Solo Practice with Wound Care Focus

[dtrack22]

the ones who need a rebalance procedure to heal a wound are not very healthy.

But depending on the procedure, they also don’t require anesthesia that would carry significant cardiac risks. So they can still be low risk for cardiac complication due to anesthesia.

I had a 91 year old lady with a medial 1st met head wound due to large bunion. Gave her some diazepam pre-op to calm her down because she was one of those old, everything hurts kind of ladies. I did it (shave bump, close wound) under local in the OR. She’s a medical/cardiac trainwreck. She was still “low risk” from a cardiac standpoint because of the meds/anesthetic used.

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[diabeticfootdr]

This is a great attitude to have to get thrown under the bus and sued into oblivion.

It’s not an attitude. It’s a fact.

And if something happens, anything really, including if the safety strap isn’t properly secured, you’re “captain of the ship” and you will be sued anyway.

My point was that if you’re following hospital policy, only you can cancel the case and while there may be pressure on you to do so, you should do what’s in your patients best interest. Sometimes the pressure to cancel the case isn’t really related to risk, it’s related to anesthesia or nursing scheduling shortages. And if it is related to risk, you must weight the risk vs the benefit (i.e. the risk of delaying the surgery).

Where this happens to me most frequently is either:

1. Emergent cases. It doesn’t matter what the A1c or glucose is. It doesn’t matter if there is no cardiac or vascular “clearance”. It is an emergency and you proceed with surgery after a consent discussion. It actually doesn’t matter if they’re NPO. (That’s actually in everyone’s guideline) I will delay an emergency in some circumstances, but I’m the surgeon and that’s my call.

2. A patient that was previously admitted and worked up, then discharged and it’s now slightly longer that 30 days after discharge. Happens frequently with STSGs for us. If there are no interval changes, it is actually appropriate to proceed with surgery without repeating “clearance” as long as all documentation reflects this.

 

[DYK343]

But depending on the procedure, they also don’t require anesthesia that would carry significant cardiac risks. So they can still be low risk for cardiac complication due to anesthesia.

I had a 91 year old lady with a medial 1st met head wound due to large bunion. Gave her some diazepam pre-op to calm her down because she was one of those old, everything hurts kind of ladies. I did it (shave bump, close wound) under local in the OR. She’s a medical/cardiac trainwreck. She was still “low risk” from a cardiac standpoint because of the meds/anesthetic used.

IVe done plenty of local. cases in the past and I agree.. Ive never administered diazepam prior. Maybe I should.

I shy away from local because I had a patient jump off the table once with local only due to a panic attack. I was only about 20% into the case. Hadnt started bone work yet. But its got me spooked.

MAC is low risk for cardiac patients. THough I did a debridement/bone biopsy on a guy with an ejection fraction of 10-15% just last week and even with MAC he nearly coded on the table.

 

[dtrack22]

Ive never administered diazepam prior

Honestly I’d only ever done it as a 1 tab Rx (10mg) for the nut jobs who ask about it before a scheduled office procedure. Usually women. No offense ladies…

In this case the patient and the daughter were squirrely and very anxious about “pain.” I did it to make them happy and I will say 5mg put the 91 year old pretty out of it, all without any respiratory or cardiac depressive effects.

I did a bunion under local on a 33 yr old guy with a valve replacement who just didn’t want to wait to see his cardiologist. He did great. Didn’t really even consider the mid-case anxiety issue but I’m glad you did because now I’ll actually consider it before booking local only cases lol

 

[DYK343]

Honestly I’d only ever done it as a 1 tab Rx (10mg) for the nut jobs who ask about it before a scheduled office procedure. Usually women. No offense ladies…

In this case the patient and the daughter were squirrely and very anxious about “pain.” I did it to make them happy and I will say 5mg put the 91 year old pretty out of it, all without any respiratory or cardiac depressive effects.

I did a bunion under local on a 33 yr old guy with a valve replacement who just didn’t want to wait to see his cardiologist. He did great. Didn’t really even consider the mid-case anxiety issue but I’m glad you did because now I’ll actually consider it before booking local only cases lol

It SUCKED. Literally was barking at me the whole start of the prep. I asked if they were OK about to start. Patient calmed down.

