Hospital - how to get others to do 💅

[air bud]

I am starting a new gig, no podiatrist before. A few PP people would come in and do outreach there and we're very busy not sure exactly what they were doing but certainly not wounds.

So I don't plan on doing nails (duh). I don't even want to open the door. Obviously as a new person I want all the initial patient visits and then pass them off. How do I convince the hospital to get a nail nurse? A big part of my practice will be limb salvage, I certainly don't mind keeping a close eye on at risk diabetics. We will have a wound care center I will be the main person at, it is run by Healogics.

So how are you managing all these patients and discussing with admin?

---

Members don't see this ad.

 

[CutsWithFury]

I am starting a new gig, no podiatrist before. A few PP people would come in and do outreach there and we're very busy not sure exactly what they were doing but certainly not wounds.

So I don't plan on doing nails (duh). I don't even want to open the door. Obviously as a new person I want all the initial patient visits and then pass them off. How do I convince the hospital to get a nail nurse? A big part of my practice will be limb salvage, I certainly don't mind keeping a close eye on at risk diabetics. We will have a wound care center I will be the main person at, it is run by Healogics.

So how are you managing all these patients and discussing with admin?

I would tell them to hire a APRN. This individual can do your surgical H&Ps if you are in a pinch and need clearance, possibly scrub surgeries, possibly see consults on the inpatient floor if you are busy in clinic, and obviously can have their own clinic seeing your post-ops and doing at risk diabetic foot care. Lots of possibilities with an APRN

 

[air bud]

I would tell them to hire a APRN. This individual can do your surgical H&Ps if you are in a pinch and need clearance, possibly scrub surgeries, possibly see consults on the inpatient floor if you are busy in clinic, and obviously can have their own clinic seeing your post-ops and doing at risk diabetic foot care. Lots of possibilities with an APRN

I will be with 2 other orthos. Everyone works for the hospital. I don't see an APRN anytime soon, but potentially in lieu of hiring another pod when I get too busy.

So how about right off the bat.

 

[PeaJay]

I am in the process of getting rid of nail care. Much time has been spent with the bean counters and compliance (lawyers). You have two options.

#1. Collect the new consult and then if they actually qualify allow them to follow in dedicated nail slots (limited to 1-2 a day). This way you are compliant with insurance contracts but not subjecting yourself to the onslaught of nails that will somehow find your clinic.

#2. Get APNP. Collect new consults. Forward to np clinic.

These options are formulated as per compliance the patients cannot go to a hospital cash pay clinic unless evaluated and deemed not qualified. Also compliance states that the nail care has to be performed by an md/do/DPM/apnp (weirdly not PA). Care cannot be delegated to rn/ma/at/emt per compliance. However cash pay can be done by RN/ma.

 

[air bud]

I am in the process of getting rid of nail care. Much time has been spent with the bean counters and compliance (lawyers). You have two options.

#1. Collect the new consult and then if they actually qualify allow them to follow in dedicated nail slots (limited to 1-2 a day). This way you are compliant with insurance contracts but not subjecting yourself to the onslaught of nails that will somehow find your clinic.

#2. Get APNP. Collect new consults. Forward to np clinic.

These options are formulated as per compliance the patients cannot go to a hospital cash pay clinic unless evaluated and deemed not qualified. Also compliance states that the nail care has to be performed by an md/do/DPM/apnp (weirdly not PA). Care cannot be delegated to rn/ma/at/emt per compliance. However cash pay can be done by RN/ma.

And these are CMS rules? Sounds like I need to round up an existing APRN

 

[PeaJay]

To be honest I have no idea where the lawyers get all the info. I just let the lawyers do their thing. Our group tends to be very conservative on compliance though so they might be forcing certain points to be on the safe side.

 

[wakaflocka88]

My group is in early process of hiring a RN for me to manage all the above stuff. Ortho very supportive of this and want me to maximize my work flow.

 

[air bud]

I am in the process of getting rid of nail care. Much time has been spent with the bean counters and compliance (lawyers). You have two options.

