Uh oh…..is the cash party over?

[DYK343]

It depends. If 20% of my patients would ultimately become symptomatic sub 2nd met after a 1st TMT fusion would I put 100% of them through a 2nd met head surgery? No. If that number was 80%? Sure.

I’ve seen plenty of X-rays where the 2nd met is long from a textbook standpoint and patient had no symptoms. It’s certainly not a guarantee. The lapiplasty also shortens the first met, are the social media lapiplasty folks downplaying the complication rate of a shortened 1st met in terms of transfer pain? I could certainly believe that.

I’m not saying there is inherently anything wrong with prophylactic procedures. But how I answered those questions like the ones above in my head, would largely dictate wether I end up doing it or not.

The convo here has largely been what the Dr thinks. I think the ultimate answer here is to tell the patient the risks of sub 2nd metatarsalgia and let them decide.

They probably dont want more prophylactic surgery but you need to tell them what can happen and may require a 2nd surgery in the future.

I would wager 75% of the people i have this discussion with request the prophylactic Weil.

Key is not to lie, oversell, or undersell. Just gotta be honest with what you know and think. Patients like that.

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[NatCh]

There was a poster on this forum maybe a little over a decade ago who (IIRC) said that she routinely did global lesser metatarsal shortening osteotomies whenever she did Lapidus in order to have a nice parabola. I wonder if she still does that?

I couldn’t help but think that it would sentence the patient to always needing to buy two different sizes of the same shoe.

 

[DYK343]

There was a poster on this forum maybe a little over a decade ago who (IIRC) said that she routinely did global lesser metatarsal shortening osteotomies whenever she did Lapidus in order to have a nice parabola. I wonder if she still does that?

I couldn’t help but think that it would sentence the patient to always needing to buy two different sizes of the same shoe.

Krabmas?

 

[NatCh]

They probably dont want more prophylactic surgery but you need to tell them what can happen and may require a 2nd surgery in the future.

I would wager 75% of the people i have this discussion with request the prophylactic Weil.

A patient I’m working on now had a prophylactic Weil with her Lapiplasty by someone else previously. She has the dreaded floating 2nd toe. “No one told me that could happen.”

 

[NatCh]

Krabmas?

Yeah. Do I remember it right?

 

[DYK343]

Yeah. Do I remember it right?

The days of Jonwill, Krabmas, Ilizarob are so long ago. I cant remember. The discussions today are far different than they used to be though. Were definately more bitter now. We upgraded to pitchforks.

Ive been posting on here since 2007 but deleted my account awhile back then reactivated. Its crazy how much time of my life ive "wasted" on here lol.

 

[DYK343]

A patient I’m working on now had a prophylactic Weil with her Lapiplasty by someone else previously. She has the dreaded floating 2nd toe. “No one told me that could happen.”

Happens. Sucks when it does. But mega short lapidus also causes issues sub 2nd. I would say I dont weil more than I do with bunions but when the 1st is short its short and gotta discuss it with the patient. I also discuss possibility of the floating toe. I typically do the double parralel cut 2nd met osteotomy which doesnt plantarflex the 2nd met and i havent had much issues with floating toe.

Edit: clarity/typos.

 

[NatCh]

The days of Jonwill, Krabmas, Ilizarob are so long ago. I cant remember. The discussions today are far different than they used to be though. Were definately more bitter now. We upgraded to pitchforks.

Ive been posting on here since 2007 but deleted my account awhile back then reactivated. Its crazy how much time of my life ive "wasted" on here lol.

Yeah, the tone of this forum has really changed over the years

 

[Feli]

The days of Jonwill, Krabmas, Ilizarob are so long ago. I cant remember. The discussions today are far different than they used to be though. Were definately more bitter now. We upgraded to pitchforks.

Ive been posting on here since 2007 but deleted my account awhile back then reactivated. Its crazy how much time of my life ive "wasted" on here lol.

He works about 2hr from me now... I try to send him the TAA, Charcot recon, 4th intervention after a major trauma, etc consult ppl that I dont' want to do... but I think most of them figure out from my facial expression that the surgery is a longshot.

Yeah, the tone of this forum has really changed over the years

100%

 

[HardRoadPaved]

A long second met is pathology.

What's the icd10 for billing purposes

 

[Weirdy]

Its crazy how much time of my life ive "wasted" on here lol.

"Well if you can't find a job, at least you can put SdN mOdErAtOr on your resume." - Wife

 

[MalleableMan]

Just to chime in.. I would not prophylactically do an osteotomy on an asymptomatic 2nd met after a lapidus.

I’d rather educate my patients pre op to take a chance with orthotics than deal with the risks of a Weil for “prophylactic” purposes. There’s absolutely no evidence that transfer metatarsalgia is inevitable.. especially if the 1st ray sagittal plane is accounted for (like a lapidus is supposed to be done)

A lapidus can be done without resecting a cm of bone from the MCJ.. stupid cut guides.