Patient then wanted second to second updates once I started.

I told them I needed to concentrate on what I was doing. It was an Austin bunionectomy. I pulled the saw out and tested it. Once the patient heard the saw they freaked out and jumped off the table.

Never again. I ended up getting them back on the table. Pulse lavaging. Stitching it up. Never made the osteotomy.

 

[Shiyuan]

I often look at posts here and think... “I dont have the time nor the patience to type that much.” 😁

 

[HardRoadPaved]

I do my distal met bunions mostly under local. They sit up right, wear headphones. I tell them the nasty 10 sec to do a two-stick 1st ray block will save them the time of getting "clearance" and the expense of that visit and paying for anesthesia. Other advantages are no NPO, no recovery room time.

 

[shadesofgrey]

I've also done a fair number of procedures under local. I would say most of the patients are fine with soft tissue procedures but the times I've had to use the saw is a different animal. Almost all become anxious/hate the noise but especially the vibration of the saw.

 

[air bud]

Other than some simple 5th digit 4th digit Hammer toes, never really done stuff under local only electively but ton of infection stuff. Patient selection obviously is huge but, and I love the term neuropathy of the brain, fortunately they don't seem to mind you cutting stuff off while they are awake.

 

[HardRoadPaved]

Almost all become anxious/hate the noise but especially the vibration of the saw.

Yea if you run it fast enough you can get it to emit a lot of smoke. Most dont like the smell

 

[AttackNME]

-The more complicated, deep, etc the wound is the worst for you because the products and dressings and what not are likely included within the reimbursement for the debridement.

Wondering if you can elaborate on that because deep wounds that need 11043 and 11044 are very profitable for me. mostly use betadine gauze too which is cheap. What expensive stuff are you using?

These patients are sick. IMO it’s not as easy as "Just lengthen the P longus for a sub 1st met ulcer". There are more moving parts than that.

PL surgery can be done under straight local, so can a TAL. Don’t we all think forefoot offloading surgery really is simply that easy?

 

[Pronation]

Don’t we all think forefoot offloading surgery really is simply that easy?

No way, need an articulating ring ex fix with at least 4 adjustable struts. This way the hospital knows that I’m a serious surgeon and only I’m the one who gets to cancel one of these highly complex cases.

 

[edog10]

So the hospital wound care center is wanting me and my partner to provide services there once per week. We would have access to 3 nurses, can dictate which insurances we see, and also take some patients back to our office to apply skin subs. They would like for us to manage HBO on lower extremity patients as well. Personally I think it's a win-win bc we will not be responsible for over-head and will not be required to see un-insured patients. Obviously we will have an increase with in-patients but I think we can manage that and when busy enough hire a mid-level ( NP.) Anyone in a MSG/PP have experience with this? I believe they are run by healogics so that requires 80 hours of training.

 

[Pronation]

So the hospital wound care center is wanting me and my partner to provide services there once per week. We would have access to 3 nurses, can dictate which insurances we see, and also take some patients back to our office to apply skin subs. They would like for us to manage HBO on lower extremity patients as well. Personally I think it's a win-win bc we will not be responsible for over-head and will not be required to see un-insured patients. Obviously we will have an increase with in-patients but I think we can manage that and when busy enough hire a mid-level ( NP.) Anyone in a MSG/PP have experience with this? I believe they are run by healogics so that requires 80 hours of training.

Just understand that the overhead is baked into the deal. Your reimbursement is going to be garbage, around $50 for a wound debridement. It’s only a win if you can knock out 30+ patients in a day with the nurses doing a majority of the care for you where you only come in to the room to do the debridement and walk out - all measurements, dressings/casts, setting up instrument trays etc done by nurse.

 

[Adam Smasher]

So the hospital wound care center is wanting me and my partner to provide services there once per week. We would have access to 3 nurses, can dictate which insurances we see, and also take some patients back to our office to apply skin subs. They would like for us to manage HBO on lower extremity patients as well. Personally I think it's a win-win bc we will not be responsible for over-head and will not be required to see un-insured patients. Obviously we will have an increase with in-patients but I think we can manage that and when busy enough hire a mid-level ( NP.) Anyone in a MSG/PP have experience with this? I believe they are run by healogics so that requires 80 hours of training.

