How procedures get reimbursed

[heybrother]

I started writing this weeks ago and I'm still not sure it is what I intended it to be, but its something different and I still think a lot of people don't know how they are actually reimbursed.

Disclaimer: This document pertains only to Private Practice podiatry. I'm not some fancy out of network biller and I don't unbundle. I'm not in a big group. My experiences attempting to negotiate so far have really only been minimally successful so I'm not putting myself out there as an example of success. I've made 2 pairs of customs in the past 2ish years so I'm not going through every insurance benefit looking for this. I've been reading this forum for years now and I think the quality of information people provide about practices is better than its ever been. One of the things that stands out to be is the profound differences in collections that people report. We're all obviously different. We treat differently. We code differently. That said, I've had a strong feeling recently that the number one thing holding me down is the quality of my practice's contracts. My hope is to try and give people who are just starting out a headstart on understanding how they get paid for their services so they can adjust accordingly. It goes without saying that if you are an associate and your owner won't let you see how claims are paid you'll be missing out.

It Shouldn't be a Mystery
When I first started seeing patients and operating I always wondered - what am I going to get paid? I really had no idea at all. I'd go back through my patients a month after the fact looking back to see what was worth more and what was worth less. My EHR really didn't make it easy. I'd pull charges and see all manner of different rates being paid for what appeared to be the same insurance. I ultimately found myself having to separate my partner and I's patients and literally look at patient's insurance cards. I don't think I'm alone in my initial ignorance. I recently spoke to a colleague's wife who is their office manager. They described for me their disappointment at the reimbursement for a matrixectomy performed at surgery center. To me the reason is clear as day - in facility reimbursement but they didn't seem to be aware of this. They thought - surgery at facility, must pay well. Sadly not. It takes effort to sort all this out, but I think it benefits you to learn things sooner rather than later.

Basics

In general - the first step for figuring out your reimbursement is the Medicare fee schedule lookup tool. Most insurance uses these values in some form. Pick your code and your specific locality ie. most states are divided into specific areas with different rates paid based on location and theoretically cost. Yes, NYC type localities will have higher values than backwater rural areas. You can pull multiple codes at a time. Its very involved, but you can technically pull all the CPT codes into an excel table (its time consuming) and then use the vlookup function in excel to check the values an insurance company offers you. There are sometimes mistakes in their values. Its also nice to just have all the values in 1 place for checking and comparison.

Some codes list both "office" (non-facility) and facility reimbursement. In general, more complex codes ie. ankle fusion, will only have a facility value because they'd only be performed in a facility. The office value is essentially always higher than the facility value. Sometimes the values are somewhat similar. Othertimes they are quite different. Dtrack has explained this elsewhere (better) but when you receive reimbursement in your own clinic the value includes both professional and facility component reimbursement theoretically taking into account the cost of delivering the service. Its more technical than that - any CPT code can be broken down into all manner of components and pre/intra-op/global etc components. When you perform the service in a facility you only receive the professional component (though assuredly the facility receives a larger facility fee than your office would have).

Consider the following codes followed by "office" and "facility" values (these are rounded numbers)

10060 - $120 - $100 - similar
11750 - $160 - $100 - different
11042 - $128 - $60 - very different
11056 - $82 - $22 - what what?

Some of these I can sort of try to explain. For example, since in general you can't charge for dressings the 11042 difference accounts for supplies and materials that would be used (TAO and bandaid...) Calluses - I don't know. Perhaps nursing homes aren't all they are cracked up to be by the many happy nursing home doctors I've met.

I list the above because they are straight forward common minimalist procedures. You can also perform some surgeries both in your clinic or at a facility. Consider.

28296 - $880 - $500
28297 - $1000 - $580
28285 - $525 - $370
28232 - $370 - $230
28825 - $290 - $170

Will you perform a lapidus in your office? Probably not (talk to your Lapiplasty rep about in office Lapiplasty...). You should also always check with the insurance company before you perform a "real" surgery in your office because they may use this as an excuse to deny it. My office recently accidentally submitted the location of a 28113 as in the office rather than at a facility. The insurance denied it stating they wouldn't cover that procedure in an office. Medicare obviously provides fee values for both.

Some of the values listed above are obviously for very minimalist procedures ie. open flexor tenotomy, partial toe amp. Others are almost always associated with expenses ie. sterile field, gloves/gowning, hardware, power hardware, fluoroscopy.

The impression I'm under is that if you perform surgery in your office you can either
(a) accept the non-facility reimbursement which covers all reimbursement and expenses ie. whatever hardware (READ: K-wires) you use, all the dressings etc
or (b) go through some sort of enormous regulatory process to try and turn your procedure room into a "Surgery Center" which will require a separate entrance and all sorts of other stuff.

Not an expert on the above, but if you have 1 pot of reimbursement for a procedure you won't be using $100 cannulated screws.

OK! Thus concludes a brief overview on how Medicare sets its fee schedule / pays and somewhat the basis/starting point for thinking about codes. Note that Medicare Advantage is NOT Medicare. More on that later.

But how does insurance pay!?!?

Variably. And to figure it out you either have to have the contract, get the schedule or you have to tear the values apart.

(1) Insurance can DEFINITELY pay different doctors in the practice different amounts. You are the new associate. You join an established practice. A lot of times the new doctor is listed as "Rendering" but not as "Supervising" (right or wrong). If you become "Supervising" and "Rendering" and your reimbursement goes down compared to your partner then they have different values than you do. One of the take homes here is that if a practice is renewing a plan they need to look at the documents for every doctor because different doctors may have different values in the back of their fee schedules.

(2) Insurance can pay different values for different types of services and even different locations. The general breakdown of services are some variation of (a) E&M (b) procedures/surgery (c) imaging (d) J codes (e) DME (f) laboratory etc. You can have different multipliers of all these values. One of my better insurances pays 150-155% for procedures in the office but 190-195% for procedures in a surgery center. Remember though that these multipliers are applied to facility and non-facility base values and the non-facility base value is often substantially larger.

(3) Insurance can screw with the base values for multipliers ie. ignore location. For example, a recent insurance of mine that I cracked paid all services based on the facility value multiplied by a multiplier. They literally provided 1 fee schedule value for all services regardless of where they were performed ie. same fee in the office or in a facility. Relevance of this? When you multiply a "facility" value by a multiplier it produces a smaller number than if you'd multiplied the non-facility value by the same number. The difference between 11750 in the office verse in the facility is so large that the multiplier barely brought the reimbursement over the facility value.