#1. Collect the new consult and then if they actually qualify allow them to follow in dedicated nail slots (limited to 1-2 a day). This way you are compliant with insurance contracts but not subjecting yourself to the onslaught of nails that will somehow find your clinic.

#2. Get APNP. Collect new consults. Forward to np clinic.

These options are formulated as per compliance the patients cannot go to a hospital cash pay clinic unless evaluated and deemed not qualified. Also compliance states that the nail care has to be performed by an md/do/DPM/apnp (weirdly not PA). Care cannot be delegated to rn/ma/at/emt per compliance. However cash pay can be done by RN/ma.

Will the APRN do wound clinic as well?

 

[PeaJay]

Yes.

My np will be starting soon. Will see wounds following initial consult or after deemed non surgical. Will take nail/callus care as well as post-ops that are beyond what my nurse can handle. Will only see other things as overflow.

 

[DYK343]

I agree with PeaJay.

I allowed 5-10% of my day to be nail care an no more.

Keep the 10% to the patients that actually need it or face amputation. Not someone who just wants it because you're a toenail cutting expert.

There is nothing wrong with nail care. But in my experience its simply not nearly as profitable to do nails all day on wRVU system. GIve me the P fasciitis, arthritis workups, wound debridements. Those are wRVU generating patients.

If you accept every patient that wants their nails cut within 12 months that will be your whole schedule. You will do nothing but nails and grow bored quickly. ER follow ups, fracture care, etc will be turned away because youre 4 months booked out with toenails and have no openings. Tell the medical director this. They will understand (assuming you can fill your schedule daily with enough non nail care patients).

NP sounds great if you can convince one to do that all day. I dont think it will be easy to find someone to agree to a life of toenail cutting but if you can that would be amazing.

Anyone ever had a certified nail tech/MA do it? Ive seen the courses online but im not sure if thats legal or not. From comments above sounds like it might not be.

 

[dtrack22]

Anyone ever had a certified nail tech/MA do it? Ive seen the courses online but im not sure if thats legal or not. From comments above sounds like it might not be.

My understanding is that the issue with letting MA/RN do it (and I worked at 2 different groups where an MA did basically all of the nail care) is the fact that you are billing a CPT code. As dumb as it seems, trimming nails is no different than a wart excision or tenotomy or matrixectomy. It’s a “procedure” and bills out as such. The legal issue is billing a “procedure” that you did not perform. Now, do any private practice docs actually follow that rule/line of thinking? Absolutely not. MA or RN does the procedure and podiatrist steps in and says hi to the patient, maybe shaves a callus or clips a nail to look like he/she did something. They bill Medicare and nothing happens. But I think if Medicare found out you were billing a “debridement” code and not actually doing the debridement, they would take some money back from you…

 

[dtrack22]

As far as nail care, I took those consults until I had around 3 RFC patients per day. Which sadly did not take very long. Now I take the initial consult and refer them to our wound clinic where they do routine foot care. It’s RNs and they can’t bill a professional fee but still charge the facility portion which makes it doable from a financial standpoint.

If you don’t have a facility that can take or do routine foot care, then I would get on admin now about it. Just let them know the visits don’t pay, and that they prevent you from doing wound care, seeing higher acuity problems, and keep you out of the OR if you don’t stop or limit them early. It’s generally an easy conversation. “Hi Suit, my clinic is being filled with 0.5 wRVU visits while 2-3 wRVU visits are being scheduled out weeks, and at times going elsewhere because of it. My OR volume is dropping too because of these gremlins on my schedule. I can stop taking these referrals or we can hire an NP to help out. Let me know which one you would prefer. Thanks.”

 

[DYK343]

Standard sidetrack.... Did anyone ever have formal toenail debridement training in school?

I was given a nail nipper and told to get in there and get it done. No supervision. I dont think we even had a lecture. Nothing.

Fake it till you make it.

I sense a meme coming....

 

[shadesofgrey]

Standard sidetrack.... Did anyone ever have formal toenail debridement training in school?