I did this for a while. It depends on the fee schedule/payer mix. Unless your clinic is really slow, this could be a massive loss for you. You will bill plenty of 11042 and 15275 but you will do it at the facility fee schedule and not the office fee schedule. I was getting reimbursed less for a 11042 in wound clinic than for a 11721 in office. Not to mention patients complain that why should they pay your bill when they already paid the wound clinic copay.

Of course I have friends who say wound clinic is a goldmine so YMMV

 

[Pronation]

I did this for a while. It depends on the fee schedule/payer mix. Unless your clinic is really slow, this could be a massive loss for you. You will bill plenty of 11042 and 15275 but you will do it at the facility fee schedule and not the office fee schedule. I was getting reimbursed less for a 11042 in wound clinic than for a 11721 in office. Not to mention patients complain that why should they pay your bill when they already paid the wound clinic copay.

Of course I have friends who say wound clinic is a goldmine so YMMV

Bingo. Yes, I do believe the wound clinic is a goldmine… if it’s owned and run by the hospital… and you’re employed by said hospital. If you’re in PP, you should just do these wounds in your office and get double the reimbursement…

This is again a byproduct of egregious over saturation in podiatry. These PP podiatrists are so desperate and thirsty for more patients that they are flocking to these stand-alone wound clinics in hopes for more business.

 

[edog10]

I did this for a while. It depends on the fee schedule/payer mix. Unless your clinic is really slow, this could be a massive loss for you. You will bill plenty of 11042 and 15275 but you will do it at the facility fee schedule and not the office fee schedule. I was getting reimbursed less for a 11042 in wound clinic than for a 11721 in office. Not to mention patients complain that why should they pay your bill when they already paid the wound clinic copay.

Of course I have friends who say wound clinic is a goldmine so YMMV

We can limit what insurances we will see. bluecross, medcost, medicare, etc
If they said we couldn't take some of the patient's to our office for "grafting" then I wouldn't even think about it.
They are giving us 3 nurses to use at our disposal, basically document and wrap/dress everything. I would be responsible for DX, billing and the plan.
HBO - Make $200 per patient per dive, 2 chambers

 

[Adam Smasher]

We can limit what insurances we will see. bluecross, medcost, medicare, etc
If they said we couldn't take some of the patient's to our office for "grafting" then I wouldn't even think about it.
They are giving us 3 nurses to use at our disposal, basically document and wrap/dress everything. I would be responsible for DX, billing and the plan.
HBO - Make $200 per patient per dive, 2 chambers

I told the director there that I would work at the wound clinic as long as it was mutually beneficial for us. After a year, it was apparent that it was not, which is why I'm no longer there. So give it a year and see if this is the best you can be doing, you'll make a big difference in people's lives, so good luck!

 

[HardRoadPaved]

https://www.hmpgloballearningnetwork.com/site/podiatry/videos/charting-course-success-limb-salvage-private-practice-one-surgeons-experience

I'm a surgical podiatrist practicing in Albuquerque, New Mexico. My expertise is diabetic limb salvage. That's all I do almost a hundred percent......There are days when I am so slammed that I have no time to round and I'm approaching burnout, 20 consults, 20 surgeries in a week or so.

From the inpatient side:

20 consults x $138.21 (Medicare fee schedule) = $2768.20
20 CPT 28005 90 day global x $559.24 = $11,184.80 high end or on low end CPT $138.38 28002 or $258.94 28003 0 day global low end (will bill post op days if you go)

So pay can range 350k-700k for just inpatient management side.

 

[heybrother]

We're all doing it wrong. I saw someone write a reddit post the other day saying podiatry was amazing.

See 25 a day
Bill $100 per patient
Work 5 days a week
Work 50 weeks a year
Keep 50% of it.
Boom. $300K.

I'm going to guess the person believes building a stable of 61 day 11056/11720 patients is good business.
25 patients a day x 5 days a week x 50 is 6250 "encounters". If you see each patient consistently 5 times a year then you only need 1250 patients.

 

[HardRoadPaved]

.... And that's without the shoes!

