in individuals with predominantly sensory symptoms, it is difficult or impossible to clinically estimate the type or severity of nerve injury.

4 EMG/NCV has not changed since the early 1960s State-Of-The-Art-Review EVALUATING RADICULOAPTHY: HOW USEFUL IS ELECTRODIAGNOSTIC TESTING? 1999 Page 252: Only if there is obvious muscle atrophy can one know for certain that motor axon degeneration has occurred.

5 Pain Translation of Symptoms and Signs in Neuropathic Pain 2003;93:147 There is a urgent need for a simple method to diagnose pain disorders.

6 AXON-II Pain Smoke Detector In 15 minutes your nurse can perform a painless AXON-II exam to identify pain fiber injury or pathology with 100% statistical peer-reviewed accuracy. NIH data shows that 43% of spine pain patients develop chronic symptoms and up to 80% of spine surgeries end in failure. Why? Because over 50% of pain patients have referred pain and physical exams cannot detect the difference in location between real and referred pain.

7 EMG/NCV EMG is like needing over half the roof to be burned away before a fire can be detected. EMG cannot test small pain fibers, and the large fibers it tests require at least a 50% loss of the protective myelin before any change can be detected. The AXON-II is the only electrodiagnostic test that measures pain fiber function and it does it with peerreviewed sensitivity approaching 100%.

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11 Peer-Reviewed Study Randall Cork, MD, PhD LSU PAIN CENTER Three year study on chronic and failed surgery cases. Conclusion: A-delta NCS has 95% sensitivity Dr. Cork has gone on record that pf-ncs is the Gold Standard in locating pain fiber pathology.

12 LSU Study Peer-Reviewed Study Title: Piriformis Syndrome Diagnosed by A-delta NCS Using the A-delta NCS, Cork and his team tested 48 patients with a diagnosis of piriformis entrapment. It was discovered that when L5 and S1 dysfunction is present on the same side, there is an 80% probability of concomitant piriformis entrapment along with radiculopathy.

13 LSU Study American Society of Regional Anesthesiology and Pain Medicine (ASRA) Scientific Conference Title: Getting to the (nerve) root of fibromyalgia Using the Neural-Scan prototype, patients with a diagnosis of fibromyalgia were tested. Many were found to have previously undiagnosed radiculopathies and these were treated. Ten were available for 6 and 12 month follow ups. All ten were free of fibromyalgia symptoms.

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15 CERTIFICATION Purchase includes cost for physician certification through the AASEM. About 2 hours over fax and phone. Five years certification is available by attending a local AASEM Workshop.

16 HISTORY OF PF-NCS

17 Medical Equipment Systems, Inc. Fall Prevention Medicare Guide to Fall Assessments

18 Fall Statistics One out of every three Seniors Fall Of these fallers, 75% fall repeatedly Falls are the leading cause of accidental death, injury, and hospital trauma admissions 20-30% of people who fall suffer moderate to severe injuries, such as hip fractures, head trauma, and lacerations *According to the CDC

19 ARCHIVES OF INTERNAL MEDICINE May 25, 2009 Inner ear balance disorders common, associated with falls among older Americans Individuals with vestibular dysfunction were more likely to report having dizziness and a history of falls These findings suggest the importance of diagnosing and treating vestibular deficits to reduce the burden of fall-related injuries and deaths "Our survey shows that balance testing needs to be part of basic primary care, and that all physicians need to be monitoring and screening their patients for vestibular dysfunction so that we can take preventive measures to guard against falling," Minor said. The Johns Hopkins University

20 Medicare Guidelines PQRS Measures Three PQRS Measures for falls 1. Screen all seniors for risk of falls 2. Provide fall assessments for all seniors at risk for falls 3. Provide Plan of Care

21 Medicare Preventive Services Annual Health Review Review of the beneficiary s functional ability and level of safety Use direct observation of the beneficiary, or any appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations to assess, at a minimum, the following topics: Hearing impairment, Ability to successfully perform ADLs, Fall risk Home safety. *CMS

