Proposes CMS decreased reimbursement for DPMs and E/M codes

[ExperiencedDPM]

We have all heard about and have read about the proposed CMS changes for specialized E\M codes for DPMs with the anticipated lower reimbursement. I was just on another site that loves to bash the profession, and there is an excellent post that raises concerns.

If these proposed changes actually occur, how will that impact DPMs employed by orthopedic groups, multi-specialty groups, etc. It will mean that every E/M visit billed by a DPM will be paid at a lower rate than an MD/DO in the practice. Will these practices begin to utilize nurse practitioners or physician assistants more since their reimbursement does not seem to be impacted?

I know that PAs and NPs can’t perform surgery, but there are some groups who hire non surgical DPMs. These DPMs have cause to worry. If these E/M changes to go through, it will have a significant negative trickle down effect across the board.

Bottom line is “it ain’t lookin’ good”

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[dtrack22]

Big thanks to all the TFPs that do a bunch of level 2 visits and routine foot care. The whole G codes specific to podiatry is entirely their fault. Treat real problems and real pathology and we would be seeing a pay increase instead of a reduction.

Though I'm curious to hear more about the legality of all this. It seems that paying a "physician" (medicare defines us as one wether our allo- and osteopathic friends like it) less money for the exact same work-up/treatment/service is ripe for discrimination law suits. But they are the feds and can probably do whatever they want. And to think some of you want all of us to be insured and employed by them...

 

[Masttt91]

Can someone please explain the following line from the CMS proposal:

"Those specialties that tend to bill lower level E/M visits would benefit the most from the proposed change to single PFS payment rates, while those specialties that tend to bill more higher level E/M visits would see the largest decreases in payment with the change to a single PFS rate. The single payment rate for E/M code levels 2 through 5 would benefit podiatry the most because, due to the nature of most podiatric E/M visits, they tend to bill only level 2 and 3 E/M visits."

They have us listed as getting the largest pay increase from this, at 12%. I don't understand their logic. Isn't this contrary to what everyone else is saying.

 

[bunNfxr]

Can someone please explain the following line from the CMS proposal:

"Those specialties that tend to bill lower level E/M visits would benefit the most from the proposed change to single PFS payment rates, while those specialties that tend to bill more higher level E/M visits would see the largest decreases in payment with the change to a single PFS rate. The single payment rate for E/M code levels 2 through 5 would benefit podiatry the most because, due to the nature of most podiatric E/M visits, they tend to bill only level 2 and 3 E/M visits."

They have us listed as getting the largest pay increase from this, at 12%. I don't understand their logic. Isn't this contrary to what everyone else is saying.

It is a separate issue. Issue one is a single code that would pay higher than a level 2 or maybe higher than a 3. The second issue is giving podiatry its own podiatry E&M code that would pay less than the original level 2 code because we are supposedly not doing as much of an exam and management as an MD or DO. So if they killed the podiatry E&M we might benefit if we always bill level 2 codes. If they consolidate codes for MD/DO providers but add a new podiatry code, we loose.

 

[dtrack22]

an someone please explain the following line from the CMS proposal:

"Those specialties that tend to bill lower level E/M visits would benefit the most from the proposed change to single PFS payment rates, while those specialties that tend to bill more higher level E/M visits would see the largest decreases in payment with the change to a single PFS rate. The single payment rate for E/M code levels 2 through 5 would benefit podiatry the most because, due to the nature of most podiatric E/M visits, they tend to bill only level 2 and 3 E/M visits."

They have us listed as getting the largest pay increase from this, at 12%. I don't understand their logic. Isn't this contrary to what everyone else is saying.

Medicare is consolidating all E/M codes to a couple of codes. The new E/M code will be a $ amount that is somewhere between what a level 3 and level 4 visit currently pays. Therefore, specialities that bill a lot of level 4 and 5 visits (I'd think someone like med onc) would get paid less. Specialities that bill a lot of level 2 visits (Podiatry) would get a pay increase. Podiatrists bill so many more level 2 visits than anyone else, we WOULD get the largest pay increase (on average) at 12%. Because giving Podiatrists the largest pay increase while cutting the pay of real doctors is unacceptable, they added a special code (G) to put in front of the E/M in order to designate that a podiatrist was doing the billing. The 12% pay increase you quoted is what would happen IN THEORY if the CMS rule stopped at consolidating E/M codes. However, the reality is that the proposal goes on to say that these G codes would reimburse at a lower rate. You know, so podiatrists don't get a 12% bump because its unfair to the other doctors. And that's what people are talking about when they say we'll be taking a pay cut. We would continue to work up plantar fasciitis and document and treat it no different than an urgent care doc or a PCP or an ortho would. But they would bill 9920X and we would bill G9920X, and ours would pay less, something below a current level 3.

Medicare basically did this: Figure out how much we pay per visit on average in terms of billed E/M codes. Tell the doctors we are throwing them a bone by simplifying coding requirements, reducing documentation and consolidating E/M codes, so that we can come up with a single code that pay 2-3% less than our current "average" cost per visit. The system saves money by reducing physician pay while trying to convince physicians that this is all about helping them...and not cutting their pay.

 

[ExperiencedDPM]

Medicare is consolidating all E/M codes to a couple of codes. The new E/M code will be a $ amount that is somewhere between what a level 3 and level 4 visit currently pays. Therefore, specialities that bill a lot of level 4 and 5 visits (I'd think someone like med onc) would get paid less. Specialities that bill a lot of level 2 visits (Podiatry) would get a pay increase. Podiatrists bill so many more level 2 visits than anyone else, we WOULD get the largest pay increase (on average) at 12%. Because giving Podiatrists the largest pay increase while cutting the pay of real doctors is unacceptable, they added a special code (G) to put in front of the E/M in order to designate that a podiatrist was doing the billing. The 12% pay increase you quoted is what would happen IN THEORY if the CMS rule stopped at consolidating E/M codes. However, the reality is that the proposal goes on to say that these G codes would reimburse at a lower rate. You know, so podiatrists don't get a 12% bump because its unfair to the other doctors. And that's what people are talking about when they say we'll be taking a pay cut. We would continue to work up plantar fasciitis and document and treat it no different than an urgent care doc or a PCP or an ortho would. But they would bill 9920X and we would bill G9920X, and ours would pay less, something below a current level 3.

