Nail care in podiatry

[PODDPM19]

Hi all! long time practitioner first time poster!

Not to beat a dead horse on this threat, but nail care in pod is always an issue. Figured id take a shot at putting some input in.

The way I see it is this...if all you see on a patient is "nails", all you will find on a patient is "nails". And you will be limited by those nails in your exam and treatment.

Routine care is what it is. What I've seen time and time again in my practice is pathology that a patient doesn't always bring up. Why? becasue oh i just come for my nails. They think that's all you do. They'll see the real doc for the other stuff.

For example, they come in for a callus, turns out the etiology of that callus is a hammertoe. The etiology of that hammer toe is a flat foot etc etc. If all youre doing is trimming that callus and sending them home, billing out a callus code, thats fine. But, to provide deeper context, in the realm we live in today of DPM vs MD/DO etc, we need to treat problematic patholgy and offer solutions. We need to find the pathology and bring it up to them.

Why not talk to them about a crest pad, (obviously on the conservative end), or even hammertoe correction, or orthotics etc? Can throw in XR for further eval and you're now at a full blown EM.

You see, even if they don't want the other services right away, you've planted the seed to grow your practice into more than a nail mill. Plenty of these older folk can benefit greatly from tenotomies, padding or inserts. And its now a service where a more complete H/P was done instead of just chip and clip. Folks still struggle to understand what podiatry does, and its a stigma that needs to be broken bny us practioners offering more than just chip and clip.

Other things can be found as well. DTI's overlying bony prominences, tinea pedis if you truly take the time to examine. These are all additional diagnosises that may be worked up, and treated.

Now, the world may be different in a hospital setting, or even a multi doc setting. But this has been my experience in private practice. Im proud to say we've been able to offer a variety of different treatments. We get our fair share of patients coming in and seeking certain treatments or options, but theres something to say about the routine care patients that have pathology waiting to be treated; and these are treatments theyll do well with and appreciate you for. They just don't know what you can do.

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[Adam Smasher]

@PODDPM19 has generally good advice. And I love my 25 mods. However, I still dislike engaging in "podiatric mission creep." It stinks of being a solution looking for a problem.

 

[air bud]

@PODDPM19 has generally good advice. And I love my 25 mods. However, I still dislike engaging in "podiatric mission creep." It stinks of being a solution looking for a problem.

lobster nails something something lobster

 

[Adam Smasher]

lobster nails something something lobster

Don't be an ass. I'm not the one who has characterized podiatry as a "make your own luck" venture. Hunting out add-on services during a nail trim visit is doing just that, just in increments one patient at a time.

PCPs do NOT care that you offer these add-on screenings, just that the patients' nails are trimmed. And maybe that they're getting a pair of magic shoes in the process.

 

[NatCh]

@PODDPM19 has generally good advice. And I love my 25 mods. However, I still dislike engaging in "podiatric mission creep." It stinks of being a solution looking for a problem.

It becomes a problem when you start seeing pathology that’s not really there.

Edit: not implying that it’s what anyone in this thread is doing

 

[icebreaker32]

There is nothing inherently wrong with treating these type patients. It is not about ego and it all comes down to the average collections per patient you need. If you are making enough by being thorough and not scammy then it it might be working for you. Some believe you treat these patients well and you get more referrals from PCPs and will see the rest of grandma’s family. Most unfortunately find out that you only get lots more nail referrals as a result. Some actually court these type of patients by using whirlpools and applying lotions in large metros due to saturation, but this is becoming less common.

The common trap is that these type patients can fill some open slots on your schedule even though they might not generate the income that is necessary per appointment to make sense and are more of a break even type situation. These patients are usually appreciative and it seems to make sense in the short term to have a filled patient slot rather than an empty slot to help towards overhead. The key is to remember is that you are not just filling an opening on your schedule one time with these patients, They often come back every couple of months for years and years and years. Some podiatrists will claim the opposite, but these patients often miss appointments for minor weather events. If you have only a couple on your schedule this is not a big deal, but as your schedule gradually fills with more and more and more of these patients it is a problem when many on your schedule that are not necessary profitable not only fail to show up but are rescheduled which completely fills your schedule for the following couple of weeks. More profitable patients will end up at other offices as a result.