(4) Insurance can literally just produce a hodge-podge mix of different values for every single service with no rhyme or reason. I have a fee schedule for an insurance in which every procedure when charted against Medicare is being multiplied by a different value. What's the take home here. You MUST do your best to get the company to send you the fee schedule. My bizarre feeling when I acquired one of these schedules recently was that some podiatrist had gone through and picked over certain values to game it for themself. For example - 20550 paid $50 but 20551 paid $80. Percutaneous flexor tenotomy codes paid more than open codes. 11750 paid over $200 but 11730 paid under $100.

(5) A small nice thing. Some small boutique insurances generate one fee schedule and use the non-facility value as the basis for all values.

(6) Insurance can lock to a specific year preventing you from benefiting from changes/upgrades in the Medicare fee schedule. If you are locked by a plan to 2021 you'll miss all the benefits of the E&M change. ie. my 99213 went up like $15-16 in 2021 but not for plans locked to 2020.

(7) Insurance can sometimes pay simply a multiplier of your fee schedule. I don't believe this is common at all. If you've set a very reasonable fee schedule this can be super detrimental and annoying. Awhile back I realized a plan was paying us a straight 60% multiplier of our fee schedule. It was a small boutique plan. I didn't have a contract but figured it out by tearing the data apart.

Sooooooo. Wait. How do I figure these values out / get these values / etc.

This is one of the hard parts. In general, new insurances will usually send you the rates when you start the process of applying for the plans. All recent new insurances requests we've received have contained an Appendix and interestingly all have offered some variation of a straight multiplier of Medicare. *Sneaky thing - they often include some sort of variable short line about how "Uncovered/Unlisted" services will be paid at 50%. I'd have to read the line again but I took it to mean they were demanding a 50% reduction of how you were to charge their patients. Watch out for that if you have some sort of cash pay uncovered charge you push on everyone.

Major insurances ie. United often offer a series of summary pages. The first will list a series of breakdowns ie. E&M, procedure etc and the reimbursement rate ie. 80% of Medicare followed by another page listing common codes and their reimbursement value in dollars for both both in non-facility and facility.
***I'm probably going to repeat this elsewhere but VERY IMPORTANT. There is no such thing as a "RENEWAL" with a major company ie. UNITED. United will change your contractual reimbursement any chance they get. If you get a contract and are like "we should just sign this" you are making a mistake. Read the fee schedule line by line. They will cut your rate if you aren't looking for it.

Asking for contracts has been more useful than asking for free schedules. When I ask for a contract we seem to get it. When we ask for a fee schedule - nothing. Like we asked months ago and nothing. Some plans list their values on Availity. My experience is these values are incomplete and often wrong. My Availity account conclusively demonstrated to me that I was accepting 3 different BCBS fee schedules. However, the facility surgery values were wrong for at least one of them. Availity claimed to include the Aetna fee schedule values but a line by line review of my Aetna data shows at least 2 different fee schedules.

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[heybrother]

How do you crack the data if you can't get a fee schedule?

You literally go line by line pulling codes and their reimbursement. So you'd pull all the 99213s, all the 20550s, etc. Things to be careful of.
(1) Pull individually by provider. Its possible each person is paid differently.
(2) Check the time of the year. January and December will likely be on different year fee schedules depending on when Medicare release the values
(3) Consider even checking the insurance card. My EHR was combining 2 different BCBS HMO plans. The reimbursement difference between them was substantial and it produced that feeling where you wonder why sometimes you get more and sometimes you get less. In this case I was seeing 2 different plans combined together. That said - I told you already that I have 2 different Aetna schedules (at least). I looked at Aetna cards and they were identical. I can't figure them out.

*Remember - you'll never truly sort out a "hodge podge" plan this way unless you truly use all codes.

Anyway, you pull the values and hopefully see consistent numbers. Then you line them up on an excel for each code and figure out how they compare to Medicare. Hopefully they represent a consistent modifier. ie. E&M x 1.35 or whatever. FYI they'll never come out to 1.35 exactly. It'll be like 1.34680 etc.

You need to check at least
(1) one E&M ie 99213
(2) one in office procedure ie. 11750
(3) one facility procedure - ideally a procedure with facility/non-facility - 28297
(4) and your imaging - 73630

All could have different values. Consistent values between different procedures at the same location is a good thing ie. gives you confidence in consistency. Don't let a surgical 59 50% reduction throw off your numbers ie. look at the primary procedure or likely double the value of secondary procedures. Watch out for 50 modifiers also as they can throw things off.

What if the insurance/patient paid me exactly my fee schedule price
Some combination of:
(a) the insurance punted the whole bill to the patient - ie. HMO patient with no referral
(b) your fee schedule is lower than the rate they will pay you ie you could increase your fee schedule
*Find out your best plan and check all of your fees accordingly
(c) coding issue - for whatever reason coding issues either result in the charge being zeroed or the patient eating the bill. An example I've seen a few times - you code 17110 but bill it to porokeratosis (it isn't porokeratosis, btw). I cringe when the patient gets this whole bill since a lot of practices have 17110 set at an enormous number. The patient would have been better served if the insurance had contractually reduced it and then refused to pay.

Very Rare Specific Thing (not sure where else to put this)
-You perform a multi-procedure surgery and the Insurance denies the first procedure.
-You must fight this because you are likely getting super screwed. Essentially the first procedure is going to be paid at full contractual value. If they cut the first procedure you will often receive 50% for later procedures. Whenever this happens they never pay the 2nd procedure at full value. So not only have you lost a procedure, you've lost the full value procedure. I have a recent case where a calcaneal osteotomy got denied and essentially I'm missing greater than $1000 on the case until it gets fixed.

How Should I Set My Fee Schedule

Well, now that's a deeply personal question. Also, theoretically talking to other doctors and matching their schedule may or may not be some sort of anti-competitive behavior/thing that can get you in trouble. I don't know and anyone is free to demolish this line. My weird experience about cash pay is - when I see doctors fee schedules I often think they are absurd, but when I speak to podiatrists I find all sorts of DPMs setting their cash price at trivial levels. Perhaps this is a sweet gesture but why complain about what insurance pays if you won't ask for what you are worth...

First things first. Setting a really high fee schedule will in general not make insurance pay you more. So if you are sitting there saying - man, no one pays us anything and you decide to fight back by increasing prices - its only going to increase revenue on cash pay patients if you can actually collect the money from them. The real enemy is insurance.

Cash pay people cover the full gamut of society. There are rich people who don't want to pay for insurance. There are nurses with no benefits maximizing their pay. There are upper, lower, and middle class people - just trying to get by. Broke students without insurance like you probably were a few years ago etc. So - if you get a fee schedule that is ridiculous etc - do you want to haggle/negotiate with every person?