Medicare basically did this: Figure out how much we pay per visit on average in terms of billed E/M codes. Tell the doctors we are throwing them a bone by simplifying coding requirements, reducing documentation and consolidating E/M codes, so that we can come up with a single code that pay 2-3% less than our current "average" cost per visit. The system saves money by reducing physician pay while trying to convince physicians that this is all about helping them...and not cutting their pay.

Excellent explanation.

 

[king22]

While these proposed rules are concerning, they aren't a for-gone conclusion- far from it. Pretty much every physician's specialty association, as well as the AMA have vocally opposed the combining of the E&M codes and cuts to the 25 Modifier. If that's not enough, around 90 congressional representatives also wrote letters in opposition to these two proposed rules. CMS rescinds proposed rules all the time and I can't see them forging ahead with this amount of opposition. I may be wrong though.....

 

[dtrack22]

While these proposed rules are concerning, they aren't a for-gone conclusion- far from it. Pretty much every physician's specialty association, as well as the AMA have vocally opposed the combining of the E&M codes and cuts to the 25 Modifier. If that's not enough, around 90 congressional representatives also wrote letters in opposition to these two proposed rules. CMS rescinds proposed rules all the time and I can't see them forging ahead with this amount of opposition. I may be wrong though.....

This is correct. Though I'm not going to pretend to know what CMS will actually do...

I just don't get why CMS has to make this so hard. Have codes based on time, remove all documentation requirements. Meaning the physician only needs to document what they need for themselves, or what they feel would be needed for another provider to follow along, or what they would need to protect themselves in the case of a malpractice suit. Put the onus of documentation on the provider and let the consequences of poor or inaccurate documentation set the standard of what needs to go into a note. Don't make it some requirement to get paid. Then instead of auditing charts, you can audit time billed vs patient's seen/scheduled. ie, some doc bills 30, 30 min visits in a clinic one day. Medicare says you didn't work for 900 minutes that day, here's your fine. And lets be honest, if physicians billed on time, medicare would save money. I rarely meet what would be the face to face time requirement when billing. I could count on one hand the number of times I spent 30 minutes of face to face time with a new patient (the time requirement for a 99203), yet I bill level 3's all of the time. Physicians would have significantly less time spent on the computer and could therefore see more patient's if they wanted (so more people get care), or they have more time to sit in the room with the patient listening, counseling, etc. (patients get better care?). Seems simple to me.

 

[hyperbaricoxy]

Big thanks to all the TFPs that do a bunch of level 2 visits and routine foot care. The whole G codes specific to podiatry is entirely their fault. Treat real problems and real pathology and we would be seeing a pay increase instead of a reduction.

Why use the abbreviation "TFP" ("Typical F'in Podiatrist" for those who don't know)? It’s offensive, derogatory and seeing our own field use it is a shame.

Yes there are non-surgical pods that abuse the system and there are surgical pods that abuse it just as much. This isn’t the majority with either and this is obviously present in every single field of medicine and is no worse in podiatry.

There is a growing trend of surgical podiatrists looking down on those who are non-surgical, AKA your TFP, and it’s disheartening the field is becoming divided like this. Why not create one for surgical pods while we’re at it, maybe FOWP ("F'in Ortho-Wannabe Podiatrists") or FMSRSP ("F'in Med School Rejected Surgical Podiatrists"). But we don't because it's stupid, dividing and offensive like TFP.

I did a fair amount of surgeries before I quit it all together. Later on I started only doing non-elective surgeries I found interesting but I still wasn’t happy… for ME the stress and risk vs reward isn’t worth it w surgery. I am in debt $350-400K from school and we get reimbursed chump change for helping someone walk again with surgery or saving their life, while some high school dropout car mechanic gets the same amount if not more for replacing some car parts in 20 minutes. Dropping surgery was the best decision I ever made. My income hasn’t dropped one bit, I’ve never been happier, and I have more time for my family and hobbies. This obviously isn’t the case for everyone and to each their own. But I am what you call a TFP, and fail to see what is wrong with that.

 

[air bud]

Why use the abbreviation "TFP" ("Typical F'in Podiatrist" for those who don't know)? It’s offensive, derogatory and seeing our own field use it is a shame.

Yes there are non-surgical pods that abuse the system and there are surgical pods that abuse it just as much. This isn’t the majority with either and this is obviously present in every single field of medicine and is no worse in podiatry.

There is a growing trend of surgical podiatrists looking down on those who are non-surgical, AKA your TFP, and it’s disheartening the field is becoming divided like this. Why not create one for surgical pods while we’re at it, maybe FOWP ("F'in Ortho-Wannabe Podiatrists") or FMSRSP ("F'in Med School Rejected Surgical Podiatrists"). But we don't because it's stupid, dividing and offensive like TFP.

I did a fair amount of surgeries before I quit it all together. Later on I started only doing non-elective surgeries I found interesting but I still wasn’t happy… for ME the stress and risk vs reward isn’t worth it w surgery. I am in debt $350-400K from school and we get reimbursed chump change for helping someone walk again with surgery or saving their life, while some high school dropout car mechanic gets the same amount if not more for replacing some car parts in 20 minutes. Dropping surgery was the best decision I ever made. My income hasn’t dropped one bit, I’ve never been happier, and I have more time for my family and hobbies. This obviously isn’t the case for everyone and to each their own. But I am what you call a TFP, and fail to see what is wrong with that.