I was given a nail nipper and told to get in there and get it done. No supervision. I dont think we even had a lecture. Nothing.

Fake it till you make it.

I sense a meme coming....

Ha! Yeah, no instruction on how to cut the nails, just do it (admittingly I would probably make more fun of an extended nail debridement class).

For calluses, it was 20 minutes with a 10# blade and a orange, "try to only remove the peel". After my successful fruit slicing, here are some homeless Medicaid patients. Don't cut them....

 

[AttackNME]

I’ve had my fair share of cutting chunks of flesh off the toe when the nail was so thick and pincer’s that it fused into skin so it was hard to tell difference between skin and nail. A heads up woulda been nice

 

[heybrother]

So - new form of PP hell. United Healthcare has been selling patients a "nail package" so that uncovered nails and calluses are covered. The patients pay for it so they "know" they have the benefit and show up ready to argue and demand 6 visits a year.

My office manager shows me on the United website where people have the benefit. I explain to her that we decide when people come back and that uncovered nailcare is the very, very, very, very last thing in the world that should get in the door.

 

[PeaJay]

So - new form of PP hell. United Healthcare has been selling patients a "nail package" so that uncovered nails and calluses are covered. The patients pay for it so they "know" they have the benefit and show up ready to argue and demand 6 visits a year.

My office manager shows me on the United website where people have the benefit. I explain to her that we decide when people come back and that uncovered nailcare is the very, very, very, very last thing in the world that should get in the door.

Here come the night terrors.

$20 reimbursement every 3 months is $80 a year. Insurance Then charges the patient $160 for this policy and laughs to the bank as they deny the claims anyway.

 

[Boba Foot]

So - new form of PP hell. United Healthcare has been selling patients a "nail package" so that uncovered nails and calluses are covered. The patients pay for it so they "know" they have the benefit and show up ready to argue and demand 6 visits a year.

My office manager shows me on the United website where people have the benefit. I explain to her that we decide when people come back and that uncovered nailcare is the very, very, very, very last thing in the world that should get in the door.

Refer to closest podiatrist that does laser nail treatments.

 

[NatCh]

Standard sidetrack.... Did anyone ever have formal toenail debridement training in school?

I was given a nail nipper and told to get in there and get it done. No supervision. I dont think we even had a lecture. Nothing.

Fake it till you make it.

I sense a meme coming....

I recall having some informal training, meaning someone explained what he was doing as he did it. "Take it off in layers, don't go too deep, be careful around the thick middle area."









.

 

[air bud]

People I am trying to figure out how NOT to do nail care, not how to be better at it. Thanks @DYK343

 

[Pronation]

You’ll want to set your dremel at 15,000 RPM. 2.5x loupe magnification is usually sufficient but I prefer the telescoping 3.5x loupes for this.

 

[619]

$20 reimbursement every 3 months is $80 a year. Insurance Then charges the patient $160 for this policy and laughs to the bank as they deny the claims anyway.

Not any difference than Humana where a patient has a $100 co-pay that maybe only covers x-ray but not treatment or DME. It's crazy to pay monthly premium and also $100 at every doctors visit. Insurance companies are making serious bank.

 

[Boba Foot]

Insurance companies are making serious bank.

yeah, I picked some ****ty high deductible Humana plan from my employer mainly just so I can open an HSA to lower tax & student loan repayment burden. But the deductible is so high that I never want to actually use it and go to a doctor because it’ll all be out of pocket. So I’m basically paying Humana on a monthly basis for the privilege of having insurance in case of catastrophe and having an HSA. It’s a racket.

 

[thefootfixer]

What about seeing said consult, if they meet criteria , debride once and done.

If they don’t just don’t do the nails and bill hospital consult code, make the note more detailed etc. And obviously indicate why exactly nails weren’t done?

 

[DYK343]

What about seeing said consult, if they meet criteria , debride once and done.

