ACFAS Coding and Billing Course

[Ipronate]

I will be graduating form residency next year and am looking to learn more about coding and billing. In particular, I'm looking at the two options below.

ACFAS in person course: "Coding and Billing for the Foot and Ankle Surgeon" for $400 + travel expenses: ACFAS - Coding and Billing for the Foot and Ankle Surgeon

They also offer an online course: "Coding Fundamentals OnDemand" for $125 (resident member price): American College of Foot and Ankle Surgeons: Coding Fundamentals 2024

For those who have attended similar in person ACFAS courses, would you recommend it?
If you've done the OnDemand course do you recommend it?
Are the in person courses significantly better than the OnDemand option?
Also, are there better coding/billing courses/resources you recommend?

Thank you for your insight!

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[Adam Smasher]

APMA dues your first year in practice are very inexpensive, it was about $177 for me. That opens you up to some prerecorded webinars on coding e/m, modifiers, nails, and ulcers. That's a solid foundation for you.

I found the ACFAS billing course to be excellent as well, but that was before there were online offerings. Generally in-person lectures are good if you like to ask questions of the presenters or want to reconnect with people but online courses can be perfectly fine too

 

[ExperiencedDPM]

I do not recommend the ACFAS billing course. A few of our associates went over the past few years and came home with some “pearls” that could have gotten them in trouble. One of our certified coders is also an RN who was an OR nurse who worked ortho and pod cases. She KNOWS coding and edits and nuances. She flipped out when they showed her some of what was taught.

So now we pay her to train our staff.

 

[Forcewielder]

I found it helpful, but I feel like the only way to really learn is by trial and error. Obviously you need the basics but once you start getting stuff denied or you have the billing department hounding you, you learn quick.

 

[air bud]

There is one coming up in Chicago this november. It's interesting there's actually going to be done in conjunction with aofas. And then also there's specific talk about wound care coding which has not been a focus necessarily. It's also the day and a half course which will be much more in depth than the one-day course at acfas. I am going assuming my job will give me time off...

 

[msion]

The best resource I found to be helpful was actually spending some time at attending's clinic and went over billing.
The courses do teach you some "tricks" or "don't leave the money on the table" kinda thing. It's nothing new. All the codes and associated ICD 10s are already in any coding book.

But honestly the best way to avoid audits and denials is to keep it simple. Weird and scary things start to happen when you add in multiple modifiers, and multiple lines of CPTs.

I would say at this time a great majority of my clinic is either a 992x3 or 992x4, or one or two lines of CPT codes for dedicated clinic procedures. Just make sure the CPT match with the one of the common associated ICDs to get paid.

After this the insurances that still give you issues or keep denying claims are the ones you need to drop.

 

[Feli]

...Just make sure the CPT match with the one of the common associated ICDs to get paid.

After this the insurances that still give you issues or keep denying claims are the ones you need to drop.

Be nice to Hew manna.

...but yeah, spot on. Most coding is very basic.
Nearly all of the specialties do the same stuff over and over - but the best of them do it efficiently and with better payers. For us, that's just e&m, injects, DME, RFC, IGN and various derm proc. For rheum or PM&R is injects... derm, it's excisions and biopsies... FP/IM is office visits... GI is e/m and scopes, etc. There is no need to re-invent the wheel, and as a specialist, you will have most common office codes memorized in a few years.

I always tell residents to collect superbill code sheets from attendings they like while shadowing in office, review them, then make their own (most are 80-90% similar, but it has serious learning value to type it up and organize it oneself).

Surgery coding podiatry is a bit harder as there are more you need to look up and you have to definitely put the highest RVU code first line, but it's still fairly straightforward if you have a code book or website. In PP of any type, it's your own NPI (or your biz if owner), so you can't pull the "aggressive" OR surgery coding that inpt/hospital/wound pods can try. Well, you could... but it usually doesn't end well.

 

[Podstar]

Any recommendations for good basics online course that is reasonably priced to do before starting as a new attending?

 

[deleted1162946]

Any recommendations for good basics online course that is reasonably priced to do before starting as a new attending?

Would like to know as well.. or any reading available?

 

[GreenHousePub]

Come work for me. I'll teach you all about billing and coding and give you a lucrative salary of 90k a year.

Fellowship training a must, or you better have a decade of research experience to be considered.