No, you are not a TFP. A TFP is NOT a non-surgical podiatrist. It is someone who thinks custom orthotics fix everything, who thinks hypocure is the answer to everything etc. It is the person in todays PM News who has been billing a nerve block seperately for nail matrixectomies. It is the person selling nutraceuticals out of their office etc.

 

[air bud]

And I like FOWP - I may use that if you are ok with it. I will just use FOW.

 

[bunNfxr]

350-400K? FUUUUUUUUUUUUUUUUUDGE

 

[hyperbaricoxy]

No, you are not a TFP. A TFP is NOT a non-surgical podiatrist. It is someone who thinks custom orthotics fix everything, who thinks hypocure is the answer to everything etc. It is the person in todays PM News who has been billing a nerve block seperately for nail matrixectomies. It is the person selling nutraceuticals out of their office etc.

I like what you did there air bud, but you know dang well that is not what is meant with TFP. And even if that is the accepted definition, that is worse! The key word here is TYPICAL. That is not your TYPICAL podiatrist and that is not a good look on the field if so. What you described is an AIP (Atypical Idiotic Podiatrist). Now since we don't have an urban dictionary or wiki page for TFP, we have to go by word of mouth and some Present Podiatry post from 2009, and that is not what is meant by it. I can picture it now, a young high schooler asks his guidance counselor "I'm thinking about podiatry, what does a typical podiatrist do?"...."Well Susie if you mean your typical f'in podiatrist allow me to explain just how bad this field is..."

350-400K? FUUUUUUUUUUUUUUUUUDGE

Surely I'm not the only one with this kind of debt? This was living FRUGALLY too! And since I worked all throughout undergrad I was able to pay all of my debt there, so this is NOT including 4 years of college so I imagine the number is even higher for most unless their parents helped them out or they worked during school?

 

[air bud]

If a high school student is discouraged from podiatry learning about a TFP (or any podiatrist) - good for them they just made a smart career decision.

 

[dtrack22]

Why use the abbreviation "TFP" ("Typical F'in Podiatrist" for those who don't know)? It’s offensive, derogatory and seeing our own field use it is a shame.

I use it because the individuals I was referring to (those who bill a large number of level 2 visits) are typically guys without much training beyond the ability to treat very simple pathology. ie toenail stuff. And not much else. That was the whole point of my post. The G code is a direct result of DPMs who see a ton of routine foot care and basic toenail stuff and bill a bunch of level 2 visits. I get that you are offended by the term TFP (which also applies to guys that do surgery, like the guy in town that does in office bunions with local anesthesia and no fixation), but I'd love for you to refute my point on the reason for the G code.

Yes there are non-surgical pods that abuse the system and there are surgical pods that abuse it just as much. This isn’t the majority with either and this is obviously present in every single field of medicine and is no worse in podiatry.

Which surgical codes get flagged for audit as often as 11721 does?

I am in debt $350-400K from school and we get reimbursed chump change for helping someone walk again with surgery or saving their life, while some high school dropout car mechanic gets the same amount if not more for replacing some car parts in 20 minutes

I got paid $1700 for a retorcalc with a gastroc recession. Took me an hour. The whole, surgery doesn't pay is a load of bull. Inefficient surgery or sporadic surgery doesn't pay. But when you have 5-6 cases lined up on a set day where you aren't paying near as much for overhead because some or all of your office staff isn't getting paid, and maybe you are invested into the facility or the hardware you are using (all legal for now), it pays no different that clinic.

I am what you call a TFP, and fail to see what is wrong with that.

There is nothing wrong with it. Fly your TFP flag proud, brother

Surely I'm not the only one with this kind of debt? This was living FRUGALLY too! And since I worked all throughout undergrad I was able to pay all of my debt there, so this is NOT including 4 years of college so I imagine the number is even higher for most unless their parents helped them out or they worked during school?

That is absolutely insane. $400k in debt after residency means you borrowed something like $85k per year. You did not live frugally, or you were irresponsible, or both. Either way, $350-400k of debt without counting any undergrad money is not normal.

 

[ExperiencedDPM]

I use it because the individuals I was referring to (those who bill a large number of level 2 visits) are typically guys without much training beyond the ability to treat very simple pathology. ie toenail stuff. And not much else. That was the whole point of my post. The G code is a direct result of DPMs who see a ton of routine foot care and basic toenail stuff and bill a bunch of level 2 visits. I get that you are offended by the term TFP (which also applies to guys that do surgery, like the guy in town that does in office bunions with local anesthesia and no fixation), but I'd love for you to refute my point on the reason for the G code.


Which surgical codes get flagged for audit as often as 11721 does?


I got paid $1700 for a retorcalc with a gastroc recession. Took me an hour. The whole, surgery doesn't pay is a load of bull. Inefficient surgery or sporadic surgery doesn't pay. But when you have 5-6 cases lined up on a set day where you aren't paying near as much for overhead because some or all of your office staff isn't getting paid, and maybe you are invested into the facility or the hardware you are using (all legal for now), it pays no different that clinic.


There is nothing wrong with it. Fly your TFP flag proud, brother


That is absolutely insane. $400k in debt after residency means you borrowed something like $85k per year. You did not live frugally, or you were irresponsible, or both. Either way, $350-400k of debt without counting any undergrad money is not normal.

You got paid $1700 for a retrocalcaneal ostectomy and a gastroc recession. I’d love to know that insurance.

The national Medicare fee schedule is:

28118 partial ostectomy of calcaneus
$429.48

27687—gatroc recession
$468.71

Grand total- $898.19

And the 898.19 does NOT include the reduced fee for the 2nd procedure which is often 75% or 50% of the allowable fee. In this case it would be:

$468.71 plus 429.48 x 0.75 (or x 0.5)

$468.71 + $322.11 for a grand total of:

$790.82

Even if you are dealing with private insurance, I do not know of any present carrier that pays over 200% of the Medicare allowable fee.