 

[deleted1149159]

What's the icd10 for billing purposes

I don't believe there is one. You can use M77.4 and then "1" for right or "2" for left. That's just "Metatarsalgia". This is what I do when billing for lesser met osteotomy (28308) and it pays every time in the NE.

 

[ExperiencedDPM]

I’m confused….prophylactic surgery? So now you’re performing surgery on Trojans?

 

[HardRoadPaved]

I don't believe there is one. You can use M77.4 and then "1" for right or "2" for left. That's just "Metatarsalgia". This is what I do when billing for lesser met osteotomy (28308) and it pays every time in the NE.

That was kind of my point. Cant just do as @EDPM said "work on trojans." Metatarsalagia is pain of the metatarsals but if its asymptomatic then how can you bill that code. Computers will always pay you but when @EDPM gets a hold of your op note they can easily claw that money back.

(a better code would be M21.961 or some other unspecified acquired deformity of the extremity)

 

[msion]

Just to chime in.. I would not prophylactically do an osteotomy on an asymptomatic 2nd met after a lapidus.

I’d rather educate my patients pre op to take a chance with orthotics than deal with the risks of a Weil for “prophylactic” purposes. There’s absolutely no evidence that transfer metatarsalgia is inevitable.. especially if the 1st ray sagittal plane is accounted for (like a lapidus is supposed to be done)

A lapidus can be done without resecting a cm of bone from the MCJ.. stupid cut guides.

True. I feel like at this point in my life the first ray/medial column is a lot more important in our field. A well performed lapidus should really re-establish some of the more normal mechanics and may even help with some of the more common foot problems we treat.
Heck I am even doing less and less hammertoe surgeries nowadays. Those semi-rigid ones won't be fully straight after a first ray procedure, but a great majority of them will eventually have less dorsiflexion at the MTPJs after 6 months or so. At least for my patients they are not really bothered by them and even happy that they didn't have to commit to the hammertoe surgeries initially. The rigid hammertoes are a different story of course.
Just my 2 cents. For me it's a win that I don't have to do a forefoot slam. One line of CPT 29297 and less than 2 hours for a case make my surgery day and billing so much easier.

 

[NatCh]

I’m confused….prophylactic surgery? So now you’re performing surgery on Trojans?

There's a joke in here somewhere involving Ilizarov...

 

[ExperiencedDPM]

That was kind of my point. Cant just do as @EDPM said "work on trojans." Metatarsalagia is pain of the metatarsals but if its asymptomatic then how can you bill that code. Computers will always pay you but when @EDPM gets a hold of your op note they can easily claw that money back.

(a better code would be M21.961 or some other unspecified acquired deformity of the extremity)

Not an accurate comment about claim reviews. When I’m asked to review a surgery already performed, it’s not about medical necessity. Medical necessity is determined on the front end in the pre-authorization process.

When I’m requested to review a surgery already performed, I am not sent the entire office chart and records. I’m sent the operative report and codes billed.

I am not reviewing for medical necessity. I am reviewing for the appropriateness of the billing. Did the surgeon perform what was billed? Did the surgeon embellish a procedure in the billing? Did the surgeon unbundle? Did the surgeon bill the correct code(s), etc.?

When they ask for the op report AND prior records, that’s when there is suspicion and you may want to change your underwear. That’s an investigation and/or audit.

 

[deleted1149159]

That was kind of my point. Cant just do as @EDPM said "work on trojans." Metatarsalagia is pain of the metatarsals but if its asymptomatic then how can you bill that code. Computers will always pay you but when @EDPM gets a hold of your op note they can easily claw that money back.

(a better code would be M21.961 or some other unspecified acquired deformity of the extremity)

"Unspecified" codes tend to get more scrutiny than I'm comfortable with. Then you'll be asked for your op note, etc, and it generally goes downhill from there. That being said, I don't operate on asymptomatic issues. Unless it's a suspect skin or soft tissue lesion.

 

[ExperiencedDPM]

"Unspecified" codes tend to get more scrutiny than I'm comfortable with. Then you'll be asked for your op note, etc, and it generally goes downhill from there. That being said, I don't operate on asymptomatic issues. Unless it's a suspect skin or soft tissue lesion.

I don’t agree. Unlisted codes will be reviewed, but why should that cause discomfort.

The reason it’s reviewed is simply to let the reviewer know what procedure is being associated with the unlisted procedure.

The reason for most denials on these cases is simply because the provider didn’t identify which procedure was being attached to the unlisted code.

Somewhere in the operative report it needs to state that the unlisted code is for a plantar plate repair, lesser metatarsal implant, endoscopic gastroc recession, etc.