 

[ExperiencedDPM]

Learn about “edits” which are codes that should not be billed together. Using a modifier like 59 on surgical coding does not erase the edit. It’s to designate that it’s a different pathology in a different location.

I would invest in a subscription to Optum 360 Encoder Pro or Code-X. I use these almost exclusively for surgical coding. They show edits, exclusions, etc.

Please google Medicare’s “definition” of modifier 59 and you’ll see how it’s often used incorrectly. Also, erase from your mind that a separate incision justifies billing an additional procedure. We don’t get paid according to how many incisions we make.

And go on CMS.gov and find the NCCI policies. These are government documents that private insurance companies DO follow.

The most applicable chapters for what we do are chapters 1 and 4 with some info that’s applicable in 3 and 9.

These are not podiatric specific, but you will be enlightened and learn an amazing amount about the editing rules, especially chapters 1 and 4. It will take you 15 minutes to read both and you’ll learn why you don’t get paid for many of these edits.

It’s a game changer when it comes to understanding billing, especially surgical.

 

[Retrograde_Nail]

Please google Medicare’s “definition” of modifier 59 and you’ll see how it’s often used incorrectly. Also, erase from your mind that a separate incision justifies billing an additional procedure. We don’t get paid according to how many incisions we make.

Can you elaborate?

If I fix a bunion and then make a new and separate incision to fix a hammertoe and then I make another new and separate incision to fuse a joint in the hindfoot I should be able to bill all three procedures as they are addressing different pathologies/problems for the patient.

 

[PMG03470]

Can you elaborate?

If I fix a bunion and then make a new and separate incision to fix a hammertoe and then I make another new and separate incision to fuse a joint in the hindfoot I should be able to bill all three procedures as they are addressing different pathologies/problems for the patient.

I think he means the people who try to bill a hammertoe arthrodesis separately from a capsulotomy at the MPJ. Because it was a different incision when both procedures are correcting the hammertoe and thus this is considered unbundling

 

[heybrother]

I think he means the people who try to bill a hammertoe arthrodesis separately from a capsulotomy at the MPJ. Because it was a different incision when both procedures are correcting the hammertoe and thus this is considered unbundling

Your example is specifically called out here (below). Unfortunately I know of someone who is completely convinced that you can bill hammertoe corrections + MPJ capsulotmy and their comment is "our hospital coders know the rules".

If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure,”the procedure is subject to NCCI PTP edits based on this designation. CMS does notallow separate reporting of a procedure designated as a “separate procedure” when it isperformed at the same patient encounter as another procedure in an anatomically relatedarea through the same skin incision, orifice, or surgical approach.

https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-4.pdf

 

[ExperiencedDPM]

Can you elaborate?

If I fix a bunion and then make a new and separate incision to fix a hammertoe and then I make another new and separate incision to fuse a joint in the hindfoot I should be able to bill all three procedures as they are addressing different pathologies/problems for the patient.

Of course that’s okay. I’m talking about making an incision to perform a bunionectomy with a distal osteotomy. And then making a different incision to perform an Akn. And then making a small incision for the lateral release. That’s one CPT code which is 28299, a bunionectomy with double osteotomy. It can’t be unbundled to component procedures simply because you made 3 incisions.

 

[msion]

Your example is specifically called out here (below). Unfortunately I know of someone who is completely convinced that you can bill hammertoe corrections + MPJ capsulotmy and their comment is "our hospital coders know the rules".

This. The hospital employed or the coders are the worst offenders for this type of thing.

Say I did a hammertoe and Weil. A hospital DPM told me to bill 28308, 28270, and 28285. Also bill the codes for local blocks.
The most epic example is probably bill Lapidus as TMT fusion plus met head work as long as the notes said there is instability involved, per the coder.

But at the same time they are pretty strict with clinic procedures. If you see a new patient coming in with an ingrown toenail and you did a procedure, apparently you can only bill the CPT for the procedure, but not the office visit for the new patient. The hospital coder won't allow that even you did talk to patient about something else, include other diagnoses and prescribed medication. Per the hospital coder "CPT has an intrinsic EM component to it."

It's weird. I don't know.

