What Are the Costs of Hip Osteoarthritis in the Year Prior to a Total Hip Arthroplasty?

The Journal of Arthroplasty xxx (2019) 1e5

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What Are the Costs of Hip Osteoarthritis in the Year Prior to a Total Hip Arthroplasty? Azeem T. Malik, MBBS, John H. Alexander, MD, Daniel D. Li, MD, Mengnai Li, MD, PhD, Safdar N. Khan, MD, Thomas J. Scharschmidt, MD * Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH

a r t i c l e i n f o

a b s t r a c t

Article history: Received 15 August 2019 Received in revised form 11 September 2019 Accepted 13 September 2019 Available online xxx

Background: The majority of the cost analysis literature on total hip arthroplasties (THAs) has been focused around the perioperative and postoperative period, with preoperative costs being overlooked. Methods: The Humana Administrative Claims database was used to identify Medicare Advantage (MA) and Commercial beneficiaries undergoing elective primary THAs. Preoperative healthcare resource utilization in the year prior to a THA was grouped into the following categories: office visits, X-rays, magnetic resonance imagings, computed tomography scans, intra-articular steroid and hyaluronic acid injections, physical therapy, and pain medications. Total 1-year costs and per-patient average reimbursements for each category have been reported. Results: Total 1-year preoperative costs amounted to $21,022,883 (average ¼ $512/patient) and $4,481,401 (average ¼ $764/patient) for MA and Commercial beneficiaries, respectively. The largest proportion of total 1-year costs was accounted for by office visits (35% in Commercial; 41% in MA) followed by pain medications (28% in Commercial; 35% in MA). Conservative treatments (steroid injections, hyaluronic acid injections, physical therapy, and pain medications) alone accounted for 40%-44% of the total 1-year costs prior to a THA. A high healthcare utilization within the last 3 months prior to surgery was noted for opioids and steroid injections. Conclusion: On average, $500-$800/patient is spent on hip osteoarthritis-related care in the year prior to a THA. Despite their potential risks, opioids and steroid injections are often utilized in the last 3 months prior to surgery. © 2019 Elsevier Inc. All rights reserved.

Keywords: THA costs preoperative conservative treatment resource utilization total hip arthroplasty

Total hip arthroplasty (THA) for the management of degenerative osteoarthritis has been hailed as one of the most popular orthopedic procedures, successfully relieving pain and promoting return to quality-of-life in more than 90% of patients [1]. Given the rise in the elderly population, as well as an increasing access-tocare, it is of no surprise that the utilization of primary THAs is expected to grow by 71% to nearly 635,000 procedures annually by 2030 [2]. However, the rapid increase in the utilization of this procedure, coupled with high costs of healthcare in the United

One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.09.020. * Reprint requests: Thomas J. Scharschmidt, MD, Division of Musculoskeletal Oncology, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, OH. https://doi.org/10.1016/j.arth.2019.09.020 0883-5403/© 2019 Elsevier Inc. All rights reserved.

States [3], has sparked debate regarding ways to improve the value of hip osteoarthritis care in the current healthcare system. With a gradual shift toward value-based payment models, joint arthroplasty surgeons and their associated institutions are being motivated to reduce costs associated with THA while maintaining quality of care. Most of the current cost minimization literature in THA has focused on the perioperative period, with a particular emphasis on resource utilization associated with postoperative complications and rehabilitation [4,5]. There is a paucity of literature regarding the cost of care for hip osteoarthritis in the time immediately leading up to surgery. Given that most patients undergo a trial of nonoperative management prior to receiving a THA, a focused analysis of the costs associated with conservative modalities and diagnostic imaging prior to surgery may provide additional insight on further improving the value proposition of arthroplasty. In the light of the latter observations, we used a national insurance claims database to investigate the cost of nonoperative care in the year prior to receiving a THA.

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Materials and Methods

Table 1 Baseline Clinical Characteristics of the Study Population.