My general thoughts when establishing a schedule are:

(a) Do review your fee schedules. If someone is going to pay you 200% for surgery and you set your values lower than that you are leaving money on the table. Surgery really should pay you every dollar you deserve because the whole insurance-surgery-system is designed to screw and defraud you with globals and what not. You are going to do surgeries for free where insurance just completely refuses to pay after the fact or Medicare claims the coding is wrong even though its flawless. You will look back and think - I cannot believe I did that entire surgery for free.

(b) I personally only want to have 1 fee schedule. I don't want to do the haggling game or be bouncing forth between things or coming up with 20% reductions.

(c) This is your opportunity to ask for what you are worth - perhaps you are perfectly happy with what your highest paying insurance pays or perhaps this is the encounter where you should be paid more.

(d) For surgery or complicated things - do not feel like you are somehow a dishonest person if you set the values at what you would want to be paid to do the service. That said - there's a lot of mental agony you can inflict on yourself here. I was recently asked to do a cash-lapidus. Medicare in my area pays sub-$600 for a lapidus. Decent commercial insurance pays like $1100. If you want to set your cash pay price at $3000 or $10,000 - whatever, so be it. Its probably less likely to happen at the higher number raising the question - if you are willing to do it for $1000 for insurance why won't you do it for $3K for cash. Lot of circles we could walk in here. That said, my Triple and Ankle fee schedule prices are higher and I won't be engaging in any mental calisthetics on those. If someone wants to pay a cash ankle fusion then I want full value and it isn't anywhere close to what Medicare thinks this is worth. You may feel differently.

(e) I personally make similar services the same fee schedule price. I don't care that 20550, 20605, 20600, etc all have different base values that come out to different numbers. I view performing them all as the same and charge identically for them. Keep steroid pricing in mind. If you're going to charge cash will you include the steroid in the lump price or add it separately. My steroid materials have become much more expensive this year.

(f) Similarly - my experience, a follow-up 99213 and a 20550 are very likely a similar length visit. "I'm a little better but still hurting" - let me (a) refill your meloxicam or (b) give you another shot. I don't make these wildly divergent personally. That said - 99213 is now based on a much higher Medicare base than 20550 so don't accidentally set that too low (if you have positive multiplier plans).

(g) Make services you perform the expensive/valuable service. If the patient shows up and just talks to you for 15 minutes - you should still be satisfied with the pricing of the visit. This is probably something very specific to me, but patients at my office who are cash always want to argue/avoid x-ray. I will admit - our x-ray cost is more than double Medicare. Another provider told me there's is 4x Medicare. I don't even do the x-rays. My MA does them before hand. Set your main service at a price you'll be happy at regardless of what else happens in the visit. If they show up and do zero x-rays, zero injections, whatever - this should still be a profitable visit. This isn't a problem for most doctors since most people set astronomically high visits but I felt quite a bit happier about mine after I increased it awhile back (and bonus, we were below the schedule for a plan).

(h) Do ask yourself - am I giving a quality service. Is the patient getting their moneys worth. I feel ...a tiny bit guilty at my 17110 price since I added cantharone. Its a lot of money for literally the world's easiest procedure. That said, we do need to win every once in awhile.

(i) Speaking of which. We do need to win. Everyone else in medicine ie. hospitals thinks their services are priceless. If a patient comes in and wants to talk about nerve pain and gets x-rays and shots and a new visit - there isn't anything wrong with them leaving $400-500 at your front desk.

(j) The most variable number I hear from people is their cash price number for nails/calluses on uncovered patients. For whatever reason, a lot of people are perfectly happy to accept $50 for this. My number is too low, but that's way too low. The value Medicare sets for 1172x is just too low. I get that it doesn't take a lot of thought but its still annoying to do on a lot of people. We can't complain that nothing pays anymore and then accept Medicare's slop on this. 11056 and 11720 together are like over $100 in most localities. I get it - a lot of people on a fixed budget will be the one's receiving this service but you still have to respect yourself here. Medicare will pay you almost $90 in my area for a 99213 which is often a substantially shorter visit than a 11721.

Long story short - there's a lot of directions you can go with all of this. Medicine is an interesting field - no one puts their prices online so unless the patient calls ahead to ask about all services a lot of the time they don't know what they'll be paying. Awhile back an ED doctor yelled at my office manager because his cash pay wife was charged $350 for a matrixectomy. He said we were horrible people for not charging her Medicare since she was cash pay. Everyone's got an opinion.

Medicare Advantage

Is the devil. In my experience all Medicare Advantage plans will try to screw you. They make money by denying care. These are commercial plans running Medicare type services. They do not have to pay you full Medicare value. They are big. In general they always require prior authorization for surgery ie. compared to Medicare which usually doesn't though I'm sure its coming.

(a) Humana. Probably the worst Medicare Advantage company hands down. If you perform boring old covered diabetic/PVD care - they will regularly deny services every other visit. So for example - if you see someone every 3 months and bill 11720/11056 - they will deny the 11720 every other visit. They will also routinely deny an E&M performed with c&c even if its a clearly documented and diagnosed problem ie. the patient wants to discuss their arthritis at the same time. Going back through your billing and fighting 50x 11720s for $20 a piece will just make you scream. Your office manager will say - why are we fighting this, its not enough money.

(b) United. Also terrible. The number one denier of surgeries performed at a hospital/surgery center. In my area their contract is 3 years long and can only be broken on anniversaries of the contract with 90 days notice. How does a company like this stay in business? Because we accept them. As I indicate above - never sign a contract from this company without reading it. FYI they claim if you want to negotiate your rate you need to contact them 90 days before the contract expires at which point they will presumably tell you to screw off.

(c) Aetna. Not common for me. For all of their plans (commercial and MA) they pay 3rd and after procedures at 25% instead of 50%. Aetna commercial is probably the number one denier of the 25 modifier. You can do an injection, go through/interpret an MRI for a patient, and discuss/schedule an ankle scope and they'll deny either the visit or the shot.

OK - so like. What do we actually get paid though.

You get paid what your contract says. So when people say "Oh, there's so much money in procedures" - there's money in certain procedures and in things multiplied by a positive number. I have only practiced in one place and therefore I've only seen a handful of plans and situations. Other people may be in entirely different situations and the things I describe may seem foreign to them.

Let's consider 4 different numbers:

80% of Medicare, 100% of Medicare, 135% of Medicare, and 200% of Medicare.