 

[Adam Smasher]

On the subject of coding, has anyone gotten approached for Qutenza yet? (Topical capsaicin patch delivery system claiming to reduce/resolve neuropathic pain, administered in clinical setting.) The manufacturer Averitas distributes billing info including advice on how to buy-and-bill (lol, no thanks). In addition to the J code, they also suggest for administering the drug CPT 64640 (external neurolysis of plantar nerves) which reimburses quite well when you figure it's just applying the patches and monitoring the patient for side effects for 30 min.

I looked up the code in a manual which suggests you need to inject something or apply a RF nerve ablation device or do some otherwise invasive treatment. My question: is 64640 appropriate? Or is the company making things up just to sell drugs? Or have I answered my own question?

 

[ExperiencedDPM]

This. The hospital employed or the coders are the worst offenders for this type of thing.

Say I did a hammertoe and Weil. A hospital DPM told me to bill 28308, 28270, and 28285. Also bill the codes for local blocks.
The most epic example is probably bill Lapidus as TMT fusion plus met head work as long as the notes said there is instability involved, per the coder.

But at the same time they are pretty strict with clinic procedures. If you see a new patient coming in with an ingrown toenail and you did a procedure, apparently you can only bill the CPT for the procedure, but not the office visit for the new patient. The hospital coder won't allow that even you did talk to patient about something else, include other diagnoses and prescribed medication. Per the hospital coder "CPT has an intrinsic EM component to it."

It's weird. I don't know.

Most insurance companies will consider 28270 inclusive to 28285 or 28308. There is an edit with 28285 and you already have the capsular tissues open for the Weil (basically).

Billing for local anesthesia is included in the surgical procedure when performed by the surgeon. This is clearly addressed in NCCI.

Don’t get me started on your Lapidus comment. A Lapidus is a Lapidus is a Lapidus. It is a bunionectomy with a first TMT fusion. Doesn’t matter if your secondary dx is an arthritic TMT joint, hypermobilty, instability, etc. Your are still performing a bunionectomy with first TMT fusion. There is ONE correct code…28297.

I know all the BS arguments and that there is no CCI edit for 28292/28740.

BUT NCCI clearly states that you must bill to the highest specificity and if there is one code that describes what you’re doing you must be that one SINGLE code.

And in the insurance world NCCI trumps the CCI edits in the CPT manual.

The above is factual not opinion.

 

[deleted285117]

On the subject of coding, has anyone gotten approached for Qutenza yet? (Topical capsaicin patch delivery system claiming to reduce/resolve neuropathic pain, administered in clinical setting.) The manufacturer Averitas distributes billing info including advice on how to buy-and-bill (lol, no thanks). In addition to the J code, they also suggest for administering the drug CPT 64640 (external neurolysis of plantar nerves) which reimburses quite well when you figure it's just applying the patches and monitoring the patient for side effects for 30 min.

I looked up the code in a manual which suggests you need to inject something or apply a RF nerve ablation device or do some otherwise invasive treatment. My question: is 64640 appropriate? Or is the company making things up just to sell drugs? Or have I answered my own question?

Qtenza is a joke. I tell people to buy OTC capsaicin and occlude it with seran wrap wherever they want the effect. Boom. Ghetto-style Qtenza.

Saved the patient $500 👍😁

 

[msion]

On the subject of coding, has anyone gotten approached for Qutenza yet? (Topical capsaicin patch delivery system claiming to reduce/resolve neuropathic pain, administered in clinical setting.) The manufacturer Averitas distributes billing info including advice on how to buy-and-bill (lol, no thanks). In addition to the J code, they also suggest for administering the drug CPT 64640 (external neurolysis of plantar nerves) which reimburses quite well when you figure it's just applying the patches and monitoring the patient for side effects for 30 min.

I have used it once, and only once. Patient didn't need pain meds for the neuropathy prior to the application, but required Norco for 3 days after the application due to the severe burning pain. It's so backwards.

Screw this company and the product. Never again. The really bad neuropathy patients get spinal cord stimulators anyway. Or they smoke weed which is surprisingly effective if you happen to live in the right state.

 

[Feli]

Qtenza is a joke. I tell people to buy OTC capsaicin and occlude it with seran wrap wherever they want the effect. Boom. Ghetto-style Qtenza.

Saved the patient $500 👍😁

I buy capsaicin at the dollar (+25c) store and sell it for $3 in my office. Often just give it to ppl.