Not sure if you also billed for a repair of the Achilles, but $1700 for what you describe is NOT the norm.

 

[air bud]

1700 still isn’t very enticing considering the risks and headaches for me.

I have a newfound respect for that area...it is ripe for headaches. I put achilles hardware on post op antibiotics and will likely also add in an incisional wound vac going forward.

 

[air bud]

You got paid $1700 for a retrocalcaneal ostectomy and a gastroc recession. I’d love to know that insurance.

The national Medicare fee schedule is:

28118 partial ostectomy of calcaneus
$429.48

27687—gatroc recession
$468.71

Grand total- $898.19

And the 898.19 does NOT include the reduced fee for the 2nd procedure which is often 75% or 50% of the allowable fee. In this case it would be:

$468.71 plus 429.48 x 0.75 (or x 0.5)

$468.71 + $322.11 for a grand total of:

$790.82

Even if you are dealing with private insurance, I do not know of any present carrier that pays over 200% of the Medicare allowable fee.

Not sure if you also billed for a repair of the Achilles, but $1700 for what you describe is NOT the norm.

You can also throw in FHL transfer and maybe a gastroc lengthening too - obviously if pathology justifies. But I believe this is how you would get to that number.

 

[ExperiencedDPM]

I have a newfound respect for that area...it is ripe for headaches. I put achilles hardware on post op antibiotics and will likely also add in an incisional wound vac going forward.

Have fun getting reimbursed for that incisional wound vac.

Insurance companies are on the war path. I was consulted for policies for a well known insurance company. Unless there is significant supportive literature, new gadgets and procedures are being considered investigational and/experimental.

These include amniotic injections for tendon pathology, PRP injections, Topaz, Tenex, ESWT, and lots of others.

Using an amniotic graft to enhance bone healing is not being paid. The insurers are only allowing amniotic grafts, PRP, etc for wounds. They will pay for wound vacs for open wounds but not for incisional use. And the list goes on and on.

Many of these decisions are also based on abuse. When a doctor shoves a piece of amniotic membrane or shoots some into every surgical site, it’s abused. And that’s what happens with everything.

When I review samples they send me, I can tell you that DPMs are x-ray and ultrasound crazy. If a patient has tinea pedis, they get bilateral x-rays. The abuse is staggering.

Many of the hammers that are coming down are due to the few bad apples who have abused the system beyond your comprehension.

 

[hyperbaricoxy]

I use it because the individuals I was referring to (those who bill a large number of level 2 visits) are typically guys without much training beyond the ability to treat very simple pathology. ie toenail stuff. And not much else. That was the whole point of my post. The G code is a direct result of DPMs who see a ton of routine foot care and basic toenail stuff and bill a bunch of level 2 visits. I get that you are offended by the term TFP (which also applies to guys that do surgery, like the guy in town that does in office bunions with local anesthesia and no fixation), but I'd love for you to refute my point on the reason for the G code.


Which surgical codes get flagged for audit as often as 11721 does?

I'm not disagreeing there is abuse in the system, just pointing out the TFP and that every single field of medicine has its abuse.

I got paid $1700 for a retorcalc with a gastroc recession. Took me an hour. The whole, surgery doesn't pay is a load of bull. Inefficient surgery or sporadic surgery doesn't pay. But when you have 5-6 cases lined up on a set day where you aren't paying near as much for overhead because some or all of your office staff isn't getting paid, and maybe you are invested into the facility or the hardware you are using (all legal for now), it pays no different that clinic.

I never got close to that amount for a retrocalc w gastroc. Good for you if you did a straightforward retrocalc/gastroc and got that amount. There are always going to be exceptions with certain procedures. Again, unless a good amount of the procedures are reimbursing that much (which they aren’t even close for me or my colleagues) I didn't find surgery to be lucrative especially when I am employed at the office and my overhead/staff will be there regardless.

That is absolutely insane. $400k in debt after residency means you borrowed something like $85k per year. You did not live frugally, or you were irresponsible, or both. Either way, $350-400k of debt without counting any undergrad money is not normal.

I did the calculations and tried to tier each school based on total cost of attendance (mostly using the 2015-2016 data, so Im sure all prices are slightly higher, but i think the order will be the same).

I was wondering if these seemed right to you, or if I'm off.

1. Samuel college of podiatry -- 81,000/yr. (tuition/fees: 44,000....cost of living: 35,000)
2. Midwestern - Arizona -- 67,000/yr. (tuition/fees: 43,270....cost of living: 24,300)
3. Cali -Western -- 65,000/yr. (tuition/fees:43,000...cost of living: 22,000)
4. Kent State University -- 64,000/yr. (tuition/fees: 41,700....cost of living: 22,000)
5. New York -- 60,000/yr. (tuition/fees: 36,500...cost of living: 23,500)
6. DMU -- 59,300/yr. (tuition/fees: 35,700...cost of living: 23,500)
7. Temple -- 58,000/yr. (tuition/fees: 40,100...cost of living: 18,000)
8. Scholl -- 56,200/yr. (tuition/fees: 39,200...cost of living: 17,000)
9. Barry -- 46,600/yr. (tuition/fees: 42,500...cost of living: 4,000?)

I posted the above from a previous post on SDN. Granted it's not completely accurate as it should be even higher, but just for giggles let's go somewhere around the average (minus Barry which is clearly wrong in the cost of living) and you can easily reach my debt I listed 3 years after residency which is around where I'm at. Depending on the school many will reach my level of debt right out of residency! I went to one of the more expensive schools with a high cost of living. I don’t see how this is "insane" or that I was living extravagantly and/or irresponsibly as you would say. I am more towards $350k while another classmate I'm friends with is more toward $400k. Nowadays interest is around 6-7% and I consolidated it all the second I could. It’s absolutely ridiculous. If you’re lucky and your state permits you can consolidate with Sofi or another program to get it slightly lower but you are obligated to pay it off in a shorter time frame when compared to other plans. I feel I lived relatively frugal, the main luxury I had was I lived alone and rented out a small studio as opposed to sharing an apartment with another person which would have saved money but wasn’t worth it for me.