Unless one is pushing lots of orthotics, potions, lotions and laser treatments or doing way to many vascular testings and diagnostic ultrasounds/sudomotor testing etc it is often tough to come out ahead. If you accept HMO Medicare you are likely not even breaking but losing money. You need to take a look at how little the patients reimburse, how many are rejected and consider the time your billers spend if you do it in house. Also consider how much time your staff spends on checking the last date of service and rescheduling from minor weather events. How many of these patients take longer to get in and out the treatment rooms and spend lots of time chatting with staff when they arrive and before they leave? Sadly this all comes off wrong the way I have phrased it as these patients are often very friendly and appreciative and the work can be rewarding. Sadly in private practice it rarely makes sense to be performing a service you are breaking even or losing money on.

Again if it works for you, then great and keep doing it. Many of these patients really do need someone to treat them. In many areas a nurse at the local senior center can see most of these patients for $10 to $20 dollars. They can always come back for a true ingrown nail and you can keep the diabetics that are really at risk. You can see them as new patients, treat the other pathology that exists and then stop seeing them when it is only nails.

You need treatment protocols that are ethical and reimburse enough. If we were only treating plantar fasciitis with OTC NSAIDS, OTC arch supports and stretching we would not be making enough for that either. More and more are realizing they just can't ethically make the every 61 days nail care type patients work for them....unless they have an associate.

 

[PODDPM19]

It becomes a problem when you start seeing pathology that’s not really there.

Edit: not implying that it’s what anyone in this thread is doing

Well, the problem is actually there. How can you miss a bunion that clearly has an irritated "bump"? patient is non surgical, skin is thin, friable etc. Is if out of line to treat this with a pad? Isn't the diagnosis hallux valgus ? Or are we still stuck at onychomycosis? Like I said, if all one is seeing is nails, then we're missing the picture here.

The only problem RFC patients are just those lazy ones with long nails and just dont want to cut them. Almost all others that I've seen, have benefited greatly by additional treatments and recommendations.

 

[PODDPM19]

There is nothing inherently wrong with treating these type patients. It is not about ego and it all comes down to the average collections per patient you need. If you are making enough by being thorough and not scammy then it it might be working for you. Some believe you treat these patients well and you get more referrals from PCPs and will see the rest of grandma’s family. Most unfortunately find out that you only get lots more nail referrals as a result. Some actually court these type of patients by using whirlpools and applying lotions in large metros due to saturation, but this is becoming less common.

The common trap is that these type patients can fill some open slots on your schedule even though they might not generate the income that is necessary per appointment to make sense and are more of a break even type situation. These patients are usually appreciative and it seems to make sense in the short term to have a filled patient slot rather than an empty slot to help towards overhead. The key is to remember is that you are not just filling an opening on your schedule one time with these patients, They often come back every couple of months for years and years and years. Some podiatrists will claim the opposite, but these patients often miss appointments for minor weather events. If you have only a couple on your schedule this is not a big deal, but as your schedule gradually fills with more and more and more of these patients it is a problem when many on your schedule that are not necessary profitable not only fail to show up but are rescheduled which completely fills your schedule for the following couple of weeks. More profitable patients will end up at other offices as a result.

Unless one is pushing lots of orthotics, potions, lotions and laser treatments or doing way to many vascular testings and diagnostic ultrasounds/sudomotor testing etc it is often tough to come out ahead. If you accept HMO Medicare you are likely not even breaking but losing money. You need to take a look at how little the patients reimburse, how many are rejected and consider the time your billers spend if you do it in house. Also consider how much time your staff spends on checking the last date of service and rescheduling from minor weather events. How many of these patients take longer to get in and out the treatment rooms and spend lots of time chatting with staff when they arrive and before they leave? Sadly this all comes off wrong the way I have phrased it as these patients are often very friendly and appreciative and the work can be rewarding. Sadly in private practice it rarely makes sense to be performing a service you are breaking even or losing money on.