...Don’t get me started on your Lapidus comment. A Lapidus is a Lapidus is a Lapidus. It is a bunionectomy with a first TMT fusion. Doesn’t matter if your secondary dx is an arthritic TMT joint, hypermobilty, instability, etc. Your are still performing a bunionectomy with first TMT fusion. There is ONE correct code…28297.

I know all the BS arguments and that there is no CCI edit for 28292/28740....

You forget that it's 28740 + 28292... plus another 28740 for the intercunieform screw "spot weld"?!? 🙂

...Say I did a hammertoe and Weil. A hospital DPM told me to bill 28308, 28270, and 28285. ...

If you legit do all three, you can bill them. There are plenty of cavus hammertoes, bad PDS, RA or various bad claw foot situations, etc that you legit do both (or all three) procedures for a digit/ray. As ExpDpm said, the 28270 almost always gets tossed by most payers (even if it was performed).

Hospital billing is much different. Some of them get paid for what rvu they bill out, and it's the hospital and not so much the doc NPI it's all billed under. They will often do the amps + bone biopsy, add plastics codes to a lot of stuff, nerve repairs with a lot of stuff, unbundle a lot of stuff. If you bill like that in PP with your own/group NPI, it'll likely blow up in your face very fast.

I think he means the people who try to bill a hammertoe arthrodesis separately from a capsulotomy at the MPJ. Because it was a different incision when both procedures are correcting the hammertoe and thus this is considered unbundling

That is not a hard and fast rule. Some hammertoes need MPJ release +/- EDL lengthen, and most others don't. Some payers allow both codes, most will not.

 

[heybrother]

When the Quetenza people spoke to my office manager they wanted you to bill (a) an office visit (b) the nerve code - that doesn't fit (c) and the J code. The impression I was under was that probably all the money was made on the difference between what you paid for the patches and what you got reimbursed on the J code. It would potentially blow a patient's mind to know you are billing hundreds of J code units on this that is going to come out to like more than $1000 a patch. This is again probably another Medicare only product like grafts. Don't know that - but strongly suspect it. The other issue is that if you try to do it on Medicare Advantage plans you may have a fee schedule (again your reimbursement is not what you deserve - its what you can negotiate) in which you are reimbursed a percentage of Medicare on J codes. You could potentially be looking at sub-Medicare reimbursement and then potentially losing 8-9% out of it through an EHR like Athena. A lot of doctors - oncologists, rheumatologists, etc - have made money on these differentials between cost and reimbursement, but this wasn't something I was particularly excited about. Especially because I got a lot of people to try OTC capsaicin through the years and most of them did not like it, benefit etc

In fact this is one of my favorite encounters of all time -

Patient following up on neuropathy:
Me: We had talked about trying capsaicin cream the last time you were here. Did you try it?
Patient: "Oh yes. That was a funny trick you played on me."

 

[heybrother]

Last of all - the current lapidus trickery is - 28740 + 28270 and you don't take anybone from the 1st metatarsal head because by definition a bunionectomy requires a medial eminence resection. Insurance figured out the 28740 + 28292 or whatever forever ago.

ExpDPM is not wrong that Chapter 4 of the CMS MSK document says a bunion is a bunion - stop unbundling. Meanwhile, there are actualy famous podiatry coder speakers describing and writing about the above.

 

[Feli]

I can't get over how obsessed podiatry is with surgery codes.
For the hospital limb guys who do rvu bonuses and do 3+ amps and a couple DPCs and a recon or two per week (1.5+ days per week in OR)... I get it (esp if they're paid regardless of collect and they aren't 50% on all non-primary CPTs each OR case). Surgery is how you get paid, you have to throw up a ton and hope most sticks.

But for the vast majority of podiatrists, the surgery CPTs are just such a small % of our overall revenue (assuming you don't own ASC you do them at). There is less than 5% of DPMs in the country that do not make 5x as much on 11750 and 20550 and L4361 as they do on 28297 or 27792 or 28285.

For the newer grads, if you just get the basics of clinical coding, the surgery coding is not too hard (you just look most stuff up each time you board/bill cases)... and the surgery nuances are pretty inconsequential in the grand scheme if you're group pod/msg/ortho paid on collections. Don't be those guys arguing how to get more out of de/reattach coding when you are not even coding DME that you do every single day right. 🙂

 

[air bud]

I can't get over how obsessed podiatry is with surgery codes.
For the hospital limb guys who do rvu bonuses and do 3+ amps and a couple DPCs and a recon or two per week (1.5+ days per week in OR)... I get it (esp if they're paid regardless of collect and they aren't 50% on all non-primary CPTs each OR case). Surgery is how you get paid, you have to throw up a ton and hope most sticks.