80% -Nothing is really worth anything at 80% of Medicare. Question #1 at 80% of Medicare is - are you locked to 2020 or before or are you using 2021+. The issue here is there's a decent difference between 99213 etc between these years. In my area its to the tune of $16. 80% of 2020 is sub-$60 for a 99213. A 20550 will be $40ish. Surgery is free at this multiplier. A lapidus in a facility will get you $400ish. Who will pay you this rate? Both Medicare Advantage Plans and even some commercial insurance. I am currently firing a plan that pays less than this. I hope to fire more.

100% - Obviously this is what Medicare "pays". Common codes that break $100 - 11750, 11730, 17110. I'm personally not bothered by what they currently pay for E&M. True facility surgical reimbursement is still painful unless its a multi procedure case. Injections are free in the $50ish range.

135% - Here's the interesting thing to me about insurance. Insurance that negotiates and pays ...decently seems to either (a) pay a straight multiplier or (b) do some sort of tiered system with different values for surgery verse in office etc. So I have a few different times been offered something along the lines of straight 135% for everything. 135% for everything is interesting. Surgical reimbursement is still meh unless you receive non-facility values. An Austin at 135% is still under $700 in my area. However, imagery and office procedures do start to pick up speed here. E&M and imagery start to become decent. Injections at this level for me cross the $70 threshold. A matrixectomy crosses $200 at this level. Nothing is amazing, but I have a lot of plans that are worse than this. If this was the only things I was paid I'd be quite a bit ahead just by virtue of lots of little things being worth $10 more.

Consider this though:
80% - 99203 + 11750 = $213
135% - 99203 + 11750 = $360
213/360 = 59.1%. A person being paid 135% has 40% more $$$ than a person with 80% plans.

200% I'm not personally paid anything at this rate though I have a few plans that approach it for surgery. You have to be approaching this value for surgery to really be worth anything. I'm not kidding here. If you asked a patient what surgery is worth - well they'd likely still list values greater than 200% of Medicare, but if you want $1000 for anything it probably needs to be multiplied by 180-190%. This brings up something godfather has written numerous places on her.

Negotiating

Good luck. The general theme of this forum is that more rural doctors seem to be able to command higher rates. The only thing I can really offer is - always ask for more. I've had 2 plans offer 10% more after we countered their offer. That said - I declined one and will be dropping out of the other. I'm mostly of the opinion that the only power we have is to drop them.

The internet offers a few different pieces of advice on plans. One piece is to do everything I describe ie. going through your plans and figuring out what they pay and then confronting them. Everyone has different sorts of practices. I'm of the opinion that if you are happy seeing - example 20-25 patients and you can turn around and drop Humana and see the same number of patients with hopefully more BCBS etc - that's a win.

The internet recommendations confronting plans about specific codes to try and seek higher reimbursement. I've only tried this once and it failed. This is probably more effective if you literally only use the same codes. If you are heavily procedural or operative you are going to use a lot of codes.

I've mentioned this already, but sometimes if you confront an insurance company they'll say "Oh, you are on an old plan - let us fix this for you" and then they send you a garbage plan with new rates worse than the old ones. Again, never sign a contract without exploring the fee schedule.

How did we get here

Because we accept trash reimbursement as a group. Why we do this is complicated. My suspicion is its a combination of

(a) Some variation of "do-goodery" - the patients need to be seen so you see them
(b) catering to your referral base
(c) historic coding douchery in which it didn't matter what codes paid since a bunion was 9 codes or you intend to push custom orthotics and expensive creams and chicanery on every patient
(d) you just sign whatever contract is put in front of you
(e) you're too busy to explore these sort of things so you see 40 patients a day and get $40 an injection
(f) perhaps you think the reimbursement is fine - ie. you only spend 1 minute in the room anyway for $50 for 1 minute is good enough

I fully admit its more complicated than the above.

Something different

So I have obviously have to act in the best interest of my business. On the other hand, I'm also a human who would like to receive high quality and reasonable medical care at a reasonable price. How do we balance these needs. How do we balance the fact that essentially hospital based care is exploding in price while private practice is slaughtered. Historically, I'm told we were paid substantially more for many things. I seem to recall my parents paying a podiatrist $500 for matrixectomies for my brothers and sisters back in the day. My fee schedule price for 11750 is less than that. My partner relates regularly receiving $1500 for an Austin back in the day while he receives about best case now - $900ish from common insurance. The general trend is downward. How low can it go though? I don't know. We as patients ourselves might like receiving "affordable" care, but will we like it if no one is in business or the only place to receive care is an overpriced hospital? Another physician today suggested to me that we are on the path to "single payor" because the goal of every insurance is to reduce reimbursement down to Medicare levels. My recent experience negotating supports this. I've said this elsewhere on here, but if all surgery is reimbursement at Medicare or less - what's the point of doing surgery.

 

[Pronation]

I tell patients that custom orthotics are more important than oxygen.

 

[air bud]

Ok residents you guys got that? Cool happy job hunting.

 

[dtrack22]

Dtrack has explained this elsewhere (better) but when you receive reimbursement in your own clinic the value includes both professional and facility component reimbursement theoretically taking into account the cost of delivering the service. Its more technical than that - any CPT code can be broken down into all manner of components and pre/intra-op/global etc components.

I don’t need to add anything to the above post (as a whole), partly because I’m lazy but mostly because it is very well done and relatively complete.

The quote here is a good reason why you should have an understanding of RVU’s even if you are in private practice. Obviously a private practice cares more about $ reimbursements, but you can’t make sense of Medicare fee schedules without understanding Relative Value Units and your localities conversion factor. Essentially RVU x conversion factor = Medicare fee schedule. This can be important in understanding your commercial contracts. While United may list your fee schedule as a % of Medicare (ie my last United contract was 139% for office visits), other carriers may list your contracted rate as conversion factor (ie BCBS was $61, while the Medicare conversion factor was more like $35). You can still think of that conversion factor as a % or multiple of Medicare but you should understand that everything you bill has an associated RVU number that is then multiplied by the conversion factor in the contract.

Employed folks, like myself now, still need to understand RVUs because wRVU (which is likely how they are compensated) is simply a component of the total RVU number. You should know that wRVU generally makes up around 66% of the total facility RVU and closer to 50% of the non-facility RVU. This probably doesn’t matter too much after you’ve started but can help you better understand pay rates when it comes to contract negotiation.

