Is burnout real during residency? (not trolling)

[PeaJay]

@Feli

off service rotations should never be at the expense of podiatry/surgery experience.

It however doesn’t hurt to have experience suturing arteries or having experience with fellowship trained ortho trauma docs. Actual rotations when available can be beneficial.

A formal medical education department does force accountability. If the handbook says weekly grand rounds, m&m, ect you will be held accountable. They will not risk running afoul because a senior didn’t want to put in the work that day or week.

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[AttackNME]

Yes. If we could get more and more DPM programs into real teaching hospitals and shut down some laggards, that'd be a boon to our overall success. There is a HUGE difference between both pod - and esp non-pod - rotations and their level of academics, involvement in OR, amount of pod academics, quality of attendings, research supports, etc between a teaching service (typically director FTE hospital with much admin time) versus non-teaching.

You know why it’s hard to run a podiatry program out of a university? Most of them have ortho presence and a foot and ankle MD on staff to help them pass OITE. Podiatrists are then mostly doing limb salvage. You need a HIGH volume of limb salvage cases then to feed the residents. Not every state has a bad enough diabetic population needed to support a high volume limb salvage based residency.

 

[dtrack22]

You know why it’s hard to run a podiatry program out of a university?

Teaching hospital does not necessarily equal university. Yes, Podiatry would be trash at UW, Wash U, HSS/Cornell because of ortho presence. But you don’t need to have robust podiatry programs at the UCLA’s of the world to have how many hundred seats we realistically need. And honestly, if you were pumping out a more consistently well trained product, you’d likely see integration into some of those historically anti-DPM Universities even with heavy ortho presence.

There is nothing wrong with community hospital based programs. But they need in house attending staff, centralized clinic, a solid foundation of foot and ankle cases at their home facility, preferably with some other residency programs (plenty of community hospitals have FM and IM programs), and then you can cover outside cases for additional experience and diversity (if needed). The problem is that too many programs either don’t have adequate volume/diversity, or don’t provide residents with any amount of clinical or surgical autonomy. What do you expect when you show up for a random case, with an attending you don’t work with regularly, whose privately insured patient that you’ve never seen or worked up is lying on the table? And those programs are for more likely to be run outside of teaching hospitals than within them.

 

[Hybrocure]

I don’t know of any university hospitals that have pod residents doing level 1 trauma call under direction of DPMs. At my residency we had level 1 trauma call at satellite hospitals but it was as I mentioned in terms of regulation..wishy washy because those hospitals were not our employed hospital.

 

[DMEpod]

Yeah having residents going around town to random cases and logging them like they are actually doing something is not right but I feel like it is difficult to establish good programs in teaching hospitals because of the trauma problem. Podiatry is not created equal hospital to hospital and some places are happy to give pods F&A trauma whereas other hospitals would rather watch the patients leg fall off than call podiatry for a fx. Not saying this makes opening BS residencies ok but it probably plays a role in all of the random PP residencies around.

 

[dtrack22]

Yeah having residents going around town to random cases and logging them like they are actually doing something is not right but I feel like it is difficult to establish good programs in teaching hospitals because of the trauma problem. Podiatry is not created equal hospital to hospital and some places are happy to give pods F&A trauma whereas other hospitals would rather watch the patients leg fall off than call podiatry for a fx. Not saying this makes opening BS residencies ok but it probably plays a role in all of the random PP residencies around.

Ortho only has around 700 seats. There are plenty of hospitals with GME programs that don’t have a huge ortho presence. Certainly enough for the few hundred high quality spots we actually need (not the 600 we have). Residents could also scrub with ortho at minimum if they aren’t handing off foot or ankle fractures to podiatry attendings.

The issue with the PP residencies was primarily due to need at a time when an even larger of majority positions were in PP. When you need to add new programs and hundreds of seats in a short period of time, you have no choice but to get whatever you can. 20 years ago (and again 7 years ago) that was Podiatrists in private practices who held hospital privileges in areas where they could get residents enough cases (supposedly). Again, had you never forced the opening of crappy programs, or stuck with a two tiered training/practice model, this wouldn’t be an issue. And you probably wouldn’t have 11 schools graduating upwards of 700 podiatrists every year.