Database and Patient Selection

Baseline Clinical Characteristics

Medicare Advantage

Commercial

This is a retrospective study carried out using the Humana Administrative Claims (HAC) database through the PearlDiver research software (www.pearldiverinc.com/). PearlDiver is a proprietary subscription-based research repository that contains deidentified data from multiple sources, including Medicare, HAC, and National Inpatient Sample datasets. The datasets are housed on a supercomputer that can be accessed by users through a remote desktop connection. In compliance with Health Insurance Portability and Accountability Act laws, all claims stored in the repository are deidentified. The datasets can be queried using combinations of Current Procedural Terminology codes and International Classification of Diseases 9th/10th Edition (ICD-9/ICD-10) diagnosis/procedural codes. Since all data retrieved are deidentified, the study was exempt from Institutional Review Board Approval. The 2007-2017 HAC database was queried using Current Procedural Terminology code 27130 to identify patients undergoing elective primary THA for hip osteoarthritis. Patients undergoing THA for osteonecrosis, fracture, deformity, periprosthetic fracture, and/or bilateral arthroplasties were excluded. Only those patients who had complete data up to 1 year preceding the surgery were included in the final study sample. The study sample was further stratified, based on insurance plan, into 2 distinct cohortsdMedicare Advantage (MA) and Commercial beneficiaries. This distinction was necessary, as reimbursement rates tend to vary between MA and Commercial insurance beneficiaries, with the latter insurance plan reimbursing a higher proportion of the initial charges billed by service providers.

Sample size (N) Age (y) <50 50-64 65-74 75-84 85 Gender Male Female Region Midwest Northeast South West Elixhauser Comorbidity Index

41,625

5956

Preoperative Healthcare Utilization and Cost Categories Current Procedural Terminology codes were used to define healthcare utilization within the 1 year prior to the THA and categorized into the following groups: office visits, X-rays, magnetic resonance imagings, computed tomography scans, intra-articular steroid and hyaluronic acid (HA) injections, physical therapy (PT), and pain medications (opioids and nonopioids). A complete list of codes used to derive the categories can be found in Appendix 1. With the exception of pain medications, all categories were crossreferenced with diagnosis codes for hip pain and/or hip osteoarthritis occurring on the same day to ensure that only relevant billing records were retrieved. The term “costs” refer to the actual payments/reimbursements made by the insurance company to the service providers. Total 1-year costs for the entire study period were calculated, along with per-patient average reimbursements (PPAR) for each healthcare resource category. We also analyzed trends in healthcare utilization for PT, opioids, and steroid injections during the 1-year preoperative period. Results Baseline Clinical Characteristics Following application of inclusion/exclusion criteria, a total of 41,625 MA and 5965 Commercial beneficiaries undergoing primary THA for hip osteoarthritis were included in the study. MA beneficiaries were typically older females, whereas Commercial beneficiaries reflected a younger male population. For both MA and Commercial beneficiaries, the majority of the patients were located in the Midwest or South regions. As expected, MA beneficiaries had a higher comorbidity burden as compared to Commercial

392 4357 20,561 13,920 2395

(0.9%) (10.5%) (49.4%) (33.4%) (5.8%)

870 4356 637 83 10

(14.6%) (73.1%) (10.7%) (1.4%) (0.2%)

16,840 (40.5%) 24,785 (59.5%)

2687 (45.1%) 3269 (54.9%)

12,522 (30.1%) 1338 (3.2%) 22,450 (53.9%) 5315 (12.8%) 8.0 ± 4.4

2060 (34.6%) 22 (0.4%) 3400 (57.1%) 474 (8.0%) 4.2 ± 3.3

beneficiaries. A complete description of baseline clinical characteristics can be seen in Table 1. Costs Associated With Healthcare Utilization Within the Year Prior to a Total Hip Arthroplasty A total of 5864 (98.3% of the total sample) Commercial and 41,021 MA (98.5% of the total sample) beneficiaries had utilized at least one of the aforementioned healthcare resources within the year prior to undergoing a THA. Total 1-year preoperative costs amounted to $4,481,401 (average ¼ $764/patient; median ¼ $460/ patient) and $21,022,883 (average ¼ $512/patient; median ¼ $349/ patient) for Commercial and MA beneficiaries, respectively. The largest proportion of total 1-year costs for both Commercial and MA beneficiaries was accounted for by office visits (35% in Commercial; 41% in MA) followed by pain medications (28% in Commercial; 35% in MA), X-rays (12.0% in Commercial; 10.2% in MA), steroid injections (7.7% in Commercial; 5.1% in MA), and PT (3.8% in Commercial; 4.0% in MA). Proportions of total 1-year costs accounted for by each healthcare resource category can be seen in Table 2 and Figure 1A and B. Utilization rates for each healthcare resource category can be found in Table 3. PPARs for each healthcare resource category were as follows: office visits (MA ¼ $222, Commercial ¼ $289), X-rays (MA ¼ $63, Commercial ¼ $111), magnetic resonance imagings (MA ¼ $370, Commercial ¼ $932), computed tomography scans (MA ¼ $187, Commercial ¼ $765), steroid injections (MA ¼ $141, Commercial ¼ $365), HA injections Table 2 Proportion of Total 1-Y Costs Accounted for by Each Healthcare Resource Category. Total 1-Y Costs