Now once you are all done there are many different payment options but I found the two most popular payment options to be: IBR (Income Based Repayment) where 15% of your income goes towards the loan for the next 25 years and you pay taxes on the forgiven amount at the end (there is also 10% for 20 years if you are a more recent borrower), or you can simply pay as much as you can (or a specific amount for a specific time frame) to pay it off as soon as possible, such as 10 years or 15 years or whatever time frame. In order for me to pay off the loans in 10 years I would basically live like a resident for the next 10 years, which I didn’t want to do. PSLF would have been a great choice but simply wasn’t an option.

So, if a person borrows a total of $250-260k for school/cost of living which is completely normal at one of the middle priced schools, at 6.8% interest, and 6 years post graduation of podiatry school while interest accumulates, paying IBR the whole time (which hardly leaves a dent in the debt as residency pay sucks and attending podiatry salaries aren’t really good until you are established several years out), you can see how this can get to $350-400k, yes?

 

[dtrack22]

You got paid $1700 for a retrocalcaneal ostectomy and a gastroc recession. I’d love to know that insurance.

The national Medicare fee schedule is:

28118 partial ostectomy of calcaneus
$429.48

27687—gatroc recession
$468.71

Grand total- $898.19

And the 898.19 does NOT include the reduced fee for the 2nd procedure which is often 75% or 50% of the allowable fee. In this case it would be:

$468.71 plus 429.48 x 0.75 (or x 0.5)

$468.71 + $322.11 for a grand total of:

$790.82

Even if you are dealing with private insurance, I do not know of any present carrier that pays over 200% of the Medicare allowable fee.

Not sure if you also billed for a repair of the Achilles, but $1700 for what you describe is NOT the norm.

Ambetter
28120 paid $590.85
27654 paid $590.47
27687 paid $536.77
And putting on the splint paid me nothing

Aetna paid me to put on the splint but the total was only $1470.29

Local HMO/hospital network was the worst
28210 paid $420.67
27654 paid $427.99
27687 paid $388.89
Again didn’t get paid to put on the splint

Austin and a hammertoe paid $649.26 and $238.17 from BCBS so $887.43. Meh.

 

[ExperiencedDPM]

Ambetter
28120 paid $590.85
27654 paid $590.47
27687 paid $536.77
And putting on the splint paid me nothing

Aetna paid me to put on the splint but the total was only $1470.29

Local HMO/hospital network was the worst
28210 paid $420.67
27654 paid $427.99
27687 paid $388.89
Again didn’t get paid to put on the splint

Austin and a hammertoe paid $649.26 and $238.17 from BCBS so $887.43. Meh.

I’m very surprised that there was no reduction for the 2nd and 3rd procedures.

I’m a consultant to Aetna and I’ve never seen them pay for a splint or cast performed the day of surgery. There is actually a CCI edit for that, since any cast, splint or strapping is inclusive to the surgery.

When you bill 27654, make sure that you are truly debriding and/or repairing the Achilles. I have reviewed MANY cases where there was no documented pathology of the Achilles. The doctor simply dissected the tendon off of the calcaneus for access to the retrocalcaneal prominence and then reattached the tendon via Speedbridge or other method and billed a 27654.

You can’t get paid for removing a tendon from it’s attachment and then reattaching. There was no pathology until the doctor dissected it off the bone. That’s considered “approach and protect”. You don’t get paid to repair something you needed to dissect for access to a surgical site.

That’s like clowns who bill laceration repair for every surgical incision. You don’t get paid for suturing an incision you made.

So when billing 27654, make sure you document the pathology and repair and not just bill the code to repair a tendon YOU released.

That’s the billing tip of the day.

 

[bunNfxr]

That is absolutely insane. $400k in debt after residency means you borrowed something like $85k per year. You did not live frugally, or you were irresponsible, or both. Either way, $350-400k of debt without counting any undergrad money is not normal.[/QUOTE]


Why would that not be normal if tuitions are 30-40; living expenses 20 and then costs of deferments? It sounds normal. Painful and arguably high risk vs return, but It doesn't sound too high on the hog to me.

 

[air bud]

Not to hijack this thread - but I just don't understand how anyone who go into podiatry these days - it is just too expensive to do so with so little upside. Tuition is only going up. Many schools are located in high cost of living areas. And the reality is that there are very few pods who are going to make 300-400k to justify that type of investment. At least with MD the majority of jobs are 300 minimum and can justify that investment. Its simple math. The problem is that pre-pods are looking at things through rose colored glasses and don't understand the harsh reality faced. They don't understand that is real money that is being borrowed and has to be paid back. They don't understand the mental weight it carries when you have to start paying it back. They don't understand that there are very few jobs that going to qualify you for PSLF. They don't understand that it is nearly un heard of for a job to offer to pay back student loans.

 

[bunNfxr]

So when billing 27654, make sure you document the pathology and repair and not just bill the code to repair a tendon YOU released.

That’s the billing tip of the day.[/QUOTE]


There is generally an equinus and /or midsubstance calcification or fibrosis. Make sure you document why you are "fixing" the Achilles.

 

[de Ribas]

At least with MD the majority of jobs are 300 minimum and can justify that investment.

Medscape and BLS show that primary care averages are around 220K only. Primary care physicians make up at least 50% of MD and DO world.

 

[dtrack22]

Why would that not be normal if tuitions are 30-40; living expenses 20 and then costs of deferments? It sounds normal. Painful and arguably high risk vs return, but It doesn't sound too high on the hog to me.