 

[air bud]

It all comes down to oversaturation. Do you think anyone living in Omaha or Columbus or Knoxville says hey you know what we have too many opthalmologists? No. They are not saturated and thus make 1 million plus a year. Except for maybe some highly desirable locations like Aspen or Jackson where there are 12 orthos for a town of 10k, everyone has more work than they need. Someone the other day said derm near them was booked out 3 months. There is no such thing as a pod booked out 3 months.

Too many pods too many schools.

 

[PeaJay]

Someone the other day said derm near them was booked out 3 months. There is no such thing as a pod booked out 3 months.

You must live in the “ big city” derm is booked out 1.5 yrs by me. The derm consult in the emr has a question that says “ is the area of concern on the foot?” If you click yes it auto changes the consult to podiatry.

 

[Feli]

...Too many pods too many schools.

I am thinking Pac NW is next... find a crusty DO school there and bippidy boppidy biomechanics?

 

[DYK343]

It all comes down to oversaturation. Do you think anyone living in Omaha or Columbus or Knoxville says hey you know what we have too many opthalmologists? No. They are not saturated and thus make 1 million plus a year. Except for maybe some highly desirable locations like Aspen or Jackson where there are 12 orthos for a town of 10k, everyone has more work than they need. Someone the other day said derm near them was booked out 3 months. There is no such thing as a pod booked out 3 months.

Too many pods too many schools.

Youre not booked out 3 months because you're not cutting toenails all day/deny the request.
I have 10+ a day that call my office wanting nail care. We deny them all.
If you accept every patient banging on your door that wants their nails cut you would easily be booked 3 months within 6-12 months time.
You would also do nothing else but cut toenails all day/every day and salivate over the bunion consult that you see scheduled 3 weeks in advance.

I built a heavy MSK practice in the past doing zero nail care. Deny, deny, deny.
Im doing the same here. At the beginning it was rough as referral sources didnt get it for awhile. Some PCPs get upset because you wont see the nails with the bunions or whatever and send their patients elsewhere. But lets be honest... its 90% nail care anyway. Not a huge loss to annoy a few referral sources in the grand scheme of things.

From day #1 gotta build the practice you want. If you accept anything that bangs on the door then referral sources will learn what you treat and its gonna be 90% nails.

Im still on the inpatient pus bus though. Ugh.

 

[Feli]

...From day #1 gotta build the practice you want. If you accept anything that bangs on the door then referral sources will learn what you treat and its gonna be 90% nails.

Im still on the inpatient pus bus though. Ugh.

Concur... shape it how you want (even if you're employed ... even associate).

I choose to take everything... I encourage MSK, neutral on nail/derm, discourage wounds. I'm lucky that it's a highly educated pop here that doesn't have a ton of wounds or DM, though. It logically turns out that my practice is mostly MSK with a blend of everything.

I was txting about this with a few current/former SDN ppl about how to get PCPs to know we do more than just nails and forefoot lately. I market before/after XRs on media and in ads, talking how we garner those refers. Part of it is just being on the surgery schedule a lot, sending a lot of pts for pre-op clearance H&P, etc... but I send post-op XRs to ER docs who sent or called me on the pt after big ORIFs or XRs to PCPs after recon stuff, progress notes or MRI results after PCPs send me injuries or deformities... but not so much nail derm/stuff. The snowball keeps rolling if you direct which direction it goes.

In PP, you don't really want to turn down money. You never know when ortho will show up and can suddenly dry up the fracture/surgery refers VERY fast if they do F&A work. It is different for hospital employed where you're more salary and will get forced refers from hospital employ PCPs regardless or might have a nails nurse, and there is always the pus bus to get the RVUs since insurance matters little or none (not the case in PP!).

One PCP asked me in the lounge, "so you want to do mostly the bigger stuff, right? The injuries and the surgery? I should send the nail care to the other podiatrists in town?" I told him no way... I'm good at the surgery but can "handle anything below the knee and take all area insurances." So, as for me, I just want to make it as easy and successful for them to refer everything to me (all PCPs: hospital employed, private solo, private group... ER, peds, other specialists, whoever). I did a STJ fusion last month for a calc fx the nearby hospital pod had casted and then lost the pt since it was a diabetic he'd told he doesn't cut nails (I saw pt for nails + shoes Rx and ended up doing inject, getting his XRs, running CT, and later surgery). I think those [meaningful] surgery out of DM foot exam or nail care pts are uber rare, but it all pays the bills.