However, an unlisted code can only be used if there is no specific code for the procedure performed.

Of course I’m referring to unlisted CPT codes.

 

[Pronation]

I don’t agree. Unlisted codes will be reviewed, but why should that cause discomfort.

The reason it’s reviewed is simply to let the reviewer know what procedure is being associated with the unlisted procedure.

The reason for most denials on these cases is simply because the provider didn’t identify which procedure was being attached to the unlisted code.

Somewhere in the operative report it needs to state that the unlisted code is for a plantar plate repair, lesser metatarsal implant, endoscopic gastroc recession, etc.

However, an unlisted code can only be used if there is no specific code for the procedure performed.

Of course I’m referring to unlisted CPT codes.

I would love to hear some input on this from our PP members. When I was an associate sucker in PP, I gave up on these unspecified codes as insurance would waste a ton of time reviewing documentation, exploding my AR, and then ultimately denying it.

#RVUs4Lyfe

 

[ExperiencedDPM]

I would love to hear some input on this from our PP members. When I was an associate sucker in PP, I gave up on these unspecified codes as insurance would waste a ton of time reviewing documentation, exploding my AR, and then ultimately denying it.
#RVUs4Lyfe

95% of the cases I was asked to review regarding unlisted codes, did NOT have the reason for the request specified by the provider.

As a reviewer, I can guess what the unlisted code is for, but I’m not allowed to guess.

So most of the aggravation you have experienced is likely due to billing the code without explanation.

Be proactive. When you bill an unlisted code for a surgery, send the operative report with the claim. Do NOT use a hi-lighter to emphasize the portion of the op report designated as the unlisted procedure. When claims are sent electronically, copied, etc., the hi-lighted area often comes out blackened.

Instead, bracket the area AND have an addendum designating “unlisted code 28899 is being billed for XXXXXXXXXXX because there is no accurate CPT code to describe this procedure”.

If requesting an unlisted code for pre authorization you again have to let those reviewing the claim know what procedure you are requesting for the unlisted code.

This does and will work.

I have found that the majority of these issues are the fault of lazy office staff. Not the provider. Not the reviewer, etc. It is lazy or poorly trained office staff.

I can give hundreds of examples. Unfortunately the majority of DPM practices don’t employ a certified coder who is familiar with the nuances of billing.

Message me if you want details.

 

[air bud]

95% of the cases I was asked to review regarding unlisted codes, did have the reason for the request specified by the provider.

As a reviewer, I can guess what the unlisted code is for, but I’m not allowed to guess.

So most of the aggravation you have experienced is likely due to billing the code without explanation.

Be proactive. When you bill an unlisted code for a surgery, send the operative report with the claim. Do NOT use a hi-lighter to emphasize the portion of the op report designated as the unlisted procedure. When claims are sent electronically, copied, etc., the hi-lighted area often comes out blackened.

Instead, bracket the area AND have an addendum designating “unlisted code 28899 is being billed for XXXXXXXXXXX because there is no accurate CPT code to describe this procedure”.

If requesting an unlisted code for pre authorization you again have to let those reviewing the claim know what procedure you are requesting for the unlisted code.

This does and will work.

I have found that the majority of these issues are the fault of lazy office staff. Not the provider. Not the reviewer, etc. It is lazy or poorly trained office staff.

I can give hundreds of examples. Unfortunately the majority of DPM practices don’t employ a certified coder who is familiar with the nuances of billing.

Message me if you want details.

Can you give examples of appropriate usage of unlisted codes? A lesser MPJ implant sounds like a good one to start with.

 

[ExperiencedDPM]

Can you give examples of appropriate usage of unlisted codes? A lesser MPJ implant sounds like a good one to start with.

Look at my prior post. I gave 3 examples. Lesser MTPJ implant, plantar plate repair, endoscopic gastroc recession.

 

[dtrack22]

endoscopic gastroc recession.

Are they using an unlisted code to try and bill/collect more than they would for the open gastroc? The CPT for a gastroc recession describes what you’re doing accurately wether you use a camera or not.

 

[ExperiencedDPM]

I don’t think they are trying to beat the system. Some have been denied when they billed 27687 so now they bill as unlisted which is not incorrect.

 

[deleted1149159]

@ExperiencedDPM thank you for the very useful insight! Extraordinarily useful stuff.

 

[ExperiencedDPM]

@ExperiencedDPM thank you for the very useful insight! Extraordinarily useful stuff.

I’m happy to help. I believe I have experience that is unique and I can honestly say that what I write is very accurate. I would not want to disseminate inaccurate info.

I’m happy to answer any questions via private message if anyone has specific questions that he/she may not want posted publicly.

 

[AttackNME]

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