Also, it’s now official. SDN > IPED. Thanks Heybrother

 

[air bud]

I have no idea what any of you guys are talking about all I know is the sound of that email when the paycheck hits my bank account

 

[CutsWithFury]

I have no idea what any of you guys are talking about all I know is the sound of that email when the paycheck hits my bank account

All you know how to do is find reasons to put skin biologics on everything that walks. Cue @ExperiencedDPM

 

[air bud]

All you know how to do is find reasons to put skin biologics on everything that walks. Cue @ExperiencedDPM

Find "medically necessary" reasons. And haven't put one on since September bro. Because waiting on reimbursement...

 

[HardRoadPaved]

I tell patients that custom orthotics are more important than oxygen.

I tell patients that if we don't biopsy the longitudinal streak in their nail that's been there for decades, that it could be melanoma.

 

[JewOnThis]

Time to find a VA job

 

[HardRoadPaved]

Time to find a VA job

Time for parity. Vision 2025, 2030, or whatever. Hello MDDODPM degree!

 

[air bud]

Ok guys let's not get off topic too fast. Amazing thread from @heybrother I learned a bunch of stuff. I have been private practice for a year or so now and know very little of what he talked about. I should know more.

 

[619]

Good writing by @heybrother . I own my practice and keep my billing in house. Every morning before clinic starts, I look at my collections and look at every single EOB. I have a spread sheet of all my codes and I write down what each insurance reimburses for every procedure. Being doing this for over a year now I have very solid pay schedule that covers everyone. It's funny when with the same insurance for example BCBS have paid anywhere from $188 to $284 for the same 11750.
Anyway my point of looking at the EOB everyday and creating a pay schedule (for each insurance) is that based on the patients insurance and If they have a high deductible (my office verify all new patients benefits), I can collect the exact amount at time of service. I don't have an army of billing team to chase patients down or send them to collections.

 

[potcake76]

How do you crack the data if you can't get a fee schedule?

You literally go line by line pulling codes and their reimbursement. So you'd pull all the 99213s, all the 20550s, etc. Things to be careful of.
(1) Pull individually by provider. Its possible each person is paid differently.
(2) Check the time of the year. January and December will likely be on different year fee schedules depending on when Medicare release the values
(3) Consider even checking the insurance card. My EHR was combining 2 different BCBS HMO plans. The reimbursement difference between them was substantial and it produced that feeling where you wonder why sometimes you get more and sometimes you get less. In this case I was seeing 2 different plans combined together. That said - I told you already that I have 2 different Aetna schedules (at least). I looked at Aetna cards and they were identical. I can't figure them out.

*Remember - you'll never truly sort out a "hodge podge" plan this way unless you truly use all codes.

Anyway, you pull the values and hopefully see consistent numbers. Then you line them up on an excel for each code and figure out how they compare to Medicare. Hopefully they represent a consistent modifier. ie. E&M x 1.35 or whatever. FYI they'll never come out to 1.35 exactly. It'll be like 1.34680 etc.

You need to check at least
(1) one E&M ie 99213
(2) one in office procedure ie. 11750
(3) one facility procedure - ideally a procedure with facility/non-facility - 28297
(4) and your imaging - 73630

All could have different values. Consistent values between different procedures at the same location is a good thing ie. gives you confidence in consistency. Don't let a surgical 59 50% reduction throw off your numbers ie. look at the primary procedure or likely double the value of secondary procedures. Watch out for 50 modifiers also as they can throw things off.

What if the insurance/patient paid me exactly my fee schedule price
Some combination of:
(a) the insurance punted the whole bill to the patient - ie. HMO patient with no referral
(b) your fee schedule is lower than the rate they will pay you ie you could increase your fee schedule
*Find out your best plan and check all of your fees accordingly
(c) coding issue - for whatever reason coding issues either result in the charge being zeroed or the patient eating the bill. An example I've seen a few times - you code 17110 but bill it to porokeratosis (it isn't porokeratosis, btw). I cringe when the patient gets this whole bill since a lot of practices have 17110 set at an enormous number. The patient would have been better served if the insurance had contractually reduced it and then refused to pay.

Very Rare Specific Thing (not sure where else to put this)
-You perform a multi-procedure surgery and the Insurance denies the first procedure.
-You must fight this because you are likely getting super screwed. Essentially the first procedure is going to be paid at full contractual value. If they cut the first procedure you will often receive 50% for later procedures. Whenever this happens they never pay the 2nd procedure at full value. So not only have you lost a procedure, you've lost the full value procedure. I have a recent case where a calcaneal osteotomy got denied and essentially I'm missing greater than $1000 on the case until it gets fixed.

How Should I Set My Fee Schedule

Well, now that's a deeply personal question. Also, theoretically talking to other doctors and matching their schedule may or may not be some sort of anti-competitive behavior/thing that can get you in trouble. I don't know and anyone is free to demolish this line. My weird experience about cash pay is - when I see doctors fee schedules I often think they are absurd, but when I speak to podiatrists I find all sorts of DPMs setting their cash price at trivial levels. Perhaps this is a sweet gesture but why complain about what insurance pays if you won't ask for what you are worth...

First things first. Setting a really high fee schedule will in general not make insurance pay you more. So if you are sitting there saying - man, no one pays us anything and you decide to fight back by increasing prices - its only going to increase revenue on cash pay patients if you can actually collect the money from them. The real enemy is insurance.

Cash pay people cover the full gamut of society. There are rich people who don't want to pay for insurance. There are nurses with no benefits maximizing their pay. There are upper, lower, and middle class people - just trying to get by. Broke students without insurance like you probably were a few years ago etc. So - if you get a fee schedule that is ridiculous etc - do you want to haggle/negotiate with every person?

My general thoughts when establishing a schedule are:

(a) Do review your fee schedules. If someone is going to pay you 200% for surgery and you set your values lower than that you are leaving money on the table. Surgery really should pay you every dollar you deserve because the whole insurance-surgery-system is designed to screw and defraud you with globals and what not. You are going to do surgeries for free where insurance just completely refuses to pay after the fact or Medicare claims the coding is wrong even though its flawless. You will look back and think - I cannot believe I did that entire surgery for free.

(b) I personally only want to have 1 fee schedule. I don't want to do the haggling game or be bouncing forth between things or coming up with 20% reductions.

(c) This is your opportunity to ask for what you are worth - perhaps you are perfectly happy with what your highest paying insurance pays or perhaps this is the encounter where you should be paid more.

(d) For surgery or complicated things - do not feel like you are somehow a dishonest person if you set the values at what you would want to be paid to do the service. That said - there's a lot of mental agony you can inflict on yourself here. I was recently asked to do a cash-lapidus. Medicare in my area pays sub-$600 for a lapidus. Decent commercial insurance pays like $1100. If you want to set your cash pay price at $3000 or $10,000 - whatever, so be it. Its probably less likely to happen at the higher number raising the question - if you are willing to do it for $1000 for insurance why won't you do it for $3K for cash. Lot of circles we could walk in here. That said, my Triple and Ankle fee schedule prices are higher and I won't be engaging in any mental calisthetics on those. If someone wants to pay a cash ankle fusion then I want full value and it isn't anywhere close to what Medicare thinks this is worth. You may feel differently.