Commercial

Medicare Advantage

Office visits X-rays MRI CT Steroid injections HA injections Physical therapy Pain medications (opioids þ NSAIDS) Patients using at least 1 resource Total Average per patient (SD) Median per patient (IQR)

$1,578,020 $539,048 $455,604 $104,041 $343,571 $19,384 $168,170 $1,273,563

$8,546,544 $2,142,753 $851,799 $217,645 $1,066,736 $80,653 $846,494 $7,270,259

(35.2%) (12.0%) (10.2%) (2.3%) (7.7%) (0.4%) (3.8%) (28.4%)

(40.7%) (10.2%) (4.1%) (1.0%) (5.1%) (0.4%) (4.0%) (34.6%)

5864

41,021

$4,481,401 $764 ($764) $460 ($248-$866)

$21,022,883 $512 ($1252) $349 ($200-$601)

MRI, magnetic resonance imaging; CT, computed tomography; HA, hyaluronic acid; SD, standard deviation; IQR, interquartile range.

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Fig. 1. (A) Distribution of 1-year preoperative costs for Commercial beneficiaries. (B) Distribution of 1-year preoperative costs for Medicare Advantage beneficiaries. CT, computed tomography; MRI, magnetic resonance imaging.

(MA ¼ $399, Commercial ¼ $1020), PT (MA ¼ $287, Commercial ¼ $339), and pain medications (MA ¼ $234; Commercial ¼ $288). Conservative treatments (steroid injections, HA injections, PT, and pain medications) alone accounted for 40%-44% of the total 1year costs prior to a THA (Table 4). A high healthcare utilization was noted in the last 3 months prior to surgery for PT, opioids, and steroid injections, with up to 42%-79% of 1-year PPARs being accounted for within this time period alone (Fig. 2). Discussion Following the introduction of the Affordable Care Act in 2010, value-based care has come to the forefront in the battle against the rising costs of healthcare in the United States. With an increasing economic burden of THAs on the healthcare system, health policymakers are increasingly looking at areas where cost-containment strategies can be focused. Using a national insurance claims database, the current study demonstrates that on average $500-$800 is spent on hip osteoarthritis-related care in the year prior to a THA. Even more concerning is that despite findings from recent studies, opioids and steroid injections appear to be utilized highly within the last 3 months prior to surgery. In order to optimize the value of nonoperative care prior to THA, providers should strive to ensure that cost-effective conservative treatment modalities are preferred over other low-value interventions. Based on our results, nearly 16%-18% of patients received an intra-articular steroid hip injection within the year prior to a THA. Furthermore, utilization of steroid injections was the highest within the last 3 months prior to surgery itself. This raises concerns, given that recent evidence has shown that receiving a steroid injection within 3 months prior to a THA is associated with higher rates of prosthetic joint infections [6,7]. Even though current American Academy of Orthopaedic Surgeons clinical practice guidelines recommend the use of intra-articular corticosteroid injections for the management of symptomatic hip osteoarthritis [8], it is important to note that these recommendations are based on studies comparing functional outcomes and/or pain scores only [9e11]. With an increasing incidence and associated economic burden of prosthetic joint infections across the nation [12], surgeons be mindful of the timing:infection risk ratio when

considering the use of steroid injections as a conservative treatment modality, particularly in patients who are due for a THA soon. Approximately 53%-57% of patients had received an opioid prescription within the year prior to a THA. The majority of the opioids were prescribed within the last 3 months prior to surgery. Although the higher prescription rate of opioids before surgery may be a means of appeasing patients as they wait for the surgery to be scheduled, one must not overlook the negative impact of preoperative opioid usage on postoperative outcomes following THA. In a study published in the Journal of Bone and Joint Surgery, Weick et al [13] found that patients who had more than 60 days of preoperative opioid usage had higher rates of readmissions, 1year and 3-year revisions, as compared to opioid-naïve individuals. In another study, Bedard et al [14] found that opioid use within 3 months prior to a THA was associated with a higher revision rate within 2 years following the index surgery. Preoperative opioid use is also independently linked with higher rates of prolonged opioid use following THA [15]. Physicians should Table 3 Utilization Rate and 1-Y PPAR of Each Healthcare Resource Category. Category