Again if it works for you, then great and keep doing it. Many of these patients really do need someone to treat them. In many areas a nurse at the local senior center can see most of these patients for $10 to $20 dollars. They can always come back for a true ingrown nail and you can keep the diabetics that are really at risk. You can see them as new patients, treat the other pathology that exists and then stop seeing them when it is only nails.

You need treatment protocols that are ethical and reimburse enough. If we were only treating plantar fasciitis with OTC NSAIDS, OTC arch supports and stretching we would not be making enough for that either. More and more are realizing they just can't ethically make the every 61 days nail care type patients work for them....unless they have an associate.

This is a great assessment. I agree that these patients can add tons of value, not just financially on being able to justify EM's but as a doctor, you are providing additional value to their lives.

I agree that one cannot seem like a scam artist (etc, making recs for super expensive modalities that's just for profit). In my practice, some pads/splints, etc are just given to patients free of charge. These items don't cost a ton of money to obtain, and its now documented that a beneficial treatment has been provided. Again, no one is ripping off the patient in this process.

Treatment protocols that reimburse enough here are the obvious 99212/213 codes. If a patient wants CFO's then we have the L3000 codes etc. Also happy patients will of course spread the word and send more.

 

[icebreaker32]

Well, the problem is actually there. How can you miss a bunion that clearly has an irritated "bump"? patient is non surgical, skin is thin, friable etc. Is if out of line to treat this with a pad? Isn't the diagnosis hallux valgus ? Or are we still stuck at onychomycosis? Like I said, if all one is seeing is nails, then we're missing the picture here.

The only problem RFC patients are just those lazy ones with long nails and just dont want to cut them. Almost all others that I've seen, have benefited greatly by additional treatments and recommendations.

The problem is once you have treated the other pathology do you continue seeing them every 61 days for the rest of their life?

Too many modifiers with nails trigger audits also. I am not saying you are not documenting appropriately, but it can be a real hassle.

Seems like you are doing it ethically and it is working for you....at least for now. There might eventually come a time when you have to find a way to limit it in your practice.

 

[PODDPM19]

The problem is once you have treated the other pathology do you continue seeing them every 61 days for the rest of their life?

Too many modifiers with nails trigger audits also. I am not saying you are not documenting appropriately, but it can be a real hassle.

Seems like you are doing it ethically and it is working for you....at least for now. There might eventually come a time when you have to find a way to limit it in your practice.

That a good point to make as well. Sometimes if other issues take up much more time in the actual encounter, I wont even bother with the 11721. This mostly goes for if a patient is getting orthotics, maybe discussing preop/xray etc, since I dont like throwing too many codes onto a billing sheet.

But to answer your question, do we keep seeing them every 61 days? I do try and limit this, some patients will still schedule regardless when they check out because thats how "the other pod did it"

In cases like that, eval again and see what's needed. Curious actually how others handle those scenrios. I'm always open to learning

 

[air bud]

Whispers......not medically necessary

 

[ExperiencedDPM]

It becomes a problem when you start seeing pathology that’s not really there.

Edit: not implying that it’s what anyone in this thread is doing

You obviously need a pair of special “find the pathology” glasses. You can purchase from our website. If you act now you get a free tube of Biofreeze, coupon for a free nail laser treatment and a bottle of magic cure neuropathy pills. And the first 20 callers, will get an autographed copy of the podiatric pioneer Dr. Roth’s autobiography “I HAVE Found the Cure for All Nail Pathology”. If you don’t win it, you can find it in the fiction section at Barnes and Noble.

 

[NatCh]

Well, the problem is actually there.

unless it’s genuinely not

 

[air bud]

unless it’s genuinely not

What if there genuinely is a problem you find when the original presenting problem is not a medically necessary problem?

 

[NatCh]

What if there genuinely is a problem you find when the original presenting problem is not a medically necessary problem?

Then address it.

 

[air bud]

Then address it.