In this situation they magically show up on your schedule 3 weeks later for another nail cutting.
Cant just leave it open ended.
Hell even if you tell them 3 months they still show up 3 weeks later sometimes lol

 

[wakaflocka88]

In this situation they magically show up on your schedule 3 weeks later for another nail cutting.
Cant just leave it open ended.
Hell even if you tell them 3 months they still show up 3 weeks later sometimes lol

I’ve got a few VA patients finding their way to me because the VA nail jail is 8 months backed up. They get super angry when they have zero qualifications and try to argue they qualify because the VA or a community provider said so.

Not only am I bitter against the governing bodies but also at these garbage TFPs that continue to bill and render fraudulent care which will continue to perpetuate this expectation that we are supposed to do charity work.

 

[619]

In this situation they magically show up on your schedule 3 weeks later for another nail cutting.
Cant just leave it open ended.
Hell even if you tell them 3 months they still show up 3 weeks later sometimes lol

They now know to mention ingrown nail or toe redness/infection to get in earlier lol

 

[PeaJay]

I’ve got a few VA patients finding their way to me because the VA nail jail is 8 months backed up. They get super angry when they have zero qualifications and try to argue they qualify because the VA or a community provider said so.

Not only am I bitter against the governing bodies but also at these garbage TFPs that continue to bill and render fraudulent care which will continue to perpetuate this expectation that we are supposed to do charity work.

I would check the community referral form. This is one situation where you might want to do the nails and callus. Usually referral states that nail/callus debridement is covered. Document your findings appropriately and stat they do not meet Medicare guidelines, but have authorization for procedures from VA. VA referrals pay full price…. 180ish for nails and 325 for 1 callus

 

[NatCh]

yeah, I picked some ****ty high deductible Humana plan from my employer mainly just so I can open an HSA to lower tax & student loan repayment burden. But the deductible is so high that I never want to actually use it and go to a doctor because it’ll all be out of pocket. So I’m basically paying Humana on a monthly basis for the privilege of having insurance in case of catastrophe and having an HSA. It’s a racket.

It's such a racket. Insurance companies are evil.

 

[wakaflocka88]

I would check the community referral form. This is one situation where you might want to do the nails and callus. Usually referral states that nail/callus debridement is covered. Document your findings appropriately and stat they do not meet Medicare guidelines, but have authorization for procedures from VA. VA referrals pay full price…. 180ish for nails and 325 for 1 callus

Good call. I did read over the community referral form and it is “covered” but I’m in a MSG and I did not want to kill my wrists on his callouses for the abysmal RVU

 

[PeaJay]

Good call. I did read over the community referral form and it is “covered” but I’m in a MSG and I did not want to kill my wrists on his callouses for the abysmal RVU

yeah not going to help in wRVU model. Still the 0.5 an 0.7 wRVU and not worth it

 

[Feeter]

NP is the correct answer. Maybe tough to get one to do just nails though. Show them the reimbursement you get for these pts as that will be your strongest argument to not fill your clinic with nail care. Also it is one of the highly audited code in podiatry.

 

[air bud]

NP is the correct answer. Maybe tough to get one to do just nails though. Show them the reimbursement you get for these pts as that will be your strongest argument to not fill your clinic with nail care. Also it is one of the highly audited code in podiatry.

I think that pairing it with a wound clinic will be the way to go. Someone to do just nails no that's a tough one but the wounds you just got to find the right person who likes that stuff as well. Are nps just going to be salary based and so this is just part of their job?

 

[Weirdy]

I’ve had my fair share of cutting chunks of flesh off the toe when the nail was so thick and pincer’s that it fused into skin so it was hard to tell difference between skin and nail. A heads up woulda been nice

Not sure when you graduated but that was also my experience.

Edit: I feel very lame explaining this to students while I trim difficult nails but...whatever keeps them from hurting patients I guess.

 

[thefootfixer]

In this situation they magically show up on your schedule 3 weeks later for another nail cutting.
Cant just leave it open ended.
Hell even if you tell them 3 months they still show up 3 weeks later sometimes lol

In this situation they magically show up on your schedule 3 weeks later for another nail cutting.
Cant just leave it open ended.
Hell even if you tell them 3 months they still show up 3 weeks later sometimes lol

I feel like it can still be controlled thru scheduling. Just have the staff not enter them in for 6 months , or indicate 6 month wait

 

[dtrack22]

I think that pairing it with a wound clinic will be the way to go. Someone to do just nails no that's a tough one but the wounds you just got to find the right person who likes that stuff as well. Are nps just going to be salary based and so this is just part of their job?