Insurance Plan

Number (%)

1-Y PPAR

Office visits

Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage Commercial Medicare Advantage

5455 38,574 4863 33,883 489 2300 136 1162 941 7564 19 202 496 2954 4419 31,004 3172 23,542

$289 $222 $111 $63 $932 $370 $765 $187 $365 $141 $1020 $399 $339 $287 $288 $234 $105 $99

X-rays MRI CT Steroid injections HA injections Physical therapy Pain medications (opioids þ NSAIDS) Opioids

(91.5%) (92.7%) (81.5%) (81.4%) (9.5%) (5.6%) (2.3%) (2.8%) (15.8%) (18.2%) (0.3%) (0.5%) (8.3%) (7.1%) (74.1%) (74.5%) (53.2%) (56.6%)

PPAR, per-patient average reimbursements; MRI, magnetic resonance imaging; CT, computed tomography; HA, hyaluronic acid.

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Table 4 Costs Associated With the Use of Conservative Treatment Modalities, and Their Recommendations Based on AAOS CPGs. Conservative Modalities

AAOS CPG Recommendation

Strength of Recommendation

Commercial (% of Total 1-Y Cost)

Medicare Advantage

Steroid injections HA injections Physical therapy NSAIDS Opioids All conservative

Recommended Not supported Recommended Recommended Not recommended e

Strong Strong Strong Strong Consensus e

$343,571 $19,384 $168,170 $939,233 $334,330 $1,804,688

$1,066,736 $80,653 $846,494 $4,942,299 $2,327,960 $9,264,142

(7.7%) (0.4%) (3.8%) (21.0%) (7.5%) (40.3%)

(5.1%) (0.4%) (4.0%) (23.5%) (11.1%) (44.1%)

CPG, clinical practice guidelines; HA, hyaluronic acid.

strongly consider discontinuing opioids within 3 months before surgery, as recent evidence suggests that a 3-month opioid-free period in chronic opioid users mitigated the risks of experiencing adverse outcomes [16]. The American Academy of Orthopaedic Surgeons clinical practice guidelines have supported the use of the PT as a mainstay conservative treatment option for the management of hip osteoarthritis with mild-to-moderate symptoms [8]. In our study, PT was utilized in only 7%-8% of the patients. Since we are investigating costs in a cohort of patients who subsequently underwent a THA, it is plausible that these individuals might already have severe symptomatic hip osteoarthritis, for which PT is not routinely indicated. This hypothesis is reflected in the fact that among those who utilized PT in our study, the average number of sessions was also low, with an estimated 3.5 sessions/individual for Commercial and 3.7 sessions/ individual for MA beneficiaries. It is also possible that a certain subset of individuals with moderate hip osteoarthritis may have received some benefit from PT, and thus did not require a THA eventually. Although evaluating the effectiveness of PT is beyond the scope of our study, future study using more granular clinical data, which are not readily available in administrative claim datasets (ie, degree of osteoarthritis, functional scores, etc.), should further investigate the value of PT as a means of avoiding THA. The major limitations of the study are those inherently related to the use of an administrative database. Even though the HAC database is a comprehensive national insurance claims dataset, containing records from more than 20 million Commercial and MAinsured beneficiaries across the nation, it may not be entirely representative of the entire population in the United States. It is likely that the costs for these treatment modalities are highly dependent on geographic location and the insurance provider. Administrative databases rely on the use of billing codes to identify