22 Western Systems Research Simple 10 minute test of the entire Peripheral Vestibular System Highly Reimbursable from Medicare, Medicaid and Private Insurance FDA approved in 1986 Hundreds in use Texas since 2006 Internal Medicine, Family Practice, Neurology, Cardiology, Otolaryngology

23 VATplus Western Systems Research

24 Medicare Solution Annual Health Review and PQRS 1. Screen with a Fall Questionnaire 2. Assess with the VATplus 3. Provide a Plan of Care with Vestibular Exercises

25 Medical Equipment Systems, Inc. The Medical Practice Building Specialists

26 (DAN) is among the least recognized and understood complications of diabetes despite its significant negative impact on survival and quality of life in people with diabetes (1,2).

27 CARDIOVASCULAR AUTONOMIC NEUROPATHY (CAN) Perhaps one of the most overlooked of all serious complications of diabetes is CAN (42). CAN results from damage to the autonomic nerve fibers that innervate the heart and blood vessels and results in abnormalities in heart rate control and vascular dynamics (43). Reduced heart rate variation is the earliest indicator of CAN.

28 Cardiovascular Autonomic Neuropathy CAN is the most prominent focus of autonomic dysfunction because of the life threatening consequences of this complication and the availability of direct test of cardiovascular autonomic function. A recent meta-analysis of published data demonstrated that reduced cardiovascular autonomic function, as measured by heart rate variability (HRV), was strongly (i.e., relative risk is doubled) associated with increased risk of silent myocardial ischemia and mortality. A patient s history and physical examination are INEFFECTIVE for early detection of CAN, and therefore noninvasive tests that have demonstrated efficacy are required. Proceedings from a consensus conference in 1992 recommended that three tests (R-R variation, Valsalva maneuver, and postural blood pressure testing) be used for longitudinal testing of the cardiovascular autonomic system. All quotes from Diabetes Care, Volume 28, number 4, April 2005

29 CARDIOVASCULAR AUTONOMIC NEUROPATHY (CAN) It has been linked to: postural hypotension, exercise intolerance, enhanced intra-operative cardiovascular liability, increased incidence of asymptomatic ischemia, myocardial infarction, and decreased likelihood of survival after myocardial infarction.12 15

30 CAN AND MORTALITY MORTALITY IS HIGH Of patients with symptomatic autonomic dysfunction, 25% to 50% die within 5 to 10 years of diagnosis.(5,6) The 5-year mortality rate in patients with diabetic autonomic neuropathy is three times higher than in diabetic patients without autonomic involvement.(7) Leading causes of death in diabetic patients with either symptomatic or asymptomatic autonomic neuropathy are heart disease and nephropathy.

31 RECOMMENDATIONS FOR DETECTING/DIAGNOSING (CAN) Testing for Autonomic Neuropathy should be instituted at Diagnosis of Type 2 Diabetes and 5 years after the diagnosis of type 1 Diabetes 2005 ADA Standard of Diabetes Care Although it can cause severe cardiovascular problems and sudden death, surveys show that only 2% of people with diabetes are tested for cardiovascular autonomic neuropathy (CAN).

32 INTELLEWAVE Simple Reproducible Test Takes About 15 minutes Can be done by any Staff member Gives an Interpretive report Reimbursable by most Insurance

33 ICD-9 Codes that Support Medical Necessity DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE IDIOPATHIC PROGRESSIVE POLYNEUROPATHY OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ORTHOSTATIC HYPOTENSION SYNCOPE AND COLLAPSE GENERALIZED HYPERHIDROSIS TACHYCARDIA UNSPECIFIED

34 AUTONOMIC TESTING COMMONLY USED CPT CODES Autonomic Test Autonomic Test Lead ECG Pulse analysis Average total if both tests billed: $ Based on Novitis Published Fee Schedule for 2013