It's one thing if you're crazy busy bursting-at-the-seams PP and don't want to expand hours or hire associate(s), but the ingrowns and the simple stuff is fast and easy. I would rather do derm/nail than more wounds (mainly because of payers, but also hours and job quality). Basically, if it's a saturated area (what area is not or won't be overrun with DPMs soon???), I think it risks losing PCPs to make them think about what insurance you take or what stuff you want refers for. They might choose another who they can just send all foot path to without thinking. Jmo.

That is the cool thing about podiatry... "plenty of patients everywhere, can make it whatever you want, can sub-specialize, family-friendly, growing elderly population, save lives midnight surgery, everyone gets a bigtime surgery residency." What did I forget? "Plenty of schools to choose from!"

 

[DMEpod]

I'm w/ Feli in terms of take everything you can in PP. I'll take a nail care refer as it is a new pt visit and if all they want is a nail trimming I'll do it 1st time and send to the local medical nail salon. Ingrowns are probably my favorite thing to get as they are quick, I can get them in same week if not same day and the reimbursement is great. MSK pathology are obviously more coveted esp w/ good private payors but no need to pigeonhole a PP if you can handle everything. Where I'm at, ortho has a huge presence with a steady anti podiatry mindset and the fractures are not steady but if I just wanted to focus on those types of things my income would probably be cut in half. At the end of the day in PP a visit is a visit and you can always refer out afterwards.

 

[Pronation]

I'm w/ Feli in terms of take everything you can in PP. I'll take a nail care refer as it is a new pt visit and if all they want is a nail trimming I'll do it 1st time and send to the local medical nail salon. Ingrowns are probably my favorite thing to get as they are quick, I can get them in same week if not same day and the reimbursement is great. MSK pathology are obviously more coveted esp w/ good private payors but no need to pigeonhole a PP if you can handle everything. Where I'm at, ortho has a huge presence with a steady anti podiatry mindset and the fractures are not steady but if I just wanted to focus on those types of things my income would probably be cut in half. At the end of the day in PP a visit is a visit and you can always refer out afterwards.

 

[Hybrocure]

RIP the guy in the meme just died irl

 

[Weirdy]

RIP the guy in the meme just died irl

Saw a video on him. Was actually a pioneer in agricultural sciences. He did research on and created alternative tilling methods to retain soil nutrients.

 

[Hybrocure]

I'm w/ Feli in terms of take everything you can in PP. I'll take a nail care refer as it is a new pt visit and if all they want is a nail trimming I'll do it 1st time and send to the local medical nail salon. Ingrowns are probably my favorite thing to get as they are quick, I can get them in same week if not same day and the reimbursement is great. MSK pathology are obviously more coveted esp w/ good private payors but no need to pigeonhole a PP if you can handle everything. Where I'm at, ortho has a huge presence with a steady anti podiatry mindset and the fractures are not steady but if I just wanted to focus on those types of things my income would probably be cut in half. At the end of the day in PP a visit is a visit and you can always refer out afterwards.

The key with RFC is calluses. Just nails sucks. But nails plus calluses is great $. Now what can technically pass for a “callus” is what separates the docs making big money off routine care vs those that complain it doesn’t pay. Then there’s of course finding new E and Ms during routine visits, new X-rays for new problems. Etc.

Seeing just routine can be lucrative if done right but theres still a way to do it and not be fraudulent about it as long as you document well and don’t lie.

Almost everyone who comes in for routine has multiple other foot problems that can be brought to their attention. Tinea, hammertoes, arthritis. Nonpalp pulses with symptoms? PAD? You can do an arterial work up. Things like that.

 

[Pronation]

The key with RFC is calluses. Just nails sucks. But nails plus calluses is great $. Now what can technically pass for a “callus” is what separates the docs making big money off routine care vs those that complain it doesn’t pay. Then there’s of course finding new E and Ms during routine visits, new X-rays for new problems. Etc.