I guess half of the schools could now leave you in that type of debt, assuming you had no scholarship(s). But Tuition is at least $10k more per year than when hyperbaric and I were in school. When I was at DMU tuition was $25k and I think it rose to around $28 or so by the time I was graduating. I couldn't have taken $80k out in loans even if I wanted to. I finished residency with $140k in student loan debt from podiatry school. I believe that choosing to go to Sam Merritt or NYCP for example when you could have gone to Scholl or DMU or Ohio or any other school for $10-15k less per year is irresponsible. $400k to become a podiatrist is irresponsible. I would take out $400k in loans to be an orthopedic surgeon, an ED doc, a dermatologist or an anesthesiologist. But not a podiatrist.

or midsubstance calcification or fibrosis

I haven't taken one of these to the OR yet that doesn't have intra-substance disease in the achilles. I debride plenty of pathologic tendon to bill for the service. I'll document the findings and the estimated % of tendon that I debrided and then make a statement on why I did or did not decide to transfer the FHL (most of the time I do not). Haven't had the code rejected yet so I haven't had to appeal to see if my documentation makes the carrier happy.

 

[Weirdy]

Not to hijack this thread - but I just don't understand how anyone who go into podiatry these days - it is just too expensive to do so with so little upside. Tuition is only going up. Many schools are located in high cost of living areas. And the reality is that there are very few pods who are going to make 300-400k to justify that type of investment. At least with MD the majority of jobs are 300 minimum and can justify that investment. Its simple math. The problem is that pre-pods are looking at things through rose colored glasses and don't understand the harsh reality faced. They don't understand that is real money that is being borrowed and has to be paid back. They don't understand the mental weight it carries when you have to start paying it back. They don't understand that there are very few jobs that going to qualify you for PSLF. They don't understand that it is nearly un heard of for a job to offer to pay back student loans.

With all due respect sir, I understood all of that and podiatry was still my only way into a healthcare field I liked.
I picked this profession over optometry and PA.

Was it shortsighted? Probably, according to many people in this thread. I see why and respect those opinions.
My debt load will also be north of 300k. I am not here to cherry pick one profession over the other. Simply explaining why.

Would I encourage my kids to go in the medical field? Highly unlikely. Life is too short to spend 20+ years in school with 300k in debt only to reap its rewards when you are 60+.

Unfortunately, I was not raised in a household that encouraged any other profession outside of medicine.
When we talk to pre-pods coming in, we make sure they understand the limited scope, high debt burden, and mental taxation it will take to get there, only to be disrespected further by physicians and DPMs alike.

I may completely take on the view you have regarding podiatry and its downhill spiral after residency, but for now I am only explaining why I chose this field despite knowing the high debt burden.

 

[bunNfxr]

Medscape and BLS show that primary care averages are around 220K only. Primary care physicians make up at least 50% of MD and DO world.

The internal med residents that rotate through my clinic are all starting around 300 after completing residency. Surprised me, but that is what they tell me. I do not see that happening in podiatry. After working several sectors of this profession and doing my own billing for a while and working with people that do insurance auditing and coding reviews, it seems very unlikely to legitimately gross 700K in a first year, which is what you would need to pay a 300K salary and benefits. Hospital groups can probably take a bit on the chin because Internist and family practice are the gate keepers. But there at risk of being replaced by NPs in the near future as well/

 

[dtrack22]

After working several sectors of this profession and doing my own billing for a while and working with people that do insurance auditing and coding reviews, it seems very unlikely to legitimately gross 700K in a first year, which is what you would need to pay a 300K salary and benefits.

I think some of those groups now are so large that they can easily absorb a year's worth of inflated salary. Plus if they go the hospitalist route they are walking in to patients day 1 since that has essentially become shift work. Podiatrists obviously aren't able or willing to absorb a reasonable salary for new hires. But at some point you have to decide whether or not all of the turnover that comes along with $100k salaries is worth it.

I would bet a whole lot of money that a podiatry group could salary a new hire at closer to $200k, putting them in line with FM and Peds docs at least, and getting them closer to hospital employed DPM salaries (which I've seen as low as ~$180k, though most seem to be $200k+), and they could keep that employee salaried and happy for 2-3 years. Instead of crappy pay being the reason they left after 1 year, at least you could string them along until your crappy partnership opportunity caused them to leave in year 3...

The owner of my practice collects in the $90k range per month (when not on vacation, collections drop to the $60k range months following the 2 week vacations). You can and should make more money as a podiatrist than you would as a pediatrician. Yet a Peds doc joining a Peds group doesn't get offered $100k.

 

[king22]

We're our own worst financial enemy with all our stupid "old wives tales" in billing. How many times do we hear "never bill a 99214", "never bill a house call visit", "never bill a 99213 with a 11721/20 + 11055-57", "never bill a 11305-11307", etc? I hear it all the time. I make it a hobby of mine now to ask the individual who is telling this "tale" where the evidence is to support their claim- I find that 3/4 times it doesn't exist, it's hearsay, or its part of Medicare LCD that was replaced 10 years ago.

I'm not saying that "correct" billing with solve most of our problems, it won't, but it's something that is within our power to change. You render the service per Medicare/Insurance guidelines, you bill for it.

 

[GypsyHummus]

That’s an easy one.

When someone has lived their whole life wanting to be a doctor, and can only muster a 30%ile MCAT score after the third retake, or only has a 3.1 GPA with a worthless undergrad Bio degree and is finishing up an equally worthless masters in Bio, the options for doctoral professions become increasingly slim. MD is forever out of the picture, and unless the applicant does an extreme overhaul with a special master program and new high scoring MCAT, DO is as well. Dental is just as hard, sometimes harder than MD, so that is out as well. And we only have 6 month grace period before our 50k+ student loan debt for said worthless bio degree in undergrad and masters needs to be paid back. Up until this point, every teacher we’ve ever had has told us we could be anything we want to be and follow our dreams (regardless how dumb or economically unfeasible), better not critically think starting now and get out while we are only a bit in debt! Trade school? Welding? Plumbing? Marketable skill sets that people actually need? That’s for the peasants, I (think) I’m better than that! What’s 6-7% intrest? Daddy Gov’ment be handing out that money on grad plus like it’s raining.