But for the vast majority of podiatrists, the surgery CPTs are just such a small % of our overall revenue (assuming you don't own ASC you do them at). There is less than 5% of DPMs in the country that do not make 5x as much on 11750 and 20550 and L4361 as they do on 28297 or 27792 or 28285.

For the newer grads, if you just get the basics of clinical coding, the surgery coding is not too hard (you just look most stuff up each time you board/bill cases)... and the surgery nuances are pretty inconsequential in the grand scheme if you're group pod/msg/ortho paid on collections. Don't be those guys arguing how to get more out of de/reattach coding when you are not even coding DME that you do every single day right. 🙂

I still get annoyed at DME and why it reimburses the way it does. It's an dumb camboot you can buy for 60 bucks on Amazon. The "skill" with fitting it and determining it's use is captured in the EM code. Surgery you are getting paid for a skill.

Also OTC orthotics.

DME is stupid.

Fight me.

 

[Feli]

I still get annoyed at DME and why it reimburses the way it does. It's an dumb camboot you can buy for 60 bucks on Amazon. The "skill" with fitting it and determining it's use is captured in the EM code. Surgery you are getting paid for a skill.

Also OTC orthotics.

DME is stupid.

Fight me.

You, being a layperson, have noooo idea how to properly tighten those CAM walker velcro straps or make sure the boot is sized properly within an inch of the most lengthy digit's digtal tuft - not just its distal nail fold. Further, you will often fail miserably at planning for the girth of the upcoming surgical bandage... or you will not pump the pumpy air thing very well. You may not like getting charged 5-10x more for something just because a high school (or equivalent) educated MA explains it to you, but you need that intel, good sir.**

Realize that hundreds of folk just in the USA and probably trillions of people worldwide cause 1-2% ruptures to their Achilles fibers or strain 1-3% of grastroc myofibrils annually from improper use of generic online night splints. Buyer beware. Don't get me started on broken straps flying like a tow chain and causing blindness.

"Simple" little drug store or DIY walmart ankle braces, you say? Well well well. For this one, I just give you the eloquent response from my old supergroup pictured below... your eyes are obviouisly too naked to know rigorous standard when they see them!

**trust me bro, deada$$

 

[heybrother]

We're in a profession where people figured out that 11720 + g0217 pays better than 11721. Adding another code is surviving.

 

[ExperiencedDPM]

Last of all - the current lapidus trickery is - 28740 + 28270 and you don't take anybone from the 1st metatarsal head because by definition a bunionectomy requires a medial eminence resection. Insurance figured out the 28740 + 28292 or whatever forever ago.

ExpDPM is not wrong that Chapter 4 of the CMS MSK document says a bunion is a bunion - stop unbundling. Meanwhile, there are actualy famous podiatry coder speakers describing and writing about the above.

Don’t ever mention some of those “famous” podiatry coders in my presence. It may get ugly. That famous coder should stick to which modifier to use when cutting nails. The amount of inaccurate advice he’s given is astounding.

 

[ExperiencedDPM]

I buy capsaicin at the dollar (+25c) store and sell it for $3 in my office. Often just give it to ppl.


You forget that it's 28740 + 28292... plus another 28740 for the intercunieform screw "spot weld"?!? 🙂


If you legit do all three, you can bill them. There are plenty of cavus hammertoes, bad PDS, RA or various bad claw foot situations, etc that you legit do both (or all three) procedures for a digit/ray. As ExpDpm said, the 28270 almost always gets tossed by most payers (even if it was performed).

Hospital billing is much different. Some of them get paid for what rvu they bill out, and it's the hospital and not so much the doc NPI it's all billed under. They will often do the amps + bone biopsy, add plastics codes to a lot of stuff, nerve repairs with a lot of stuff, unbundle a lot of stuff. If you bill like that in PP with your own/group NPI, it'll likely blow up in your face very fast.


That is not a hard and fast rule. Some hammertoes need MPJ release +/- EDL lengthen, and most others don't. Some payers allow both codes, most will not.