Not following this logic

 

[entrepr23]

Well here we go again!

Glad this thread actualyl popped up when it did.

I've been in private practice for about 2 years now. Bought it from the old owner who was running it 35+ years. We closed on the deal back last summer and he recently fully departed.

Im not going to bore you all with full details, but unfortunately the nail fiasco is real and it exists.

While I was an associate , I did all the MSK stuff here, and surgery stuff. Did in office procedures too etc. He handled the "nails". Now that Im getting into the weeds of this, I've been skeptical about the billing and Im trying to correct this issue as I dont want to continue to horrid idea of running a nail farm. This thread has been very helpful with this.

The billing, as you would expect from an older pod, is office visits.

We've been setting up new protocols (such as flyers and signs in the waiting rooms DESCRIBING what needs to be seen on exam etc for RFC to qualify for coverage). We're filtering people out sometimes in the waiting rooms, or sometimes if they sneak by, I'd do an exam, courtesy cut and let them know what to expect next time . I always tell them of course, if a real medical problem exists, the RFC rules don't apply. I dont want to give patients the idea that we just dont take "insurance", since that isnt the case.

1. Billing wise, Im still struggling with the codes. Obviously DM is easy, as class findings are more often than not, satisfied. But I have other patients with CKD (various stages etc), which are sometimes an issue. And for PVD, this to me seems like a VERY subjective diagnosis, and I'm finding myself as the primary doc that is diagnosing the problem. Is that pretty standard for an I73.89? or do the need to have a PCP or vasc doc diagnosis them with this? I a

2. Also, for new patients, are you guys recommending 99203/11720/1/callus codes initally, then all procedure codes correct?

3. We're doing ok getting PCP info. Im lucky Im next to a major hospital where Im on staff and have access to EPIC where I can obtain some missing info if needed for the claim forms.

4. Also, when exactly is a RFC ABN needed??? We do them for medicare patients for orthotics and that one i've been doing since my associate days, but the nail one I have no idea.

Any input is much appreciated. And please don't mention what might be the simpliest answer which is "don't do nail care". I really cant do that. The owner recently departed and I cannot alienate patients because of hassels. Alientate due to non coverage sure, but not for the extra paperwork . I really do like this practice its just unfortunate I was not exposed to the RFC side of things. Nonetheless, no excuse. Time to rectify and move forwards.

 

[Adam Smasher]

1. Billing wise, Im still struggling with the codes. Obviously DM is easy, as class findings are more often than not, satisfied. But I have other patients with CKD (various stages etc), which are sometimes an issue. And for PVD, this to me seems like a VERY subjective diagnosis, and I'm finding myself as the primary doc that is diagnosing the problem. Is that pretty standard for an I73.89? or do the need to have a PCP or vasc doc diagnosis them with this? I a

CKD may or may not be on your medicare LCD, so check. for PAD, I use I70.91 but that's just me. And there is no higher authority to appeal to, you do not need a vascular surgeon's treatment notes, you do not need to perform ABIs. If you diagnose it, it is so. Use this power responsibly.

2. Also, for new patients, are you guys recommending 99203/11720/1/callus codes initally, then all procedure codes correct?

Yes, but I don't always use a level 3, sometimes it's just level 2 e/m on the first visit.

3. We're doing ok getting PCP info. Im lucky Im next to a major hospital where Im on staff and have access to EPIC where I can obtain some missing info if needed for the claim forms.

Never let patients leave without asking them their date last seen. If they ask why you need to know, tell them Medicare makes you ask them. It doesn't need to be the precise date, it can just be "January of 2024" which is acceptable (but check your LCD).

4. Also, when exactly is a RFC ABN needed??? We do them for medicare patients for orthotics and that one i've been doing since my associate days, but the nail one I have no idea.

whenever you think it won't be covered. Sensate, intact pulses, but they want you to submit the claim to their insurance. Also if they haven't seen their PCP in over 6 months or if they show up 59 days after their most recent visit and just can't wait any longer.

This is all my opinion, others I'm sure will have other things to offer.

