Wound wizardry questions... inject abx???

[Feli]

So, I barely get wound care where I am. I have done a ton of it in the past and I do hold the wound CAQ (rofl) since there was nothing else to use hospital CME $ on during COVID, but they're generally not refers I encourage. I just handle them when they show up these days.

Today, I get two... both fairly bad, probably partial digit amps or more soon (MRI ordered, other probably will be soon).

So, a couple quick wound master questions:

1 - Injecting antibiotic (genta) in/near the wound???
I know there is basically experimental evidence for injects of cefazolin pre-op and such, but is this a common wound wizard and WCC thing for active wounds? Is it a billing thing? It seems as crazy as the day is long to me. I never learned of it... basically just the common sense to not inject anywhere near superficial infects as you could make them deep infects. The fluid pocket injected also makes perfect space for abscess to form. I do know it can be a last-ditch effort to inject Ancef or even vanco for septic joint, but this is skin/subQ. The chart notes from prior treating doc had used about 3 or 4 different PO abx as well as the inject genta repeatedly over the winter. I think that doc knew this wound was getting away from them and was counting the days down until the pt snowbirded back up to my area. Naturally, there was also the typical wound wizardry goops and some fancy dressings du jour in the charts - and I fully expect those, but the injects?
And speaking of driving infections deeper, the other pt had had extensive wound care history for toe tuft ulcers, and he had a k-wire put in the 2nd digit to stabilize a tuft ulcer hammertoe a couple years ago (wire pulled in office a bit later), and it's been draining from the pin site intermittently ever since. I'd bet dollars to doughnuts he has distal phalanx osteo, probably middle also... MRI pend. I do not plan to inject any antibiotics.

2 - Why does wound care pay so well?
Again, I don't like or encourage it, and I amp it fast when it's hopeless... but I run my own office, and [basic] wound stuff pays pretty well (higher E&Ms, quick proc, frequent f/u). So...
Is that because MDs or DPMs or both lobbied to get more for quick & easy stuff and took less RVU on the uncommon stuff?
Is it because wound care is lame and depressing... so it has to pay ok, or nobody would do it?
These are the questions keeping us up at night - not really, but still not sure of why. It's not hard work, but it does pay ok for the straightforward ones.

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[AttackNME]

You should do your part in gatekeeping and report this egregious medical decision making to the medical board and try to get this guy’s license revoked.

 

[DYK343]

So, I barely get wound care where I am. I have done a ton of it in the past and I do hold the wound CAQ (rofl) since there was nothing else to use hospital CME $ on during COVID, but they're generally not refers I encourage. I just handle them when they show up these days.

Today, I get two... both fairly bad, probably partial digit amps or more soon (MRI ordered, other probably will be soon).

So, a couple quick wound master questions:

1 - Injecting antibiotic (genta) in/near the wound???
I know there is basically experimental evidence for injects of cefazolin pre-op and such, but is this a common wound wizard and WCC thing for active wounds? Is it a billing thing? It seems as crazy as the day is long to me. I never learned of it... basically just the common sense to not inject anywhere near superficial infects as you could make them deep infects. The fluid pocket injected also makes perfect space for abscess to form. I do know it can be a last-ditch effort to inject Ancef or even vanco for septic joint, but this is skin/subQ. The chart notes from prior treating doc had used about 3 or 4 different PO abx as well as the inject genta repeatedly over the winter. I think that doc knew this wound was getting away from them and was counting the days down until the pt snowbirded back up to my area. Naturally, there was also the typical wound wizardry goops and some fancy dressings du jour in the charts - and I fully expect those, but the injects?
And speaking of driving infections deeper, the other pt had had extensive wound care history for toe tuft ulcers, and he had a k-wire put in the 2nd digit to stabilize a tuft ulcer hammertoe a couple years ago (wire pulled in office a bit later), and it's been draining from the pin site intermittently ever since. I'd bet dollars to doughnuts he has distal phalanx osteo, probably middle also... MRI pend. I do not plan to inject any antibiotics.

2 - Why does wound care pay so well?
Again, I don't like or encourage it, and I amp it fast when it's hopeless... but I run my own office, and [basic] wound stuff pays pretty well (higher E&Ms, quick proc, frequent f/u). So...
Is that because MDs or DPMs or both lobbied to get more for quick & easy stuff and took less RVU on the uncommon stuff?
Is it because wound care is lame and depressing... so it has to pay ok, or nobody would do it?
These are the questions keeping us up at night - not really, but still not sure of why. It's not hard work, but it does pay ok for the straightforward ones.