Seeing just routine can be lucrative if done right but theres still a way to do it and not be fraudulent about it as long as you document well and don’t lie.

Ah yes, the very slightly thickened skin that the TFP shaves one micron off and calls a callus debridement.

 

[BubbaWub]

Ah yes, the very slightly thickened skin that the TFP shaves one micron off and calls a callus debridement.

Sir, this is how I make my living. Please do not ridicule me. Thank you

 

[DMEpod]

That is the business of medicine TBF. Say what you will but if you ever look at what the hospitals bill insurance companies for any kind of inpt visit, it's pretty extreme. Under billing is not a great way to run a business, so knowing what you are doing in that realm and being able to properly document it goes a long way to getting that cabin in Maine.

 

[Hybrocure]

Ah yes, the very slightly thickened skin that the TFP shaves one micron off and calls a callus debridement.

 

[Hybrocure]

That is the business of medicine TBF. Say what you will but if you ever look at what the hospitals bill insurance companies for any kind of inpt visit, it's pretty extreme. Under billing is not a great way to run a business, so knowing what you are doing in that realm and being able to properly document it goes a long way to getting that cabin in Maine.

For real. Hospital employed podiatrists like to bash how PP bills in clinic all while their organization/employer/hospital is by far the worst offender of them all when it comes to insane billing for high amounts.

Anything that TFPs are doing in clinic is nothing compared to the robbery that the hospital wound center is doing down the street with hundreds of thousands (let’s be honest - millions) of dollars with unnecessary hyperbaric oxygen, grafts, etc.

Gotta do what you gotta do to live in the suburb of Bistin.

 

[Adam Smasher]

Ah yes, the very slightly thickened skin that the TFP shaves one micron off and calls a callus debridement.

You've heard of the art of medicine right? This is the art of podiatry. At what point has the stratum corneum risen to the level to be diagnosed L84? At what point does it require shaving/paring? How much do you have to shave/pare before you can say a 11055 has taken place? Does a little scratch suffice or would that require a -53 modifier? If a large callus covers both the second and third met heads can you bill a 11056 for shaving calluses at two separate sites?

Yes I feel sleazy even wondering these questions, but who here among us can't use an extra $70.

 

[Pronation]

That is the business of medicine TBF. Say what you will but if you ever look at what the hospitals bill insurance companies for any kind of inpt visit, it's pretty extreme. Under billing is not a great way to run a business, so knowing what you are doing in that realm and being able to properly document it goes a long way to getting that cabin in Maine.

Some see it as under billing, some see it as fraud.

 

[DYK343]

Now what can technically pass for a “callus” is what separates the docs making big money off routine care vs those that complain it doesn’t pay.

To add to above my declining of nail referrals is largely because I am hospital employed on wRVU.

It pays garbage callus or not when on wRVU where PP its around $100 per prior discussion.

I would say 80% of my visits are 99203, 99204, or 99024 for post op. Its a wRVU machine. But I am hospital employed so very different from PP

 

[DYK343]

11056 = 0.5wRVU
11721 = 0.51 wRVU

99203 = 1.6 wRVU
99204 = 2.6 wRVU

It just makes more sense to be non nail/callus care when on wRVU unless "fishing" for something else to add on to get a 99213 with it (and actually trimming a callus as described above).

99203s/99204s generate more injections/surgical procedures which increases the actual worth.

- -

PP though I would probably be tooting a different horn - especially because I get 100% wRVU for each surgical procedure performed unlike PP getting 50% reduction for subsequent surgical procedures performed. wRVU pays a LOT more than PP for surgery. Nothing I like more than a forefoot slam.

 

[Hybrocure]

11056 = 0.5wRVU
11721 = 0.51 wRVU

99203 = 1.6 wRVU
99204 = 2.6 wRVU

It just makes more sense to be non nail/callus care when on wRVU unless "fishing" for something else to add on to get a 99213 with it (and actually trimming a callus as described above).

99203s/99204s generate more injections/surgical procedures which increases the actual worth.

- -

PP though I would probably be tooting a different horn - especially because I get 100% wRVU for each surgical procedure performed unlike PP getting 50% reduction for subsequent surgical procedures performed. wRVU pays a LOT more than PP for surgery. Nothing I like more than a forefoot slam.