patients and therefore are prone to miscoding/billing errors. These databases also lack granularity with regards to degree/severity of osteoarthritis (mild, moderate, and/or severe), the distinction of which would have been useful for studying variation in healthcare resource utilization. It is possible that a certain proportion of pain medications were prescribed for causes other than hip pain as pain prescriptions are not bundled with diagnosis codes during billing instances. Costs of non-steroidal anti-inflammatory drugs are also likely to be under-estimated since many of these nonopioid pain medications can be purchased over the counter. Even though we cross-referenced healthcare utilization categories with codes for hip osteoarthritis/pain, it is plausible that inconsistent coding patterns may have prevented us from identifying true utilization, resulting in an under-estimation of the true costs. The database also does not filter and/or identify patients who changed plans and/or underwent treatment under a different plan within the year prior to the THA. This can be reflected in the fact that around 8%-9% of patients did not have a documented office visit anytime during the year prior to the THA. Our study also did not evaluate the efficacy of various treatment modalities as this was beyond the scope of an administrative database. Conclusions Despite the limitations, this study is the first of its kind to characterize the costs associated with hip osteoarthritis in the year prior to a THA. Recent literature suggests that greater attention should be focused on minimizing the use of steroid injections and opioid medications within the last 3 months prior to surgery. As physicians and healthcare administrations gradually shift toward adopting value-based delivery of care for hip osteoarthritis, a judicious utilization of conservative treatment modalities is warranted.

Fig. 2. The proportion of 1-year PPAR for opioids, steroid injections, and physical therapy being accounted for at 3 different time periods (0-1 year, 0-6 months, and 0-3 months).

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References [1] Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012;2:e000435. [2] Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018;100: 1455e60. [3] Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA 2018;319:1024e39. [4] Nichols CI, Vose JG. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. J Arthroplasty 2016;31:1400e6. [5] Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which clinical and patient factors influence the national economic burden of hospital readmissions after total joint arthroplasty? Clin Orthop Relat Res 2017;475: 2926e37. [6] Schairer WW, Nwachukwu BU, Mayman DJ, Lyman S, Jerabek SA. Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty. J Arthroplasty 2016;31(9 Suppl):166e9. [7] Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty 2016;31:820e3. [8] American Academy of Orthopaedic Surgeons. Management of osteoarthritis of the hip: evidence-based clinical practice guideline. Available at: https://www. aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/OA% 20Hip%20CPG_6-11-19.pdf; 2018 [accessed15.06.19].

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[9] Lambert RG, Hutchings EJ, Grace MG, Jhangri GS, Conner-Spady B, Maksymowych WP. Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2007;56: 2278e87. [10] Atchia I, Kane D, Reed MR, Isaacs JD, Birrell F. Efficacy of a single ultrasoundguided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011;70:110e6. [11] Qvistgaard E, Christensen R, Torp-Pedersen S, Bliddal H. Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline. Osteoarthritis Cartilage 2006;14:163e70. [12] Brochin RL, Phan K, Poeran J, Zubizarreta N, Galatz LM, Moucha CS. Trends in periprosthetic hip infection and associated costs: a population-based study assessing the impact of hospital factors using national data. J Arthroplasty 2018;33:S233e8. [13] Weick J, Bawa H, Dirschl DR, Luu HH. Preoperative opioid use is associated with higher readmission and revision rates in total knee and total hip arthroplasty. J Bone Joint Surg Am 2018;100:1171e6. [14] Bedard NA, DeMik DE, Dowdle SB, Owens JM, Liu SS, Callaghan JJ. Does preoperative opioid use increase the risk of early revision total hip arthroplasty? J Arthroplasty 2018;33:S154e6. [15] Bedard NA, Pugely AJ, Dowdle SB, Duchman KR, Glass NA, Callaghan JJ. Opioid use following total hip arthroplasty: trends and risk factors for prolonged use. J Arthroplasty 2017;32:3675e9. [16] Jain N, Brock JL, Malik AT, Phillips FM, Khan SN. Prediction of complications, readmission, and revision surgery based on duration of preoperative opioid use: analysis of major joint replacement and lumbar fusion. J Bone Joint Surg Am 2019;101:384e91.