Plus, what would we say to people we don’t really like at Family get togethers or weddings? That we entered the workforce with no post doctoral plans? perish the thought, I have shallow people I need to impress! Myself included.

Let’s look at the alternatives:

Optometry- great clean profession, but quickly becoming overstaurated. Check out the OD forums, there are recent grads having trouble finding full time work. Earnings 90-120k gross if you can find work, mostly in malls and Walmart’s . Debt 200-300k. Still a “doc”.

Pharmacy- super easy to get into, great pay for only 4 years after college, but crazy saturated job market. Add to the fact Amazon is looking to get into the Pharmacy business, and the prospects start looking dismal. Earnings 110-130k. 100-200k debt depending where you go.

Physical therapy- great profession, great hours, poor pay. Earnings 60-80k, debt 100-150k.

NP: Prolly the best debt to income, as you can work while earning your degree. 80-100k for primary care, the anesthesia ones make 200k+.

PA: likely out of the picture if one cannot get a 3.4+ undergrad GPA

Carribean: Vegas, baby.

Chiro: feast or famine when it comes to earnings. Most I know barley crack (lol) 60k/year. Few will make 500k+. 200k in debt.

Now let’s look at Podiatry:
7 years of school total (ouch) 300k in debt for most places. Gross around 130k-150k, sometimes exceeding 200k. Still a “doc”. Hmmm.

Seems like the best option for someone who wanted to be a doctor all their life. Typically people who want to be docs wouldn’t be happy in anouther field like IT, or engineering.

And yes, student loans are basically Monopoly money to everyone who takes them out. It’s why we have a problem brewing in the very near future

Not to hijack this thread - but I just don't understand how anyone who go into podiatry these days - it is just too expensive to do so with so little upside. Tuition is only going up. Many schools are located in high cost of living areas. And the reality is that there are very few pods who are going to make 300-400k to justify that type of investment. At least with MD the majority of jobs are 300 minimum and can justify that investment. Its simple math. The problem is that pre-pods are looking at things through rose colored glasses and don't understand the harsh reality faced. They don't understand that is real money that is being borrowed and has to be paid back. They don't understand the mental weight it carries when you have to start paying it back. They don't understand that there are very few jobs that going to qualify you for PSLF. They don't understand that it is nearly un heard of for a job to offer to pay back student loans.

 

[GypsyHummus]

DMU is 35k+ in tuition alone.

AZPOD is 43k in tuition. That is not including eating anything or living anywhere. They budget out 70k/year that a student can take out.

Ohio is 40k in tuition.

Multiply that by 4 years and it’s easy to see why someone would get 300k+ in debt after factoring in compounding intrest at 6-7%. Not to mention some people do foreberance on the loan during residency.

The best part is, Pod schools are among the cheaper professional schools to go to. Most DOs I know end up with 400k+ debt. Most dentists are around the 550-600k mark. AT still dental school estimated their cost of attendance at 120k/year, and they are fairly normal for private schools (which is what most dental students get for acceptance unless they had high stats to get into their state schools).

I guess half of the schools could now leave you in that type of debt, assuming you had no scholarship(s). But Tuition is at least $10k more per year than when hyperbaric and I were in school. When I was at DMU tuition was $25k and I think it rose to around $28 or so by the time I was graduating. I couldn't have taken $80k out in loans even if I wanted to. I finished residency with $140k in student loan debt from podiatry school. I believe that choosing to go to Sam Merritt or NYCP for example when you could have gone to Scholl or DMU or Ohio or any other school for $10-15k less per year is irresponsible. $400k to become a podiatrist is irresponsible. I would take out $400k in loans to be an orthopedic surgeon, an ED doc, a dermatologist or an anesthesiologist. But not a podiatrist.



I haven't taken one of these to the OR yet that doesn't have intra-substance disease in the achilles. I debride plenty of pathologic tendon to bill for the service. I'll document the findings and the estimated % of tendon that I debrided and then make a statement on why I did or did not decide to transfer the FHL (most of the time I do not). Haven't had the code rejected yet so I haven't had to appeal to see if my documentation makes the carrier happy.

 

[ExperiencedDPM]

Big thanks to all the TFPs that do a bunch of level 2 visits and routine foot care. The whole G codes specific to podiatry is entirely their fault. Treat real problems and real pathology and we would be seeing a pay increase instead of a reduction.



Though I'm curious to hear more about the legality of all this. It seems that paying a "physician" (medicare defines us as one wether our allo- and osteopathic friends like it) less money for the exact same work-up/treatment/service is ripe for discrimination law suits. But they are the feds and can probably do whatever they want. And to think some of you want all of us to be insured and employed by them...

I’m not sure I agree with your assessment. Is the driving force for the changes the “TFPs” as you call them, billing too many 99212s or is it the frauds who bill too many 992x4 and 992x5 visits without justification.

By now you know that I often do consulting work for insurance companies. I was asked to review 350 cases of “4” and “5” level codings by DPMs. I did the reviews with another DPM and a certified coder.

The results were that not one of the “5” level codes was justified.

81% of the “4” level codes were not justified and out of those, 53% didn’t even justify a “3” level code.

These were claims from a wide variety of DPMs with a wide variety of age and geographic location.

There is more to the story than old farts billing only 99212s as per my above comments.

And someone else in this thread mentioned the 11305/11306/11307 codes. These codes are now on the radar since these are being abused by DPMs who are billing this code for keratotic lesions.