Yeah that is crazy good. There’s just no comparison between that system and PP when it comes to surgery. I have very little incentive to operate in comparison.

How do injections reimburse RVU wise? Because in PP I can bill like $100 for an injection. But I can’t bill an E and M with it unless it’s a new problem. So at the end of the day I make more from an office visit than a 2nd or 3rd injection for an existing problem

 

[wakaflocka88]

11056 = 0.5wRVU
11721 = 0.51 wRVU

99203 = 1.6 wRVU
99204 = 2.6 wRVU

It just makes more sense to be non nail/callus care when on wRVU unless "fishing" for something else to add on to get a 99213 with it (and actually trimming a callus as described above).

99203s/99204s generate more injections/surgical procedures which increases the actual worth.

- -

PP though I would probably be tooting a different horn - especially because I get 100% wRVU for each surgical procedure performed unlike PP getting 50% reduction for subsequent surgical procedures performed. wRVU pays a LOT more than PP for surgery. Nothing I like more than a forefoot slam.

For certain Medicare plans for my group, the billers actually have to apply a 51 modifier to additional procedures which is dumb, even if I designate stuff with a 59 modifier - it doesn’t matter. Makes a FF slam or flatfoot worth less RVU wise. I was confused because the gastroc release, syndesmosis repair, hammertoes etc was getting reduced wRVUs but accoridng to them it only applies to select contracted plans with the group

 

[wakaflocka88]

Yeah that is crazy good. There’s just no comparison between that system and PP when it comes to surgery. I have very little incentive to operate in comparison.

How do injections reimburse RVU wise? Because in PP I can bill like $100 for an injection. But I can’t bill an E and M with it unless it’s a new problem. So at the end of the day I make more from an office visit than a 2nd or 3rd injection for an existing problem

Injections aren’t worth much either since majority of our codes are 20550/20600 versus large joint injection codes for knee hip shoulder.

Majority of my patients get an injection on first visit, I have no problem billing 99203/99204 with 25 modifier. Our billers tried wiping out the E&M codes attached to any 25 modifier because of insurance issues but we stood our ground and they’re going back through all the claims and changing it back to how we coded it. About $400,000 was missing in charges for our department because of this

 

[DYK343]

Yeah that is crazy good. There’s just no comparison between that system and PP when it comes to surgery. I have very little incentive to operate in comparison.

How do injections reimburse RVU wise? Because in PP I can bill like $100 for an injection. But I can’t bill an E and M with it unless it’s a new problem. So at the end of the day I make more from an office visit than a 2nd or 3rd injection for an existing problem

Really not well to be honest.
Plantar fascial 0.70 wRVU
medium joint 0.68

I am reimbursed at about $51 a wRVU

I fight my billers too. Sometimes they only let me bill the injection but I called BS. If I spend 10 minutes talking about conservative care for p fasciitis and then at the end they request a cortisone injection I just went from a 99203 at 1.6 wRVU down to 0.7wRVU because they requested an invasive procedure.

So far I have won this battle with my billers and I am getting the 99203 + 20550.

For certain Medicare plans for my group, the billers actually have to apply a 51 modifier to additional procedures which is dumb, even if I designate stuff with a 59 modifier - it doesn’t matter. Makes a FF slam or flatfoot worth less RVU wise. I was confused because the gastroc release, syndesmosis repair, hammertoes etc was getting reduced wRVUs but accoridng to them it only applies to select contracted plans with the group

I havent had that issue. Thats a bummer.

 

[dtrack22]

How do injections reimburse RVU wise?

Crap

0.66 to 0.75 depending on joint/tendon/ligament (20550, 20551, 20600, 20605). Joint injections are the lower numbers.

I still bill e/ms with most injections, even follow ups since I make almost everyone PRN and so they are coming back with a chronic problem that has exacerbation of symptoms and I’m usually tweaking something else. Planned/scheduled neuroma injections are probably one of the few CPT only code visits

 

[Hybrocure]

I fight my billers too. Sometimes they only let me bill the injection but I called BS. If I spend 10 minutes talking about conservative care for p fasciitis and then at the end they request a cortisone injection I just went from a 99203 at 1.6 wRVU down to 0.7wRVU because they requested an invasive procedure.