(e) I personally make similar services the same fee schedule price. I don't care that 20550, 20605, 20600, etc all have different base values that come out to different numbers. I view performing them all as the same and charge identically for them. Keep steroid pricing in mind. If you're going to charge cash will you include the steroid in the lump price or add it separately. My steroid materials have become much more expensive this year.

(f) Similarly - my experience, a follow-up 99213 and a 20550 are very likely a similar length visit. "I'm a little better but still hurting" - let me (a) refill your meloxicam or (b) give you another shot. I don't make these wildly divergent personally. That said - 99213 is now based on a much higher Medicare base than 20550 so don't accidentally set that too low (if you have positive multiplier plans).

(g) Make services you perform the expensive/valuable service. If the patient shows up and just talks to you for 15 minutes - you should still be satisfied with the pricing of the visit. This is probably something very specific to me, but patients at my office who are cash always want to argue/avoid x-ray. I will admit - our x-ray cost is more than double Medicare. Another provider told me there's is 4x Medicare. I don't even do the x-rays. My MA does them before hand. Set your main service at a price you'll be happy at regardless of what else happens in the visit. If they show up and do zero x-rays, zero injections, whatever - this should still be a profitable visit. This isn't a problem for most doctors since most people set astronomically high visits but I felt quite a bit happier about mine after I increased it awhile back (and bonus, we were below the schedule for a plan).

(h) Do ask yourself - am I giving a quality service. Is the patient getting their moneys worth. I feel ...a tiny bit guilty at my 17110 price since I added cantharone. Its a lot of money for literally the world's easiest procedure. That said, we do need to win every once in awhile.

(i) Speaking of which. We do need to win. Everyone else in medicine ie. hospitals thinks their services are priceless. If a patient comes in and wants to talk about nerve pain and gets x-rays and shots and a new visit - there isn't anything wrong with them leaving $400-500 at your front desk.

(j) The most variable number I hear from people is their cash price number for nails/calluses on uncovered patients. For whatever reason, a lot of people are perfectly happy to accept $50 for this. My number is too low, but that's way too low. The value Medicare sets for 1172x is just too low. I get that it doesn't take a lot of thought but its still annoying to do on a lot of people. We can't complain that nothing pays anymore and then accept Medicare's slop on this. 11056 and 11720 together are like over $100 in most localities. I get it - a lot of people on a fixed budget will be the one's receiving this service but you still have to respect yourself here. Medicare will pay you almost $90 in my area for a 99213 which is often a substantially shorter visit than a 11721.

Long story short - there's a lot of directions you can go with all of this. Medicine is an interesting field - no one puts their prices online so unless the patient calls ahead to ask about all services a lot of the time they don't know what they'll be paying. Awhile back an ED doctor yelled at my office manager because his cash pay wife was charged $350 for a matrixectomy. He said we were horrible people for not charging her Medicare since she was cash pay. Everyone's got an opinion.

Medicare Advantage

Is the devil. In my experience all Medicare Advantage plans will try to screw you. They make money by denying care. These are commercial plans running Medicare type services. They do not have to pay you full Medicare value. They are big. In general they always require prior authorization for surgery ie. compared to Medicare which usually doesn't though I'm sure its coming.

(a) Humana. Probably the worst Medicare Advantage company hands down. If you perform boring old covered diabetic/PVD care - they will regularly deny services every other visit. So for example - if you see someone every 3 months and bill 11720/11056 - they will deny the 11720 every other visit. They will also routinely deny an E&M performed with c&c even if its a clearly documented and diagnosed problem ie. the patient wants to discuss their arthritis at the same time. Going back through your billing and fighting 50x 11720s for $20 a piece will just make you scream. Your office manager will say - why are we fighting this, its not enough money.

(b) United. Also terrible. The number one denier of surgeries performed at a hospital/surgery center. In my area their contract is 3 years long and can only be broken on anniversaries of the contract with 90 days notice. How does a company like this stay in business? Because we accept them. As I indicate above - never sign a contract from this company without reading it. FYI they claim if you want to negotiate your rate you need to contact them 90 days before the contract expires at which point they will presumably tell you to screw off.

(c) Aetna. Not common for me. For all of their plans (commercial and MA) they pay 3rd and after procedures at 25% instead of 50%. Aetna commercial is probably the number one denier of the 25 modifier. You can do an injection, go through/interpret an MRI for a patient, and discuss/schedule an ankle scope and they'll deny either the visit or the shot.

OK - so like. What do we actually get paid though.

You get paid what your contract says. So when people say "Oh, there's so much money in procedures" - there's money in certain procedures and in things multiplied by a positive number. I have only practiced in one place and therefore I've only seen a handful of plans and situations. Other people may be in entirely different situations and the things I describe may seem foreign to them.

Let's consider 4 different numbers:

80% of Medicare, 100% of Medicare, 135% of Medicare, and 200% of Medicare.

80% -Nothing is really worth anything at 80% of Medicare. Question #1 at 80% of Medicare is - are you locked to 2020 or before or are you using 2021+. The issue here is there's a decent difference between 99213 etc between these years. In my area its to the tune of $16. 80% of 2020 is sub-$60 for a 99213. A 20550 will be $40ish. Surgery is free at this multiplier. A lapidus in a facility will get you $400ish. Who will pay you this rate? Both Medicare Advantage Plans and even some commercial insurance. I am currently firing a plan that pays less than this. I hope to fire more.

100% - Obviously this is what Medicare "pays". Common codes that break $100 - 11750, 11730, 17110. I'm personally not bothered by what they currently pay for E&M. True facility surgical reimbursement is still painful unless its a multi procedure case. Injections are free in the $50ish range.

135% - Here's the interesting thing to me about insurance. Insurance that negotiates and pays ...decently seems to either (a) pay a straight multiplier or (b) do some sort of tiered system with different values for surgery verse in office etc. So I have a few different times been offered something along the lines of straight 135% for everything. 135% for everything is interesting. Surgical reimbursement is still meh unless you receive non-facility values. An Austin at 135% is still under $700 in my area. However, imagery and office procedures do start to pick up speed here. E&M and imagery start to become decent. Injections at this level for me cross the $70 threshold. A matrixectomy crosses $200 at this level. Nothing is amazing, but I have a lot of plans that are worse than this. If this was the only things I was paid I'd be quite a bit ahead just by virtue of lots of little things being worth $10 more.