This code is shaving of a lesion, not trimming of a keratotic lesion. It is to remove a lesion (even though it may eventually come back) such as a nevus and should ideally be for biopsy. This procedure should involve local anesthesia to shave REMOVE the lesion, not to trim a keratotic lesion.

It is an amazingly abused code as is 14040. But that’s another “lecture”. And the docs abusing these codes are making my wallet thicker with consultant fees. I’ve never had so many requests from insurance companies to review case.

 

[dtrack22]

I’m not sure I agree with your assessment. Is the driving force for the changes the “TFPs” as you call them, billing too many 99212s or is it the frauds who bill too many 992x4 and 992x5 visits without justification.

I explained the reasoning already. The only reason the G code was proposed is because as a profession, our average level of service billed was significantly lower (12%) than the new proposed E/M reimbursement amount. If more DPMs appropriately billed level 3's and level 4's (I can't imagine billing a level 5), then there would not be the need to reimburse us less.

I mean the whole point of the new E/M code was to find an average reimbursement amount that wouldn't increase or decrease any one specialty's pay too much. Some specialties would see a couple % pay decrease on average and some would see a couple % pay bump. Medicare would save some money and nobody would complain too much. Well then they find out Podiatrists are doing so much routine, non complex stuff that we would get paid A LOT more money in the new system if things were left as is. That's not fair to everyone else, hence the G codes that pay us less than everyone else...

The G code is based on the AVERAGE level of service that all of the podiatrists in the country bill collectively, so us having the G code shouldn't drastically affect the AVERAGE income of a podiatrist when it comes to E/M services. The problem I have is that I don't bill many level 2's (around 15% of my E/M services are level 2 while another doc in our office is just over 30%). I don't do much, if any, routine foot care. I'm not trying to squeeze level 2's out of the old folks that need their toenails cut in order to make their otherwise $45 11721 worth it. Therefore I will take a bigger hit with the G code than other DPMs. Again, as a group we will get paid about the same because that is what the whole G code proposal is based off of.

It's not inappropriate level 4 and 5 visits that were cause for the G code, it was the fact that without it we would be getting a 12% pay raise because of all the level 2s we bill as a profession.

 

[ExperiencedDPM]

I explained the reasoning already. The only reason the G code was proposed is because as a profession, our average level of service billed was significantly lower (12%) than the new proposed E/M reimbursement amount. If more DPMs appropriately billed level 3's and level 4's (I can't imagine billing a level 5), then there would not be the need to reimburse us less.

I mean the whole point of the new E/M code was to find an average reimbursement amount that wouldn't increase or decrease any one specialty's pay too much. Some specialties would see a couple % pay decrease on average and some would see a couple % pay bump. Medicare would save some money and nobody would complain too much. Well then they find out Podiatrists are doing so much routine, non complex stuff that we would get paid A LOT more money in the new system if things were left as is. That's not fair to everyone else, hence the G codes that pay us less than everyone else...

The G code is based on the AVERAGE level of service that all of the podiatrists in the country bill collectively, so us having the G code shouldn't drastically affect the AVERAGE income of a podiatrist when it comes to E/M services. The problem I have is that I don't bill many level 2's (around 15% of my E/M services are level 2 while another doc in our office is just over 30%). I don't do much, if any, routine foot care. I'm not trying to squeeze level 2's out of the old folks that need their toenails cut in order to make their otherwise $45 11721 worth it. Therefore I will take a bigger hit with the G code than other DPMs. Again, as a group we will get paid about the same because that is what the whole G code proposal is based off of.

It's not inappropriate level 4 and 5 visits that were cause for the G code, it was the fact that without it we would be getting a 12% pay raise because of all the level 2s we bill as a profession.

You may be correct. What’s the source of your information? I can tell you that private carriers are looking at it a little differently than CMS. They are looking at the percent that is being overbilled. Regardless, going after podiatry is the path of least resistance.

There’s not a significant concern when there are a grand total of 15,000 DPMs bitching vs several hundred thousand MDs/DOs.

Podiatry is simply an easier target.

 

[heybrother]

Its within the 2019 CMS proposal pdf that is like 1400 pages. I read a significant amount of it when it came out and I think dtrack summarized it fairly. Had they simply paid us a "1-5 averaged-to-like-3.5" we would have come out ahead.

We'll be an easier target still when we are pulled into our open separate system. They'll be able to punish us without hitting anyone else.

 

[Creflo]

Interesting posts on this forum. My opinion is that the debt incurred to become a podiatrist is nowhere near worth it for the reimbursements. Having served in the military doing mostly sports medicine podiatry and getting good surgical experience and ABFAS certification, now in private practice I find that it is not worth the reimbursements to do surgery. Just look at the achilles repair numbers mentioned above, in no way is this anywhere worth it. Same goes for lapidus, not worth it. I'm happy to give an achilles repair to an orthopedic surgeon, I'll make more doing other things. The answer is not a 3 year residency for all. Dentistry has it right. The more we can model our profession after Dentists, the better off we will be.

 

[heybrother]

APMA sent something out today indicating the podiatry specific E&M codes did not go through. If anyone can find anything more specific I would be curious.

CMS Finalizes Changes to Advance Innovation, Restore Focus on Patients | CMS (this link is a November 1, 2018 release)

 

[heybrother]

Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 | CMS

After consideration of concerns raised by commenters in response to the proposed rule, CMS is not finalizing aspects of the proposal that would have: (1) reduced payment when E/M office/outpatient visits are furnished on the same day as procedures, (2) established separate coding and payment for podiatric E/M visits, or (3) standardized the allocation of practice expense RVUs for the codes that describe these services.

 

[DexterMorganSK]

Excellent news

Can CMS try to do the same in the future?

 

[de Ribas]

Excellent news

Can CMS try to do the same in the future?

I read in other sources that they only delayed that until 2021 so there is more time for discussions and recommendations in the future.

 

[Creflo]

Wonderful news!