 

[Pronation]

https://www.hmpgloballearningnetwork.com/site/podiatry/videos/charting-course-success-limb-salvage-private-practice-one-surgeons-experience

I'm a surgical podiatrist practicing in Albuquerque, New Mexico. My expertise is diabetic limb salvage. That's all I do almost a hundred percent......There are days when I am so slammed that I have no time to round and I'm approaching burnout, 20 consults, 20 surgeries in a week or so.

From the inpatient side:

20 consults x $138.21 (Medicare fee schedule) = $2768.20
20 CPT 28005 90 day global x $559.24 = $11,184.80 high end or on low end CPT $138.38 28002 or $258.94 28003 0 day global low end (will bill post op days if you go)

So pay can range 350k-700k for just inpatient management side.

It still cracks me up when TFPs talk about their “expertise” in toe pus… the most basic and mindless cases that interns learn how to hold a knife on. What cracks me up even more is when ortho, vasc, or gen surg is like “oh yea for sure this complex toe infection case should go to the podiatric surgeon because they’re the expert” and the TFP on call eats it up like it was truly some giant compliment.

 

[DYK343]

It still cracks me up when TFPs talk about their “expertise” in toe pus… the most basic and mindless cases that interns learn how to hold a knife on. What cracks me up even more is when ortho, vasc, or gen surg is like “oh yea for sure this complex toe infection case should go to the podiatric surgeon because they’re the expert” and the TFP on call eats it up like it was truly some giant compliment.

Understanding of the compartments of the foot and tracking infections/fascial planes does take some knowledge that a lot of ortho/gen surg will not have.

But otherwise 100% agree. Easy cases. Get in there and flush it out. Rongeur the crap out of it.

When I was a resident with gen surg they were super light with the rongeur. They used to yell at me for being too aggressive with debridements. THey left visibly dead/infected tissue behind all the time "to wait for demarcation"

Meanwhile DPM attendings just had us go to town rongeuring all that crap out of there down to bleeding viable tissue.

Our results were always better/fewer surgical returns to OR for debridements.

We are better at it. At least in the hospital I trained.

 

[Boba Foot]

It still cracks me up when TFPs talk about their “expertise” in toe pus… the most basic and mindless cases that interns learn how to hold a knife on. What cracks me up even more is when ortho, vasc, or gen surg is like “oh yea for sure this complex toe infection case should go to the podiatric surgeon because they’re the expert” and the TFP on call eats it up like it was truly some giant compliment.

I mean, gen surgeons take decubs and anal abscesses to the OR. It’s not like they’re all hot **** with no unglamorous cases.

I don’t really see why limb salvage is looked down upon compared to gloating about TARs that are guaranteed to fail in 10-15 years. Salvage can pay better than elective stuff and I will gladly take it. Do not care if it’s “intern level stuff”, it is cash in the bank.

 

[AttackNME]

It still cracks me up when TFPs talk about their “expertise” in toe pus… the most basic and mindless cases that interns learn how to hold a knife on. What cracks me up even more is when ortho, vasc, or gen surg is like “oh yea for sure this complex toe infection case should go to the podiatric surgeon because they’re the expert” and the TFP on call eats it up like it was truly some giant compliment.

Toe pus is easy I agree, but midfoot and hindfoot necrotizing infections are scary for a lot of podiatrists, they’re often undertreated or misunderstood

 

[Pronation]

I mean, gen surgeons take decubs and anal abscesses to the OR. It’s not like they’re all hot **** with no unglamorous cases.

I don’t really see why limb salvage is looked down upon compared to gloating about TARs that are guaranteed to fail in 10-15 years. Salvage can pay better than elective stuff and I will gladly take it. Do not care if it’s “intern level stuff”, it is cash in the bank.

Don’t get me wrong here, I do a ton of pus which also translates to a ton of RVUs. Turning it away would be financial suicide.

 

[Feli]

Toe pus is easy I agree, but midfoot and hindfoot necrotizing infections are scary for a lot of podiatrists, they’re often undertreated or misunderstood

100% undertreated. Sadly, most podiatrists are scared to say BKA since that will shut the cash register off. Like most things, it's a product of saturation and that they "need" that wound care patient.

There is a line between "salvage" and just plain putting the patient through a ton of stuff and weekly or bi-weekly visits that won't work or won't work for long...

"The road to amputation is littered with bandages by people who thought that by dressing the wound that they were healing the wound."