This is the problem I run into all the time. People will say oh injections are good money etc and then this happens and I’m like..no it isn’t.

 

[SouthPod7]

So far I have won this battle with my billers and I am getting the 99203 + 20550.

I usually bill the procedure + E&M if it's a new patient. If existing patient then I bill the 9921X if I don't do a procedure, or the procedure code if I do a procedure. But I don't bill a procedure code plus existing E&M code.

 

[Hybrocure]

I usually bill the procedure + E&M if it's a new patient. If existing patient then I bill the 9921X if I don't do a procedure, or the procedure code if I do a procedure. But I don't bill a procedure code plus existing E&M code.

What if you do the procedure but it pays less than the 9921x? Can you just document the procedure but just bill the office visit instead? Because an injection pays less than a 99213.

I bill as you do by the way - but it just doesn’t make sense to me if I see a patient for a follow up for PF, and I do an injection, I can only bill the crappy injection code when I could technically just have made more money not giving them the shot but telling them to stretch for another month. Especially when you carry a risk for injections (infection, pain, tendon rupture, calls etc). Why the heck does it pay less than an office visit?

 

[Pronation]

I usually bill the procedure + E&M if it's a new patient. If existing patient then I bill the 9921X if I don't do a procedure, or the procedure code if I do a procedure. But I don't bill a procedure code plus existing E&M code.

I never only bill a procedure code. Usually I will be like “sir, I noticed that your toenails are a bit long” or “it seems that your shoes are quite worn out” and as soon as they agree I will enter ICD-10 code R46. 1 for Bizarre personal appearance, then I go ahead and pop in the level 3 visit along with the procedure.

 

[Shiyuan]

11056 = 0.5wRVU
11721 = 0.51 wRVU

99203 = 1.6 wRVU
99204 = 2.6 wRVU

It just makes more sense to be non nail/callus care when on wRVU unless "fishing" for something else to add on to get a 99213 with it (and actually trimming a callus as described above).

99203s/99204s generate more injections/surgical procedures which increases the actual worth.

- -

PP though I would probably be tooting a different horn - especially because I get 100% wRVU for each surgical procedure performed unlike PP getting 50% reduction for subsequent surgical procedures performed. wRVU pays a LOT more than PP for surgery. Nothing I like more than a forefoot slam.

As a hospital DPM, how did you go about turning away diabetic nail care? These are the patients that may eventually get an ulcer/amp, after all.

I guess another way to ask... If you get a patient with a infected DFU and you heal it, do you “keep” the patient once the ulcer has healed? Since at that point all they will see you for is routine nail care anyway?

 

[DYK343]

As a hospital DPM, how did you go about turning away diabetic nail care? These are the patients that may eventually get an ulcer/amp, after all.

I guess another way to ask... If you get a patient with a infected DFU and you heal it, do you “keep” the patient once the ulcer has healed? Since at that point all they will see you for is routine nail care anyway?

I work with a private practice local non-op DPM who accepts chronic care referrals.

I treat all wounds in wound center so once discharged from wound center I send them to non op DPM. Works out because this DPM sends me surgical cases.

I explain to the patients that as hospital based I only manage acute care. I tell them I cant fill my schedule with routine follow ups because I need to keep those slots for emergencies. Thats the best way I have found to politely decline the care.

 

[newfeet]

As a hospital DPM, how did you go about turning away diabetic nail care? These are the patients that may eventually get an ulcer/amp, after all.

I guess another way to ask... If you get a patient with an infected DFU and you heal it, do you “keep” the patient once the ulcer has healed? Since at that point all they will see you for is routine nail care anyway?

I don’t turn away anything but I’m non surgical and I work for a state university. When I was a surgical hospital employee I took everything too.

 

[dtrack22]

As a hospital DPM, how did you go about turning away diabetic nail care?

You just don’t schedule it. Or see them as new patients or with acute problems and then refer to someone else in town for the nails and calluses part.