The famous spot weld arthrodesis. That all started with the Ohio group. I don’t care what happens 6 months after you throw that screw across the joint. Of course there will be bony growth around the screw. But if you don’t expose and prep a joint, you haven’t performed an arthrodesis.

So if you make a stab incision in the heel and insert a nail into the tibia, is that a spot weld ankle fusion?

 

[Flip-flop-flerpity]

Listen guys, this is all going to get sorted out when Kamala passes Medicare for All

 

[deleted1162946]

Listen guys, this is all going to get sorted out when Kamala passes Medicare for All

And we make a resident’s salary permanent.. 🙂

 

[heybrother]

Income would presumably drop for most people. Funny things about Medicare though.

FYI - Medicare has through my practice experience paid better than:

-Essentially all Medicare Advantage plans
-United commercial
-Aetna commercial - my IPA had a great contract with them 10 years ago, but alas, no more
-BCBS Marketplace plans (these have actually slightly improved, but you still have to collect from them)
-A bunch of other marketplace plans I declined to join
-It pays better for DME than almost anyone - that might be right or wrong, but you don't question it after a free Medicare surgery when you L4361 them. It pays $150 better for a boot than most commercial plans.
-It pays better for E&M visits than almost all commercial plans in my area except Cigna, but only after I joined an IPA. Not kidding. Pays better than BCBS PPO. I've had Medicare pay $30 better than some commercial insurances for a 99213 since the 2021 change
-It pays almost identically to S&W, but it doesn't fraudulently deny your claims and play modifier games.
-It doesn't require prior authorizations for surgery or MRIs.
-You can place a patient in a skilled nursing facility afterwards without a 3 day wait/ prior authorization that gets denied because the patient must not need it if they already spent 3 days at home.
-Patients who have it don't really go to collections because they have secondaries.
-You don't spend your weekends writing emails to Medicare.
-It obviously pays garbage for surgery and procedures in private practice. Good commercial insurance pays almost 2.5X what Medicare pays for an ASC surgery. Good in office procedure reimbursement rates beat it regularly by 1.6-2.1x.
-Medicare does provide an in office fee schedule for most surgeries so if you were to so daring as to try and bring MIS procedures into the office there is slightly more money available.
-It doesn't keep up with inflation and its paid very hit or miss through time. At one point (2001) it paid $87 for a 20550 which is $30 something more than it pays now in my area. In 2015 it paid $215 for a 11750 which is like $60 more than it pays now. When its rate dropped like $45 in 2016 I'm sure that frustrated the hell out of everyone.
-It massively overpays hospitals who buy up outpatient doctors and bring their work onto the OPPS fee schedule rather than the physician fee schedule.
-It does pay G2211. This is very important to hardpavedroad.
-From a cash flow perspective pays much more rapidly than most insurances. I've got insurances that don't pay for 3 months.
-Hilariously, Medicare is essentially the only insurance that pays for grafts if you are into that sort of thing.

A few years when I was still seeing Humana and getting started I probably would have welcomed Mfa. Now that I've cleared out most of my bad insurances, I'd take an enormous income hit. Like routinely $100 hits on 11750, $40 hits on injections, $900 hits on bunions. I'd immediately drop facility surgery. I've gotten pretty cold blooded about not cutting a nail or callus that is uncovered without making the patient pay. There would be ice in my veins at this point.

 

[msion]

Listen guys, this is all going to get sorted out when Kamala passes Medicare for All

We are almost there in California to be honest. Some 30% of the population are on Medicaid, another 20% on Medicare. And counting the market place plans pretty much a great majority of CA is under government insurances.

 

[Feli]

We are almost there in California to be honest. Some 30% of the population are on Medicaid, another 20% on Medicare. And counting the market place plans pretty much a great majority of CA is under government insurances.

New Mexico is 42% MCA and 21% MCR right now... top in the USA. Absolutely wild.
You have two out of three people getting something for nothing.
MCA here actually doesn't pay terrible, but it's not sustainable, especially in larger states. No matter how you spin it, it amounts to health care for more and more pts, yet the same pool of taxes/money.

It'll be interesting in USA overall as AI and automation makes more and more jobs obsolete or less necessary (thus increasing the MCA population % even more). Through politics changes (obamacare type stuff, etc) or more people un/underemployed, we will basically get to socialized medicine - and concierge - one way or another. I will quite happily be out the game by then.

