60 plantar wart removals

[AK WK]

We had to do excision of 60 warts total in the OR removal of lesions with punch biopsies and hyfrecator, 40 on the right and 20 on the left (2 years of conservative treatment failed). Please see the attached photos. As you can see multiple, diffuse, mosaic, different sizes, etc.

Can we bill for 60 lesion removals?? And what would be the appropriate CPT?

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[NatCh]

CPT 17111 "Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions"

 

[AttackNME]

Wow! I have not treated someone for this many warts but I would bill as Natch suggested. Have you considered implantation of some warty tissue into muscle belly? I've seen it done before as a sorta self-vaccine thing.

 

[NatCh]

Wow! I have not treated someone for this many warts but I would bill as Natch suggested. Have you considered implantation of some warty tissue into muscle belly? I've seen it done before as a sorta self-vaccine thing.

I've performed the autoinoculation treatment several times with good success without needing to implant it into a muscle belly. I've used a punch biopsy, reversed the cylindrical biopsy specimen, then bandaged it in place upside down within the same hole. As long as the patient doesn't actually pop the plug out of the hole when they change their Band-Aids, it will heal in place. When I have multiple verruca similar to the above post I would consider this treatment. It's pretty impressive when you have multiple verruca that disappear after only treating the one site. It's like magic (but it's science)!

 

[AttackNME]

I've performed the autoinoculation treatment several times with good success without needing to implant it into a muscle belly. I've used a punch biopsy, reversed the cylindrical biopsy specimen, then bandaged it in place upside down within the same hole. As long as the patient doesn't actually pop the plug out of the hole when they change their Band-Aids, it will heal in place. When I have multiple verruca similar to the above post I would consider this treatment. It's pretty impressive when you have multiple verruca that disappear after only treating the one site. It's like magic (but it's science)!

Pretty neat! What size punch? Do you send another sample to pathology? Would you ever do this for a persistent singular lesion? I imagine if I have one wart that never goes away and wanna do autoinoculation, to send half to pathology.

 

[NatCh]

Use the largest punch that fits, either a 3mm or a 5mm, depending on how big the wart is. I target the biggest or most pronounced-looking wart in a cluster, or whichever one would be the least painful to anesthetize since people generally hate pain. For example, if it's on a toe then those are easy to numb without pain compared to beneath a met-head. In the photos above I might've picked one of the lesions on the plantar left hallux.

After disinfecting the surface with an alcohol wipe I'll drive the punch all the way until it bottoms out at the hilt then cut the base with an #11 blade, flip the plug 180deg using sterile forceps then reinsert. Be ready with some gauze to sponge blood. If it's on a toe then an Esmarch helps prevent bleeding all over the place during the procedure. You might even want to add a small piece of Gelfoam under the bandaid. Cover with a bandaid such that the telfa layer doesn't pull the plug out when the patient changes it in 24-48 hours. Tell them to change the bandaid carefully without pulling out the plug.

You certainly could do two punches, sending one specimen to Path, but I don't do so routinely if it looks very wart-like since it would add a few hundred bucks to the patient's bill probably unnecessarily. If the lesion looks questionable to begin with or if it doesn't respond to treatment pretty soon then I may send a specimen. If it looks like a standard issue wart, has been present for years before seeing me and the patient hasn't died yet, then I reason that it's probably not malignant (fingers crossed) and is just a persistent wart.

I've done it on persistent solitary lesions, yes, although it's not my usual first-line treatment. One patient had a 1cm diameter solitary wart on a lesser digit for years, recalcitrant to several previous treatments before he saw me. Since he'd tried so many other things I went right for the auto inoculation and it resolved in about four weeks.

Edit: I figure that this technique is similar to "needling" as described below but using a punch biopsy instead.

The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

 

[Creflo]

Great posts, thanks NatCh.

 

[AttackNME]

Use the largest punch that fits, either a 3mm or a 5mm, depending on how big the wart is. I target the biggest or most pronounced-looking wart in a cluster, or whichever one would be the least painful to anesthetize since people generally hate pain. For example, if it's on a toe then those are easy to numb without pain compared to beneath a met-head. In the photos above I might've picked one of the lesions on the plantar left hallux.

After disinfecting the surface with an alcohol wipe I'll drive the punch all the way until it bottoms out at the hilt then cut the base with an #11 blade, flip the plug 180deg using sterile forceps then reinsert. Be ready with some gauze to sponge blood. If it's on a toe then an Esmarch helps prevent bleeding all over the place during the procedure. You might even want to add a small piece of Gelfoam under the bandaid. Cover with a bandaid such that the telfa layer doesn't pull the plug out when the patient changes it in 24-48 hours. Tell them to change the bandaid carefully without pulling out the plug.

You certainly could do two punches, sending one specimen to Path, but I don't do so routinely if it looks very wart-like since it would add a few hundred bucks to the patient's bill probably unnecessarily. If the lesion looks questionable to begin with or if it doesn't respond to treatment pretty soon then I may send a specimen. If it looks like a standard issue wart, has been present for years before seeing me and the patient hasn't died yet, then I reason that it's probably not malignant (fingers crossed) and is just a persistent wart.

I've done it on persistent solitary lesions, yes, although it's not my usual first-line treatment. One patient had a 1cm diameter solitary wart on a lesser digit for years, recalcitrant to several previous treatments before he saw me. Since he'd tried so many other things I went right for the auto inoculation and it resolved in about four weeks.

Edit: I figure that this technique is similar to "needling" as described below but using a punch biopsy instead.

The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

Great info, I may try that, thanks for sharing! Have you had problems with patients accidentally pulling out the plug or having to manipulate it back into the hole? I imagine putting a loose stitch might help me sleep better.

 

[NatCh]

I've only had one patient accidentally remove the plug but that's a good idea to use a suture.

 

[dtrack22]

but I don't do so routinely if it looks very wart-like since it would add a few hundred bucks to the patient's bill probably unnecessarily.

Somewhere, Brad Bakotic just punched a kitten...

Otherwise, great post!

 

[NatCh]

Somewhere, Brad Bakotic just punched a kitten...

Otherwise, great post!

Ha, totally! Every time I see him lecture I get all panicked but then I come to my senses before long.