Our wound care clinic has nurses that do it so all new patients filter through me but then get referred to the wound clinic. Obviously nurses can’t bill the CPT codes but the $75 facility fee covers their services. I do have a few patients who I still do RFC for, but it’s like 2-3 per day at the most.

I’m booked out several weeks and that’s without adding any recurrent RFC patients for the past 8-9 months. If I had accepted and kept all of those referrals (I deny all VA referrals now too just because they are a pain from a referral and treatment auth standpoint), I would be booked out over a month by now.

 

[DYK343]

You just don’t schedule it.

When they call to schedule my scheduling staff uses the term "Yes but Dr DYK only sees certain diagnosis and unfortunately we are not able to schedule this diagnosis. I am very sorry"

 

[Feli]

What if you do the procedure but it pays less than the 9921x? Can you just document the procedure but just bill the office visit instead? Because an injection pays less than a 99213.

I bill as you do by the way - but it just doesn’t make sense to me if I see a patient for a follow up for PF, and I do an injection, I can only bill the crappy injection code when I could technically just have made more money not giving them the shot but telling them to stretch for another month. Especially when you carry a risk for injections (infection, pain, tendon rupture, calls etc). Why the heck does it pay less than an office visit?

You guys are leaving a ton of $ on the table.

Bill for both the E&M and the procedure(s) if you do both... just do different dx codes. If insurance rejects the E&M or the procedures, appeal it. If they reject it a lot, bill on time and up your E&Ms... or just drop those crusty payers. If there are not different applicable dx codes for the E&M then you're not thinking hard enough you can just bill the proc code(s) only.

Heel pain f/u = 99213 for M76.821, M76.822, L85.3 and 20550-RT for M72.2, M79.671 and 20550-LT for M72.2, M79.672 and J0702-RT and J0702-LT (same icd codes as 20550s) and arch supports OTC or night splint or whatever applies (and 99214 if you do PT Rx or order MRI, etc)

Ingrown f/u (slant back didn't work or pt had scheduled it and returns) = 99213 for M20.11, L03.031 and 11750-T5 for L60.0, M79.674

Verruca f/u = 99213 for L85.3, M77.41, M77.42 and 17110 for B07.0, M79.671, M79.672

Ankle sprain f/u = 99213 for M79.671, S93.491D, R60.0 and L1902-RT for same (99214 if you Rx PT and order MRI or something)

 

[SouthPod7]

What if you do the procedure but it pays less than the 9921x? Can you just document the procedure but just bill the office visit instead? Because an injection pays less than a 99213.

Good question, I would probably still bill just the procedure code myself. I think it's more defensible. Totally agree how sad for an office procedure to pay less than a 9921x.

I never only bill a procedure code. Usually I will be like “sir, I noticed that your toenails are a bit long” or “it seems that your shoes are quite worn out” and as soon as they agree I will enter ICD-10 code R46. 1 for Bizarre personal appearance, then I go ahead and pop in the level 3 visit along with the procedure.

Okay I thought you were just being a smartass but I looked up the code and yup there it is

 

[Hybrocure]

You guys are leaving a ton of $ on the table.

Bill for both the E&M and the procedure(s) if you do both... just do different dx codes. If insurance rejects the E&M or the procedures, appeal it. If they reject it a lot, bill on time and up your E&Ms... or just drop those crusty payers. If there are not different applicable dx codes for the E&M then you're not thinking hard enough you can just bill the proc code(s) only.

Heel pain f/u = 99213 for M76.821, M76.822, L85.3 and 20550-RT for M72.2, M79.671 and 20550-LT for M72.2, M79.672 and J0702-RT and J0702-LT (same icd codes as 20550s) and arch supports OTC or night splint or whatever applies (and 99214 if you do PT Rx or order MRI, etc)

Ingrown f/u (slant back didn't work or pt had scheduled it and returns) = 99213 for M20.11, L03.031 and 11750-T5 for L60.0, M79.674

Verruca f/u = 99213 for L85.3, M77.41, M77.42 and 17110 for B07.0, M79.671, M79.672

Ankle sprain f/u = 99213 for M79.671, S93.491D, R60.0 and L1902-RT for same (99214 if you Rx PT and order MRI or something)

Great information thank you. I felt I was missing out on something with the way I was billing. I saved this info!