I sometimes wonder if these VC and supergroups fully understand that they might be conquering an empire of dirt. As the un/underemployed rises, most people will still have "insurance," but you'll have basically a single payer deciding the rates for docs and hospitals due to their controlling the growing number of ppl who stay at home (old, poor, debility, disabled, job/skill no longer needed, etc).

 

[Homo sapien]

You, being a layperson, have noooo idea how to properly tighten those CAM walker velcro straps or make sure the boot is sized properly within an inch of the most lengthy digit's digtal tuft - not just its distal nail fold. Further, you will often fail miserably at planning for the girth of the upcoming surgical bandage... or you will not pump the pumpy air thing very well. You may not like getting charged 5-10x more for something just because a high school (or equivalent) educated MA explains it to you, but you need that intel, good sir.**

Realize that hundreds of folk just in the USA and probably trillions of people worldwide cause 1-2% ruptures to their Achilles fibers or strain 1-3% of grastroc myofibrils annually from improper use of generic online night splints. Buyer beware. Don't get me started on broken straps flying like a tow chain and causing blindness.

"Simple" little drug store or DIY walmart ankle braces, you say? Well well well. For this one, I just give you the eloquent response from my old supergroup pictured below... your eyes are obviouisly too naked to know rigorous standard when they see them!

**trust me bro, deada$$


View attachment 390595

This place is replicated nationwide. Dme is ****in stupid

 

[Adam Smasher]

Yes I have long maintained that the L4361 is the absolute holy grail of profitability in PP. Is there a rational basis for these reimbursement rates? No. Is there a rational basis to be slashing reimbursements for ingrown nails and other procedures we do that actually help people? Also no. I like to hope that it all evens out in the long run.

 

[Feli]

This place is replicated nationwide. Dme is ****in stupid

That group is in 3 states now, multiple offices in each. Many similar 'supergroups' do the 99% same model. Fwiw, that review was after I'd left... not one of my pts, lol.

It is pretty shortsighted to ever tell patients DME (or anything) will be covered, but they hire a lot of new grad who will just be trying to hit bonuses any and every way they can - esp after they are converted to straight % after salary first year. I just tell patients "X will be sent to your insurance," but to guarantee coverage consistently causes problems. In that group, I had patients almost daily who were mad about their bills from other group docs for toenail clip "pathology" bills also. They were usually not even told the clippings were sent for histo or what the costs might be. This one pretty much sums up the supergroup biz overall model to perfection. They mainly want grafts and vascular refers... DME and other podiatry is good too.

 

[heybrother]

I think one of the things that is interesting about DME in medicine is that DME is one of the only things we "know the value of". We know we paid so much money and we know we were reimbursed so much. Its also interesting again because for whatever reason we are reimbursed so much better than we are paying.

For whatever reason that doesn't apply to a lot of our other supplies. I lose money on the Kenalog/Betamethasone etc ingredients on every shot I give last I did the math. Maybe pricing has stabilized, but over the last 3 years we've had non-stop issues acquiring anesthetics (lidocaine and marcaine both) and steroids with essentially surge pricing occurring for these products.

I had my staff check the price at like every distributor, but 20 mg of kenalog ie. 1/2 a mL of 40mg/ml Kenalog reimburses at like $1-2. The bottle is 10 mL which means it has 20 doses of 0.5mL doses. 20 x $2 is $40 and we were paying dramatically more than this per bottle to allow us to render a procedure - a cortisone injection - that Medicare already underpays (20550, 20605, 20600 etc) to the tune of about $30 when compared against a 99213 visit.

However dishonest it may be to tell a patient "their cam boot is covered by insurance" - there's a substantial component of medicine that is essentially based on providing non-transparent pricing with our care. A new patient comes in for plantar fasciitis. You offer them a shot. Do you think the patient with commercial insurance realizes that the act of sticking a needle in their foot potentially adds $100 to the visit? I don't get a lot of complaints about this - if it works - but there is no pricing menu sitting out in my office for patients. As they ask for more, they pay more. I've had people blow up in the past. A patient shows up for bilateral toenail surgery but wants to talk about arthritis and x-rays and what not and he's got this bizarre insurance that pays even more than BCBS. He's calling the office to complaint that he's got like a $600-700 bill but when he was being roomed he had no issue telling the nurse about all the problems he was having. And these bills are nothing compared to what the same complaints would generate in a hospital where a 20550 is $1000.