Amniotic membrane grafts for ulcers

[Creflo]

So I'm looking into applying skin substitute grafts. I've studied the LCD and am talking to different companies. Of the money that Medicare pays for the graft, one company wants 70% of it. Another company wants 60% of it. I've heard of others who split it 50/50. Just curious what you guys are seeing regarding the split? Just to clarify, you bill the Q code per sq cm to Medicare, and they pay the practice a certain dollar amount per sq cm, then the practice pays the percentage agreed upon to the graft company.

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[dtrack22]

So I'm looking into applying skin substitute grafts. I've studied the LCD and am talking to different companies. Of the money that Medicare pays for the graft, one company wants 70% of it. Another company wants 60% of it. I've heard of others who split it 50/50. Just curious what you guys are seeing regarding the split? Just to clarify, you bill the Q code per sq cm to Medicare, and they pay the practice a certain dollar amount per sq cm, then the practice pays the percentage agreed upon to the graft company.

Not all companies do it that way. Some require you to pay the full amount for the graft (after you’ve been reimbursed by Medicare so no big deal) and then they provide a “rebate” of some %.

I would go with a company that offers lots of products (ie Organogenesis) so that you only have one rep bothering you about patients that he can help you with using his magical graft. Or pick the company who gives you the biggest discount/rebate on the graft. No reason to choose anything in between. It’s all the same crap and none of it works as well as the reps promise. But you can legally make money. Just make sure your Medicare patients who aren’t double covered are ready for hundreds of dollars in wound care bills, or prepare to lose your Medicare provider # if you waive the 20% they are supposed to owe on that $5000 Q code you bill (and you get caught doing that).

 

[Feli]

... It’s all the same crap and none of it works as well as the reps promise...

ding ding ding

I agree with picking one company (I use the one mentioned above... very infrequently), but I typically just turf any long term wound (which is not going to ever heal due to very sick patient, can't or won't offload, not a recon candidate, etc) to the wound wizards at the local hospital and let them do this stuff until the patient goes to ECF or morgue or whatever.

Some other popular companies sell the whole graft piece regardless of the wound size (in which case many office DPMs save the rest and re-use it for that patient or use it pro bono for different patients... not exactly kosher, but might be fine as long as they don't contaminate it). It should sorta make us wonder how effective these super amazing cutting edge stem cell amnio outer space things are when many are fine in tinfoil and saline peel pack for long shelf life... and that "stability" is sometimes why they are popular or chosen over other ones.

This biologics stuff and the foo-foo dressings and creams are nothing but simply sprinkles on the icing on the cake. The cake is offload, debride, abx or imaging or biopsy or consult vasc/ID/O&P/etc prn... just basic good wound care. People who don't heal with that won't heal regardless of what the reps bring for lunch or what goop or graft the wound RN thinks will make the magic happen due to the "evidence" from a photo or digital science picture in the rep glossy tri-fold. The products are only useful in my hands if I want to say you tried basics and products and HBO and etc. I bet tissue paper would be comparable results with most of them in a real trial. We all know the EBM across specialties is junk and just non-inferiority or very small sponsored biased studies for the skin graft subs...

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id109TA.pdf

 

[air bud]

50% is about right and as good as it gets. There are pros and cons of using legit companies versus distributorships. Ideally, you find somebody who is associated with some type of clearing house. I use one company that once they verify and tell me it is appropriate for me to use they will guarantee the invoice price. So there's no way that I can lose money while putting it on if Medicare decides they don't want to cover it. If they are straight Medicare with no secondary then yes, they're certainly are products that are still profitable to put on but yes you would be technically obligated to collect the 20%. You cannot wave it or write it off there is certainly some gray area in terms of what it means to "attempt to collect.". If they are Medicare medicaid, Medicaid technically counts as a secondary and even though you know they are not going to pay it, you don't have to worry about attempting to collect it and again some of these graphs can still be very profitable to place on Medicare medicaid. Then you get into net 45 versus net 60. Most of my friends who are putting these on basically don't pay the bill until they get paid by Medicare and the companies don't really bother them because it's still profitable for all parties involved. The big thing with this is to make sure that there is no active infection. Different MACs have different rules. For example the one that I am in, there is no limit of 10 and 12 weeks or whatever. This is great especially when using something like puraply which is not technically amniotic membrane but still has a q code and 15271 associated with it. So can put on as many pure apply as you want and still then transition to amniotic membrane as necessary. Yes there is always some risk associated with putting these on yes we are certainly going to abuse the system and these will be banned at some point it's just a matter of time. My Ortho partners did kind of freak out and made me slow down when they saw I had 100K outstanding.... But I love me some amnio and workers comp LOL

 

[Feli]

... Yes there is always some risk associated with putting these on yes we are certainly going to abuse the system and these will be banned at some point it's just a matter of time...