 

[JustAPedicurist]

stop talking about all this billing mumbo jumbo.. the farmer meme died... that's horrible

 

[Adam Smasher]

You guys are leaving a ton of $ on the table.

Bill for both the E&M and the procedure(s) if you do both... just do different dx codes. If insurance rejects the E&M or the procedures, appeal it. If they reject it a lot, bill on time and up your E&Ms... or just drop those crusty payers. If there are not different applicable dx codes for the E&M then you're not thinking hard enough you can just bill the proc code(s) only.

Heel pain f/u = 99213 for M76.821, M76.822, L85.3 and 20550-RT for M72.2, M79.671 and 20550-LT for M72.2, M79.672 and J0702-RT and J0702-LT (same icd codes as 20550s) and arch supports OTC or night splint or whatever applies (and 99214 if you do PT Rx or order MRI, etc)

Ingrown f/u (slant back didn't work or pt had scheduled it and returns) = 99213 for M20.11, L03.031 and 11750-T5 for L60.0, M79.674

Verruca f/u = 99213 for L85.3, M77.41, M77.42 and 17110 for B07.0, M79.671, M79.672

Ankle sprain f/u = 99213 for M79.671, S93.491D, R60.0 and L1902-RT for same (99214 if you Rx PT and order MRI or something)

This is generally good advice

But -25 mods are heavily audited (according to Michael Warshaw) so make sure your documentation of medical decision making is clearly spelled out. Especially if you bill a 99213-25 for wart treatment #3 or 4.

 

[air bud]

You guys are leaving a ton of $ on the table.

Bill for both the E&M and the procedure(s) if you do both... just do different dx codes. If insurance rejects the E&M or the procedures, appeal it. If they reject it a lot, bill on time and up your E&Ms... or just drop those crusty payers. If there are not different applicable dx codes for the E&M then you're not thinking hard enough you can just bill the proc code(s) only.

Heel pain f/u = 99213 for M76.821, M76.822, L85.3 and 20550-RT for M72.2, M79.671 and 20550-LT for M72.2, M79.672 and J0702-RT and J0702-LT (same icd codes as 20550s) and arch supports OTC or night splint or whatever applies (and 99214 if you do PT Rx or order MRI, etc)

Ingrown f/u (slant back didn't work or pt had scheduled it and returns) = 99213 for M20.11, L03.031 and 11750-T5 for L60.0, M79.674

Verruca f/u = 99213 for L85.3, M77.41, M77.42 and 17110 for B07.0, M79.671, M79.672

Ankle sprain f/u = 99213 for M79.671, S93.491D, R60.0 and L1902-RT for same (99214 if you Rx PT and order MRI or something)

Yeah an MRI is it is not equivalent to RX for risk management. An MRI is no different from an X-ray.

 

[Hybrocure]

Yeah an MRI is it is not equivalent to RX for risk management. An MRI is no different from an X-ray.

Actually it can allow you to see the soft tissue structures better

 

[dtrack22]

Yeah an MRI is it is not equivalent to RX for risk management. An MRI is no different from an X-ray.

Yeah there are some screwy things in that post (e/m for pt tendonitis and xerosis for a f/u heel pain patient that’s getting a PF injection). But overall the point is a good one. Bill e/m whenever you can justify it because you are usually performing some e/m services and injections pay crap.

 

[Pronation]

Actually it can allow you to see the soft tissue structures better

I never waste my time looking. That’s What the radiologist is for.

 

[Shiyuan]

I never waste my time looking. That’s What the radiologist is for.

Total TFP move there 🥸

 

[Hybrocure]

Total TFP move there 🥸

Honestly if you know a good MSK fellowship trained radiologist and have a good relationship with them they are worth their weight in gold. I know when I get reads done by my guy they will be very good. I am wary when the general radiologist or someone not MSK does the read.

My guy will text or call me what he sees and goes over it, correlate clinically with what I tell him etc. If he’s on vacation I’ll wait til he gets back to have the read done. In residency I had the opportunity to rotate with the MSK radiologists and they REALLY know their stuff.

Take a peek and read about the MSK radiologists on SDN sometime. They’re the ones doing reads for professional athlete injuries. It’s extremely competitive.