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Appendix 1

Category

Codes

Codes for Hip Osteoarthritis

ICD-9-D-71515, ICD-9-D-71535, ICD-9-D-71595, ICD-10-D-M1610, ICD-10-D-M1611, ICD-10-D-M1612, ICD-10-D-M1631, ICD-10-D-M167, ICD-10-D-M169 CPT-99201, CPT-99201, CPT-99202, CPT-99202, CPT-99203, CPT-99203, CPT-99204, CPT-99204, CPT-99205, CPT-99205, CPT-99205, CPT-99211, CPT-99211, CPT-99212, CPT-99212, CPT-99212, CPT-99213, CPT-99213, CPT-99213, CPT-99213, CPT-99214, CPT-99214, CPT-99214, CPT-99215, CPT-99215, CPT-99241, CPT-99241, CPT-99242, CPT-99242, CPT-99243, CPT-99243, CPT-99244, CPT-99244, CPT-99245, CPT-99245 CPT-73721, CPT-73721, CPT-73722, CPT-73722, CPT-73723, CPT-73723, CPT-72195, CPT-72195, CPT-72196, CPT-72196, CPT-72197, CPT-72197 CPT-72170, CPT-72170, CPT-72170, CPT-72190, CPT-72190, CPT-73500, CPT-73500, CPT-73501, CPT-73501, CPT-73502, CPT-73502, CPT-73503, CPT-73503, CPT-73510, CPT-73510, CPT-73510, CPT-73510, CPT-73520, CPT-73520 CPT-73700, CPT-73700, CPT-73701, CPT-73701, CPT-73702, CPT-73702, CPT-72192, CPT-72192, CPT-72192, CPT-72193, CPT-72193, CPT-72193, CPT-72194, CPT-72194 DRUG_CAT-1015, DRUG_CAT-1012 GENERIC_DRUG-100055, GENERIC_DRUG-100230, GENERIC_DRUG-100504, GENERIC_DRUG-101215, GENERIC_DRUG-100548 CPT-97001, CPT-97001, CPT-97001, CPT-97001, CPT-97002, CPT-97002, CPT-97002, CPT-97002, CPT-97003, CPT-97003, CPT-97003, CPT-97003, CPT-97004, CPT-97004, CPT-97010, CPT-97010, CPT-97012, CPT-97012, CPT-97014, CPT-97014, CPT-97016, CPT-97016, CPT-97018, CPT-97018, CPT-97022, CPT-97022, CPT-97024, CPT-97024, CPT-97024, CPT-97026, CPT-97026, CPT-97032, CPT-97032, CPT-97032, CPT-97033, CPT-97033, CPT-97034, CPT-97034, CPT-97035, CPT-97035, CPT-97035, CPT-97036, CPT-97039, CPT-97039, CPT-97100, CPT-97110, CPT-97110, CPT-97110, CPT-97110, CPT-97112, CPT-97112, CPT-97112, CPT-97112, CPT-97113, CPT-97113, CPT-97113, CPT-97114, CPT-97116, CPT-97116, CPT-97116, CPT-97124, CPT-97124, CPT-97124, CPT-97139, CPT-97139, CPT-97140, CPT-97140, CPT-97140, CPT-97150, CPT-97150, CPT-97150, CPT-97161, CPT-97161, CPT-97162, CPT-97162, CPT-97162, CPT-97163, CPT-97163, CPT-97164, CPT-97165, CPT-97166, CPT-97168, CPT-97530, CPT-97530, CPT-97530, CPT-97530, CPT-97532, CPT-97532, CPT-97532, CPT-97533, CPT-97535, CPT-97535, CPT-97535, CPT-97535 CPT-20610, CPT-20611 with CPT-J0702, CPT-J0702, CPT-J0704, CPT-J0704, CPT-J1020, CPT-J1020, CPT-J1030, CPT-J1030, CPT-J1040, CPT-J1040, CPT-J1094, CPT-J1094, CPT-J1100, CPT-J1100, CPT-J1700, CPT-J1710, CPT-J1720, CPT-J1720, CPT-J2650, CPT-J2920, CPT-J2920, CPT-J2930, CPT-J2930, CPT-J3300, CPT-J3300, CPT-J3301, CPT-J3301, CPT-J3301, CPT-J3302, CPT-J3302, CPT-J3303, CPT-J3303 CPT-20610, CPT-20611 with CPT-J3470, CPT-J3470, CPT-J3471, CPT-J3473, CPT-J7319, CPT-J7321, CPT-J7321, CPT-J7321, CPT-J7322, CPT-J7323, CPT-J7323, CPT-J7324, CPT-J7324, CPT-J7325, CPT-J7325, CPT-J7326, CPT-J7327, CPT-Q4083, CPT-Q4083, CPT-Q4084, CPT-Q4085, DRUG-HYALGAN

Office Visits

MRI Scans X-rays

CT Scans All pain medications Opioid pain medications Physical therapy

Steroid injections

Hyaluronic acid (HA) injections