You mean these may go the way of...
bilateral night splints + as much other DME as the patient can carry out of the office in a Santa sack...
nail "biopsy" of clippings on every single nail when the treatment will still be the same non-treatment or cream regardless...
series of 6 sclerosing neuroma injects...
non-custom PTTD braces billed as Richie custom code...
ENFD for obvious DM2 neuropathy so that the patient can be peddled super vitamins after results...
ultrasound guided injection for MPJs and heel pain and things we have managed to hit for decades without...
billing for 10 hardware removal codes for a fibula plate and screws...
etc?

I fully agree the biologics can be billed properly and legit. That's mainly why I stick with the bigger biologic companies (tiny shred of EBM and less likely to be a non-payment overnight). I also fully trust podiatry to press that and any button that reimburses well until it breaks (if we haven't already). Maybe wound biologics are the old thing and nerve surgery and implant stims and etc are the new thing. We need to get with the times and do those fellowship applications.

 

[DYK343]

They have their uses but I rarely apply them.

I've (we've..) all had wounds that just wont heal.

I had one heal up recently with puraply that had been open for 9 months. Vasculopath with no bypass targets and not a candidate for endovascular intervention. 3-4 puraply applications and it was healed. Thats obviously a case report in terms of evidence based medicine but IMO they do have their place.

 

[Pronation]

You mean these may go the way of...
bilateral night splints + as much other DME as the patient can carry out of the office in a Santa sack...
nail "biopsy" of clippings on every single nail when the treatment will still be the same non-treatment or cream regardless...
series of 6 sclerosing neuroma injects...
non-custom PTTD braces billed as Richie custom code...
ENFD for obvious DM2 neuropathy so that the patient can be peddled super vitamins after results...
ultrasound guided injection for MPJs and heel pain and things we have managed to hit for decades without...
billing for 10 hardware removal codes for a fibula plate and screws...
etc?

I fully agree the biologics can be billed properly and legit. That's mainly why I stick with the bigger biologic companies (tiny shred of EBM and less likely to be a non-payment overnight). I also fully trust podiatry to press that and any button that reimburses well until it breaks (if we haven't already). Maybe wound biologics are the old thing and nerve surgery and implant stims and etc are the new thing. We need to get with the times and do those fellowship applications.

Thanks for the new practice management ideas!

 

[air bud]

You mean these may go the way of...
bilateral night splints + as much other DME as the patient can carry out of the office in a Santa sack...
nail "biopsy" of clippings on every single nail when the treatment will still be the same non-treatment or cream regardless...
series of 6 sclerosing neuroma injects...
non-custom PTTD braces billed as Richie custom code...
ENFD for obvious DM2 neuropathy so that the patient can be peddled super vitamins after results...
ultrasound guided injection for MPJs and heel pain and things we have managed to hit for decades without...
billing for 10 hardware removal codes for a fibula plate and screws...
etc?

I fully agree the biologics can be billed properly and legit. That's mainly why I stick with the bigger biologic companies (tiny shred of EBM and less likely to be a non-payment overnight). I also fully trust podiatry to press that and any button that reimburses well until it breaks (if we haven't already). Maybe wound biologics are the old thing and nerve surgery and implant stims and etc are the new thing. We need to get with the times and do those fellowship applications.

This is the way

 

[heybrother]

I received an ad in the mail for some sort of electrical stimulator that triggers the calf muscle leading to increased bloodflow via pumping. I'm under the impression we've historically triggered this mechanism through something called "walking". I thought about sending it to my interventional cardiologist but ultimately discarded it. Just wanted to tell you all about the next hip thing assuming there's a kickback for the doctor or something like that.

 

[dtrack22]

Walking is hard though. A tens unit on your calf is not. Easier to shove more carbs down your gullet while sitting on the couch with your calf being involuntarily stimulated…

 

[Shiyuan]

Walking is hard though. A tens unit on your calf is not. Easier to shove more carbs down your gullet while sitting on the couch with your calf being involuntarily stimulated…

Reminds me of those silly “vibration” machines and belts for weight loss 🤪

 

[air bud]

Reminds me of those silly “vibration” machines and belts for weight loss 🤪

don't you dare talk to me about my shakeweight

 

[GreenHousePub]

bilateral night splints + as much other DME as the patient can carry out of the office in a Santa sack...

Reminds me of the VA podiatry departments. I used to laugh just at home much crap these guys were given each visit.