 

[heybrother]

So - my MAs have been taking the PCP date as month/year ie. 6/2023. They say - "the patient doesn't know the exact date".

But when it gets entered into Athena - it gets translated into 6/1/2023 by the biller. The system is capturing/requiring a degree of exactness that exceeds what the MAs in the room are capturing.

Let's say the patient is then seen on 12/6/2024.

I review the billing afterwards - I'm seeing these "6 months and a few days visits" denied. Novitas says the program guidelines weren't met. It isn't happening a lot, but its happening.

My biller argues with me saying "Medicare doesn't care, they round the dates" - that's not my experience. Your mileage may vary.

We were giving patients cards to write down their PCP visit date while they were at the PCPs office but compliance is low.

 

[dtrack22]

And for PVD, this to me seems like a VERY subjective diagnosis, and I'm finding myself as the primary doc that is diagnosing the problem. Is that pretty standard for an I73.89?

There are some subjective components of qualification for RFC, but most of the boxes you must check to satisfy Q8/9 modifiers for your MACs LCD are objective findings. You can certainly make that diagnosis yourself

Also, for new patients, are you guys recommending 99203

Better be documenting time unless you’re actually offering treatment for the systemic disease that qualifies them for RFC.

 

[PeaJay]

So - my MAs have been taking the PCP date as month/year ie. 6/2023. They say - "the patient doesn't know the exact date".

So how does this work?

It is my understanding that the qualifying diagnosis needs to be managed at the listed PCP visit. So if that last visit was actually for a UTI it would not be relevant, but to the patient it was the last PCP visit. Also how do private practice docs deal with diagnosis codes. The PCP may document E11.40 but in my area they need E11.42, so despite having seen the PCP they still don’t qualify because the diagnosis code doesn’t align. If you don’t have the actual PCP note with ICD10 there is no way qualification can be judged.

 

[Adam Smasher]

So if that last visit was actually for a UTI it would not be relevant, but to the patient it was the last PCP visit.

I'm positive this doesn't matter. The date last seen is the date last seen. However, if CKD is the qualifying dx, then you need to know the date they last saw their nephrologist.

The PCP may document E11.40 but in my area they need E11.42, so despite having seen the PCP they still don’t qualify because the diagnosis code doesn’t align. If you don’t have the actual PCP note with ICD10 there is no way qualification can be judged.

You're a licensed [foot] doctor, you're allowed to make your own diagnosis. It doesn't matter if the pcp calls it E11.9 or E11.65 or E11.22, you're still allowed to diagnose the patient with E11.42

 

[dtrack22]

I'm positive this doesn't matter. The date last seen is the date last seen. However, if CKD is the qualifying dx, then you need to know the date they last saw their nephrologist.


You're a licensed [foot] doctor, you're allowed to make your own diagnosis. It doesn't matter if the pcp calls it E11.9 or E11.65 or E11.22, you're still allowed to diagnose the patient with E11.42

Correct. The PCP involvement is essentially just to ensure that they are diabetic and a physician is managing (or trying to manage) the patients metabolic disease. It’s nothing more than a check to prevent DPMs from fraudulently cutting nails because Medicare knows damn well that we will if given the chance 🤣

 

[Feli]

Correct. The PCP involvement is essentially just to ensure that they are diabetic and a physician is managing (or trying to manage) the patients metabolic disease. It’s nothing more than a check to prevent DPMs from fraudulently cutting nails because Medicare knows damn well that we will if given the chance 🤣

100% ... ditto on DM shoes Rx sign-offs.

DPMs fraud/overuse have ruined nearly anything that should be easy, hence the paperwork and runarounds - particularly for MCR.

It's just another sign of how saturated podiatry is.

 

[NatCh]

Not following this logic

I'm saying that some folks in our profession might be inclined to provide unnecessary treatment for diagnoses that the patient doesn't actually have (think fraud and abuse). If they actually have the diagnosis then by all means address it.

 

[air bud]

I'm saying that some folks in our profession might be inclined to provide unnecessary treatment for diagnoses that the patient doesn't actually have (think fraud and abuse). If they actually have the diagnosis then by all means address it.