I think you’ll find more and more NPs are production based since they can practice independently. All of our NPs are working in primary care clinics and urgent care. They are production based (could have some sort of base or maybe were salaried for their first 1-2 years) at around $45 per wRVU.

 

[Feeter]

I think that pairing it with a wound clinic will be the way to go. Someone to do just nails no that's a tough one but the wounds you just got to find the right person who likes that stuff as well. Are nps just going to be salary based and so this is just part of their job?

Yes NPs at my previous gigs were salaried. They had to see 14 pts a day to cover their salary which was easy. But with only nail pts you can't cover NPs salary and if you make an NP see 25 nail pts a day they will leave for a better job.

 

[619]

Yes NPs at my previous gigs were salaried. They had to see 14 pts a day to cover their salary which was easy. But with only nail pts you can't cover NPs salary and if you make an NP see 25 nail pts a day they will leave for a better job.

Even a medical assistant making $15/hour will quit for a better job (same pay) if you make him/her do nails all day. Almost impossible to hire an NP for nail care and why would anyone choose to fill up their schedules with nail care. Reimbursement for nail care is decreasing every year and hopefully in the near future 11721/11720 code will be discontinued and abolished. That will be great for podiatry.

 

[Pronation]

Even a medical assistant making $15/hour will quit for a better job (same pay) if you make him/her do nails all day. Almost impossible to hire an NP for nail care and why would anyone choose to fill up their schedules with nail care. Reimbursement for nail care is decreasing every year and hopefully in the near future 11721/11720 code will be discontinued and abolished. That will be great for podiatry.

It will never be abolished, just reduced to peanuts.

 

[air bud]

Even a medical assistant making $15/hour will quit for a better job (same pay) if you make him/her do nails all day. Almost impossible to hire an NP for nail care and why would anyone choose to fill up their schedules with nail care. Reimbursement for nail care is decreasing every year and hopefully in the near future 11721/11720 code will be discontinued and abolished. That will be great for podiatry.

Big Nailcare will never let them go. They will lobby harder. Too much money at stake

 

[619]

It will never be abolished, just reduced to peanuts.

It is currently reduced to peanuts. What is left

 

[heybrother]

Eliminate the coverage for mycosis+pain and just cover for actual high risk systemic conditions. Then up the rate.

 

[air bud]

Ok , so if I can't dump on a NP....just keep to a minimum and wait until I get busier and need another pod....and hire a non surgical one and dump on them....

Any other ideas?

 

[malleolusman]

Ok , so if I can't dump on a NP....just keep to a minimum and wait until I get busier and need another pod....and hire a non surgical one and dump on them....

Any other ideas?

Hire a nail tech, VAs hire them for certain pods. Some practices have a nail tech as well. Once hospital understands that nails don’t equal high revenue but do equate possible referrals for monetary pathology they will want to at the very least keep those patients while getting you busier with more profitable pathology.

 

[PeaJay]

Hire a nail tech, VAs hire them for certain pods. Some practices have a nail tech as well. Once hospital understands that nails don’t equal high revenue but do equate possible referrals for monetary pathology they will want to at the very least keep those patients while getting you busier with more profitable pathology.

In most systems/msg providers have to bust the nails themselves. It is a compliance issue with cms. You cannot bill for a procedure you did not perform. This is the same thing as resident performing surgery/seeing consults/ect without involvement of attendings. The small guys can fly under the radar, but when you get hospital size delegation of “procedures” does not fly.

 

[PeaJay]

Ok , so if I can't dump on a NP....just keep to a minimum and wait until I get busier and need another pod....and hire a non surgical one and dump on them....

Any other ideas?

Just remove all the toenails in town? Just remember the mue on nail removals