Consider this though:
80% - 99203 + 11750 = $213
135% - 99203 + 11750 = $360
213/360 = 59.1%. A person being paid 135% has 40% more $$$ than a person with 80% plans.

200% I'm not personally paid anything at this rate though I have a few plans that approach it for surgery. You have to be approaching this value for surgery to really be worth anything. I'm not kidding here. If you asked a patient what surgery is worth - well they'd likely still list values greater than 200% of Medicare, but if you want $1000 for anything it probably needs to be multiplied by 180-190%. This brings up something godfather has written numerous places on her.

Negotiating

Good luck. The general theme of this forum is that more rural doctors seem to be able to command higher rates. The only thing I can really offer is - always ask for more. I've had 2 plans offer 10% more after we countered their offer. That said - I declined one and will be dropping out of the other. I'm mostly of the opinion that the only power we have is to drop them.

The internet offers a few different pieces of advice on plans. One piece is to do everything I describe ie. going through your plans and figuring out what they pay and then confronting them. Everyone has different sorts of practices. I'm of the opinion that if you are happy seeing - example 20-25 patients and you can turn around and drop Humana and see the same number of patients with hopefully more BCBS etc - that's a win.

The internet recommendations confronting plans about specific codes to try and seek higher reimbursement. I've only tried this once and it failed. This is probably more effective if you literally only use the same codes. If you are heavily procedural or operative you are going to use a lot of codes.

I've mentioned this already, but sometimes if you confront an insurance company they'll say "Oh, you are on an old plan - let us fix this for you" and then they send you a garbage plan with new rates worse than the old ones. Again, never sign a contract without exploring the fee schedule.

How did we get here

Because we accept trash reimbursement as a group. Why we do this is complicated. My suspicion is its a combination of

(a) Some variation of "do-goodery" - the patients need to be seen so you see them
(b) catering to your referral base
(c) historic coding douchery in which it didn't matter what codes paid since a bunion was 9 codes or you intend to push custom orthotics and expensive creams and chicanery on every patient
(d) you just sign whatever contract is put in front of you
(e) you're too busy to explore these sort of things so you see 40 patients a day and get $40 an injection
(f) perhaps you think the reimbursement is fine - ie. you only spend 1 minute in the room anyway for $50 for 1 minute is good enough

I fully admit its more complicated than the above.

Something different

So I have obviously have to act in the best interest of my business. On the other hand, I'm also a human who would like to receive high quality and reasonable medical care at a reasonable price. How do we balance these needs. How do we balance the fact that essentially hospital based care is exploding in price while private practice is slaughtered. Historically, I'm told we were paid substantially more for many things. I seem to recall my parents paying a podiatrist $500 for matrixectomies for my brothers and sisters back in the day. My fee schedule price for 11750 is less than that. My partner relates regularly receiving $1500 for an Austin back in the day while he receives about best case now - $900ish from common insurance. The general trend is downward. How low can it go though? I don't know. We as patients ourselves might like receiving "affordable" care, but will we like it if no one is in business or the only place to receive care is an overpriced hospital? Another physician today suggested to me that we are on the path to "single payor" because the goal of every insurance is to reduce reimbursement down to Medicare levels. My recent experience negotating supports this. I've said this elsewhere on here, but if all surgery is reimbursement at Medicare or less - what's the point of doing surgery.

This is amazing.

 

[king22]

Excellent breakdown @heybrother. I would add, in regards to negotiating contracts, one should consider joining an IPA. The IPA i belong to has definitely resulted in a significant "upgrade" of my base fee schedules for most major insurers (Including Medicaid and Medicare plans). I've also noticed a decrease in denials as well since I've joined. For example, prior to joining I too had issues with Humana Medicare where they would often deny the 11720/11721 and/or E&M. Since joining, those denials have decreased significantly, and when they do occur, simply resubmitting with notes gets the problem rectified.

I also find it interesting how Aetna has been giving you modifier 25 problems. Aetna, atleast for me, usually gives me the least modifier 25 headache of any commercial insurer. I can't remember the last time I got a denial for them due to this. BCBS, on the other hand, has gone from bad to worse. They now outright deny any modifier 25 claim (the E&M component) other than an initial visit. I had a patient last year that I hadn't seen in over a year. He was diabetic and presented complaining of a "hole" in the bottom of his foot. No previous hx of foot ulceration. I evaluated him, obviously discovering the plantar foot ulcer. I debrided, modified his shoe gear, order lab work, x-rays, medications etc. I spent time educated on him on prevention, dressing changes, and daily care. I even spoke with his PCP to coordinate care. I billed a 99214, 73630, and a 11042. They've refused to pay for the 99214, even after resubmittal of the claim with documentation. They're claim is that the 99214 is included in the 11042. My documentation clearly states otherwise. Most recently, on a phone call, they claimed that they can't pay the 99214 because Medicare does not cover an E&M and a procedure for the same diagnosis and on the same day in any circumstance. I asked them to please tell me exactly in the

 

[DYK343]

This thread along with the costs to start a private practice should be linked which I will do here for any future readers who stumble upon this.

Thanks for taking the time to put this together brother. Nice work.

Im MSG and RVU based. So neither of those pertain but if I ever want to open my own I will be searching for this thread. Its great info.

It does show why the trend is towards RVU based work. Getting pain via RVU is exactly the same per patient and does not matter on insurance or uninsured. So much less headache and so much more time with my family.

But as ankle breaker pointed out in another thread I could wake up tomorrow and not have a W2 job as opposed to being my own boss.

Tradeoffs I suppose.

 

[air bud]

This thread along with the costs to start a private practice should be linked which I will do here for any future readers who stumble upon this.

Thanks for taking the time to put this together brother. Nice work.

Im MSG and RVU based. So neither of those pertain but if I ever want to open my own I will be searching for this thread. Its great info.

It does show why the trend is towards RVU based work. Getting pain via RVU is exactly the same per patient and does not matter on insurance or uninsured. So much less headache and so much more time with my family.

But as ankle breaker pointed out in another thread I could wake up tomorrow and not have a W2 job as opposed to being my own boss.

Tradeoffs I suppose.