Zero experience with #1 other than septic joints and vanc which I have done in ankle in the past.

I have had patients not take their antibiotics orally and grind them up or take the capsule apart and "sprinkle the antibiotic on the wound". I can assure you it was not successful at clearing the infection lol

#2 I dont think it actually pays THAT well. At least not for me. A debridement down to and including subQ (which is most wounds) is about 1 wRVU.

Add in my crappy billers who wont let me add an office visit with it unless I CLEARLY do somemething above and beyond a wound and its really kind of a loss (new patient gets 9920X and 11042). If I prescribe antibiotic due to change in wound/infection, diagnose a new wound, discuss with patient the hammertoe is why they get the wound, etc they go back and change my 99213/4 to wound debridement only. I keep challening them and they still keep doing it/changing my billing. I get paid more to NOT debride the wound. If I debride I lose money because a 99213 pays more than a 11042.

This is a medium sized hospital system in the US with a billing department that covers multiple states. For some darndest reason they are in debt. No one can figure out why. Real head scratcher.

Surgically toe amps pay garbage. TMAs pay OK but 90 day global where they fall apart and become nightmares during global. Ray amps similar. TMA + Gastroc + STATT is a nice 1.5ish hr case but overall these diabetic cases can be hit or miss wRVU wise and worth time. I do 5 toe amps for every well paying diabetic surgical case.

 

[air bud]

No such thing as partial digit. Mpj or bust

 

[air bud]

Zero experience with #1 other than septic joints and vanc which I have done in ankle in the past.

I have had patients not take their antibiotics orally and grind them up or take the capsule apart and "sprinkle the antibiotic on the wound". I can assure you it was not successful at clearing the infection lol

#2 I dont think it actually pays THAT well. At least not for me. A debridement down to and including subQ (which is most wounds) is about 1 wRVU.

Add in my crappy billers who wont let me add an office visit with it unless I CLEARLY do somemething above and beyond a wound and its really kind of a loss (new patient gets 9920X and 11042). If I prescribe antibiotic due to change in wound/infection, diagnose a new wound, discuss with patient the hammertoe is why they get the wound, etc they go back and change my 99213/4 to wound debridement only. I keep challening them and they still keep doing it/changing my billing. I get paid more to NOT debride the wound. If I debride I lose money because a 99213 pays more than a 11042.

This is a medium sized hospital system in the US with a billing department that covers multiple states. For some darndest reason they are in debt. No one can figure out why. Real head scratcher.

Surgically toe amps pay garbage. TMAs pay OK but 90 day global where they fall apart and become nightmares during global. Ray amps similar. TMA + Gastroc + STATT is a nice 1.5ish hr case but overall these diabetic cases can be hit or miss wRVU wise and worth time. I do 5 toe amps for every well paying diabetic surgical case.

People saying wound care pays well are doing delayed primary closure, rotational flaps, filet flaps, etc....

 

[Feli]

...I have had patients not take their antibiotics orally and grind them up or take the capsule apart and "sprinkle the antibiotic on the wound". I can assure you it was not successful at clearing the infection lol...

Yeah, my residency hospital had ID teaching service with fellowship program, and when I rotated with them or had them on consult, they'd basically laugh in your face for any Rx topical antibiotics ideas (silver sulfa, mupirocin, genta crm, etc). They'd just say it's not going to hurt and that you can use betadine to dry wounds, but there's no strong literature evidence or recommendations for topicals, and it should typically only be in combo with IV or PO abx if the wound looks infected.

I did not ask them about podiatry TFP favorites such as gentian violet, putting abx eye drops on ingrowns, America Gel, or silver wound dressings, lol.

This injecting antibiotic for foot and toe wounds is either something new I'm not up to date on... or it's totally made up. I have never seen this in books or on boards or on rotations. I thought the patient was making it up or describing an irrigation or something, but then I had my office call for the prior tx records... wound/cellulitis injects roughly weekly for months.

 

[msion]

And speaking of driving infections deeper, the other pt had had extensive wound care history for toe tuft ulcers, and he had a k-wire put in the 2nd digit to stabilize a tuft ulcer hammertoe a couple years ago (wire pulled in office a bit later), and it's been draining from the pin site intermittently ever since. I'd bet dollars to doughnuts he has distal phalanx osteo, probably middle also... MRI pend. I do not plan to inject any antibiotics.