Was joking. Also I will not allow you to besmirch fellow podiatrists. I hold all fellow DPMs in the highest esteem excuse me I just threw up in my mouth

 

[entrepr23]

CKD may or may not be on your medicare LCD, so check. for PAD, I use I70.91 but that's just me. And there is no higher authority to appeal to, you do not need a vascular surgeon's treatment notes, you do not need to perform ABIs. If you diagnose it, it is so. Use this power responsibly.



Yes, but I don't always use a level 3, sometimes it's just level 2 e/m on the first visit.



Never let patients leave without asking them their date last seen. If they ask why you need to know, tell them Medicare makes you ask them. It doesn't need to be the precise date, it can just be "January of 2024" which is acceptable (but check your LCD).



whenever you think it won't be covered. Sensate, intact pulses, but they want you to submit the claim to their insurance. Also if they haven't seen their PCP in over 6 months or if they show up 59 days after their most recent visit and just can't wait any longer.

This is all my opinion, others I'm sure will have other things to offer.

if pulses are present and patient is sensate, wouldnt that disqualify the patient from RFC services? I was thinking just have everyone that is coming in for RFC services sign an ABN, have the front staff explain it properly. And then during the exam I would tell them yes you fit congratulations or no sorry. Next time this visit cannot be covered and/or billed.
The whole "normal healthy patient, but bill the insurance anyways" is what's confusing a bit

 

[NatCh]

The whole "normal healthy patient, but bill the insurance anyways" is what's confusing a bit

Is it confusing?

 

[HardRoadPaved]

if pulses are present and patient is sensate, wouldnt that disqualify the patient from RFC services?

Absolutely not an automatic disqualification.... if pulses are present for sure they can still get covered.

Q7:
Any non-traumatic amp... can have pulses present and be sensate as that is not part of this criterion. Had a raynauds elderly patient who lost a toe this way

Q9:
Class B - document three trophic skin/nail changes (nails are already one of them)
Class C findings mention nothing about being sensate. They could have radicular pain unrelated to well-controlled diabetes and have numbness and burning in their feet. Or what if they have cold feet in a January visit or edema- swollen legs/feet bc they are on amlodipine.

 

[entrepr23]

Absolutely not an automatic disqualification.... if pulses are present for sure they can still get covered.

Q7:
Any non-traumatic amp... can have pulses present and be sensate as that is not part of this criterion. Had a raynauds elderly patient who lost a toe this way

Q9:
Class B - document three trophic skin/nail changes (nails are already one of them)
Class C findings mention nothing about being sensate. They could have radicular pain unrelated to well-controlled diabetes and have numbness and burning in their feet. Or what if they have cold feet in a January visit or edema- swollen legs/feet bc they are on amlodipine.

ok this makes sense. Thank you for clarifying. I just trying to filter out the ones the previous guy was just coding as "pain in toes/ony".

 

[Hybrocure]

if pulses are present and patient is sensate, wouldnt that disqualify the patient from RFC services? I was thinking just have everyone that is coming in for RFC services sign an ABN, have the front staff explain it properly. And then during the exam I would tell them yes you fit congratulations or no sorry. Next time this visit cannot be covered and/or billed.
The whole "normal healthy patient, but bill the insurance anyways" is what's confusing a bit

I go by the Q8/Q9/Q7 criteria.

 

[entrepr23]

also, on the ABN form itself, are you guys filling in the "estimated cost" box with a fee that you would charge the patient for the care?

 

[HardRoadPaved]

also, on the ABN form itself, are you guys filling in the "estimated cost" box with a fee that you would charge the patient for the care?

You should be using your bill out price. Never had a patient care that they're getting a discount.

 

[entrepr23]

Can someone please explain how to use modifiers properly? Specifically, the 59 and 51 mods

For example:

EM-25 : Dx h valgus
11056 -59
11720 -59

Wound the 59 be needed on every procedure? certain procedures only? what if theres 3 procedures?