Document NDC numbers on every injection vs. work whatever hours you want.....trade offs I suppose

 

[DYK343]

Document NDC numbers on every injection vs. work whatever hours you want.....trade offs I suppose

wait thats not a thing in private?
those lot numbers drive me CRAZY

 

[dtrack22]

wait thats not a thing in private?
those lot numbers drive me CRAZY

It’s not a thing in most employed positions either…

 

[DYK343]

It’s not a thing in most employed positions either…

The clipboard people are on me 24/7

 

[HardRoadPaved]

Query: Prescribing Oral Antifungals

I order liver enzymes prior to prescribing an oral antifungal. The blood work is a part of the risk and complications to determine the level of E/M. Can I also include the prescribing of the oral antifungal as part of risk and complications while waiting for the lab results?

Jeff Leibovitz, DPM, Indianapolis, IN

Response: Whether it is a new patient or an established patient for this specific problem, onychomycosis for this patient is to be treated via an oral antifungal medication. When you look at the Level of Medical Decision Making Table, 2 out of the 3 Elements of Medical Decision Making need to be met. Under “Number and Complexity of Problems Addressed,” onychomycosis in all likelihood would be classified as “1 stable chronic illness.” None of the criteria are met under “Amount and/or Complexity of Data to be Reviewed and Analyzed.” Since lab work is being ordered, specifically liver enzymes, under “Risk of Complications and/or Morbidity or Mortality of Patient Management,” there is a low risk of morbidity from additional diagnostic testing or treatment.” This would translate to a CPT 99203 for a new patient/initial encounter or a CPT 99213 for an established patient encounter.

The patient is rescheduled to return after the lab results are reported in order to determine whether or not this patient can be started on the oral antifungal medication. When you look at the Level of Medical Decision making Table, 2 out of the 3 Elements of Medical Decision Making need to be met. Under “Amount and/or Complexity of Data to be Reviewed and Analyzed.” it makes perfect sense that there needs to be an “Independent interpretation of tests” by the ordering physician. An independent interpretation of test performed by another physician/other qualified health care professional (not separately reported) would certainly be appropriate.

This would entail the review/interpretation of the liver enzymes that were performed by an outside laboratory. Under “Risk of Complications and/or Morbidity or Mortality of Patient Management,” by starting this patient on the appropriate regimen of oral antifungal medication, wouldn’t this be a moderate risk of morbidity from additional diagnostic testing or treatment? Of course it would. This is an example of “Prescription drug management.” This subsequent encounter would qualify for an established patient level 4 E/M service, CPT 99214


--------------------------------------

Gotta love it----- 99214 to treat toenail fungus! Clearly the other issue with this write up... The ordering doctor should be doing KOH or some $500 test to prove there is fungus also to bump up "amount and/or complexity of data to be reviewed and analyzed"

 

[heybrother]

Query: Prescribing Oral Antifungals


Gotta love it----- 99214 to treat toenail fungus! Clearly the other issue with this write up... The ordering doctor should be doing KOH or some $500 test to prove there is fungus also to bump up "amount and/or complexity of data to be reviewed and analyzed"

Some pods often have to come up with unnecessary churn visits to fill their schedules. This patient gets 1 visit and their prescription arrives once the lab shows up normal on my fax machine. Meanwhile this spot will be filled hopefully by an ulcer, ingrown toenail or heel pain.


I'm somewhat skeptical though that the person above is actually meeting the 99214 criteria - I'm open to being wrong, but they went back and added a LOT of extra text.

Check this below - "tests that do not require separate interpretation ( eg. tests that are results only) and are analyzed as part of MDM do not count as independent interpretation".

So let's go back to the E&M table.

See his highlight above - except that independent interpretation has MORE text underneath it - a test performed by another physician/etc. Reviewing AST and ALT isn't independent interpretation. It counts towards ordering and reviewing results but for a level 4 those are part of a threefer and you wouldn't meet the listing under a 4. You'd meet the listing under a 3 since 99203/99213 only rerequire 2 data "points" - ordering and reviewing.

Other stuff - again - something that was supposed to be so easy has become a lot more involved with a lot more text.

I have tons of people in this thread I need to reply to - thanks all. Sorry. Been sick.

 

[wakaflocka88]

While on the topic of fungus, how often are y’all ordering a liver panel when starting a healthy patient on terbinafine? Do you do it because TFP said you have to or doing it to CYA?

 

[Pronation]

While on the topic of fungus, how often are y’all ordering a liver panel when starting a healthy patient on terbinafine? Do you do it because TFP said you have to or doing it to CYA?

As a partner in an MSG, I check their liver panel weekly at our lab while on Lamisil. Can never be too safe, ya know?

 

[dtrack22]

While on the topic of fungus, how often are y’all ordering a liver panel when starting a healthy patient on terbinafine? Do you do it because TFP said you have to or doing it to CYA?

I haven’t checked ALT/AST in years. I prescribe terbinafine fairly regularly. I’ve also prescribed itraconazole.

When I worked for a podiatrist and was basically forced to check them on first visit and 3 weeks later and another couple of months after that (because they had a piccolo or whatever that little in office lab/centrifuge machine is called), I had exactly 0 patients with elevated ALT/AST to the point you would actually consider discontinuing treatment.

 

[air bud]

While on the topic of fungus, how often are y’all ordering a liver panel when starting a healthy patient on terbinafine? Do you do it because TFP said you have to or doing it to CYA?

If the patient tells me they have no history of liver dysfunction, they don't drink more than one drink per day or three per week I don't bother testing. I usually tell them don't bother though it won't work. Maybe I check liver enzymes one out of every 20 patients that I put on lamisil

 

[air bud]

I haven’t checked ALT/AST in years. I prescribe terbinafine fairly regularly. I’ve also prescribed itraconazole.

When I worked for a podiatrist and was basically forced to check them on first visit and 3 weeks later and another couple of months after that (because they had a piccolo or whatever that little in office lab/centrifuge machine is called), I had exactly 0 patients with elevated ALT/AST to the point you would actually consider discontinuing treatment.

Also, and don't quote me on this because I am the last person to know what studies say I just regurgitate something that I read on the internet, I think it needs to be 2X high level of ALT to even be a problem. So yeah I don't read studies I just go with what my gut tells me it's the George Bush approach. I figure if I ever get sued, I will just study up right before my deposition.

 

[HardRoadPaved]

Also, and don't quote me on this because I am the last person to know what studies say I just regurgitate something that I read on the internet, I think it needs to be 2X high level of ALT to even be a problem. So yeah I don't read studies I just go with what my gut tells me it's the George Bush approach. I figure if I ever get sued, I will just study up right before my deposition.

Lol can you imagine the TFP expert witness for the plaintiff thinking "I got this one in the bag. these young DPMs know nothing with their 'studies.' they shoulda just done lasers and formula 3 like I sell tell my thousands of patients."