2 - Why does wound care pay so well?

Man...K-wire to stabilize toe ulcer... I am always scared of poor surgical outcomes and every surgical patient was a stressor for me. I think I am fine as a surgeon now reading this.

2. From E&M standpoint it's easy to get higher level of visits with wound care. Review an x-ray, prescribe antibiotics, review notes, labs. Easily level 4. Actual pay for 11042/3s vary from insurance to insurance. But these are usually recurring weekly/biweekly procedures that some DPMs depend on. Hospital wound care centers also have a facility fee added to that, last time I looked Medicare pays over $300 for the facility fee of 11042.

 

[dtrack22]

This injecting antibiotic for foot and toe wounds

…

it's totally made up.

☝🏼

 

[heybrother]

Perceptions of payment on Wound Care

#1 - The deeper than fat codes do pay well.
#2 - The wound codes are for wound up to like 20cm^2 but the most common wounds are less than 1.0 x 1.0 on the tip of a toe. The day they implement a 1.0 x 1.0 code will be a dark day for us.
#3 - The wound code reimbursement includes dressing supplies but most PP people are probably putting a bandaid on the wound.
#4 - We usually "win" when we use the same code everyone else does. The day they implement a code for "debridement of hand" is the day that a "debridement of foot" code pays less than it.
#5 - I was looking at the wound LCDs awhile back and my suspicion is a lot of debridements probably don't qualify ie. I believe there is supposed to be devitalized tissue. That thing where you scrape an already granular wound bed probably isn't supposed to apply. I'll go look at this again, but I somewhat suspect a more rigid evaluation of the LCD would disqualify some of what we do.
#6 - No global. It always makes me laugh if you have a choice between calling it an abscess vs a wound ie. a wound has closed, is infected, there's pus etc ... calling it a debridement is a lot safer than calling it a I&D if you need to see it again that week, next week since the I&D global is 10 days.
#7 - These visits do lend themselves to an E&M for whatever the deformity is.
#8 - Whenever dyk says something doesn't pay and discusses the RVUs - my suspicion is that if he had a scrappier more knowledgeable manager they would answer - "It does pay, it pays the hospital well".
# 9 - Commercial insurance at times pays a multiplier on Medicare CPT values. Meanwhile, commercial insurance often never caught up with the 2021 Medicare E&M values. So if you have the choice of getting paid 1.5x 11042 what Medicare currently pays or 88% of Medicare E&M - it can just be really nice on the reimbursement.

 

[DYK343]

#5 - I was looking at the wound LCDs awhile back and my suspicion is a lot of debridements probably don't qualify ie. I believe there is supposed to be devitalized tissue. That thing where you scrape an already granular wound bed probably isn't supposed to apply. I'll go look at this again, but I somewhat suspect a more rigid evaluation of the LCD would disqualify some of what we do.

Correct thats a selective debridement.

#8 - Whenever dyk says something doesn't pay and discusses the RVUs - my suspicion is that if he had a scrappier more knowledgeable manager they would answer - "It does pay, it pays the hospital well".

I complained about clipboard nurses in my last job. Those are gone now. Thank god.

Now ive moved onto complaining about the billers. I constantly am fighting them for changing my stuff despite good documentation to support billing. I've talked to management about it and got a response along the lines of "Yes, we are aware that our billing practices are along the conservative side of things"

 

[DYK343]

People saying wound care pays well are doing delayed primary closure, rotational flaps, filet flaps, etc....

Ahh yes the TFP "5th toe amputation with possible rotational flap closure" I see on the OR boards from time to time...

 

[Pronation]

Ahh yes the TFP "5th toe amputation with possible rotational flap closure" I see on the OR boards from time to time...

I find that the rotational flap closures heal so well that I only need to see them once in the office to take their sutures out. Without the rotational flap closure I generally find that I have to see them back many times in the office and frequently have to make them custom orthotics due to the sensitive skin from the effects on the subtalar joint axis and the neutral calcaneal stance position.

 

[Hybrocure]

The attendings at my residency billed every single toe amp as a soft tissue rearrangement or flap lol.

 

[dtrack22]

The attendings at my residency billed every single toe amp as a soft tissue rearrangement or flap lol.

Sounds like a program run by Boffeli…