Amniotic Fluid Injections - Alert

[air bud]

Regarding amniotic injection clawback, what are everyone's thoughts on if Medicare will do this for amniotic graft sheets for ulcers?

No

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[DYK343]

Tenaculum, pin distractor, 4.0 screw, simple 4 hole locking plate. I use a burr on the lateral side of the met and cuneiform. 60 minutes... 75 if I add in an Akin... Toe is straight when they leave the OR, without any magical bandage holding it straight either... I let them protected WB immediately.

All of these Lapidus systems are a joke...

Why the burr? Any particular reason or just to get past subchondral layer?

 

[Pronation]

Why the burr? Any particular reason or just to get past subchondral layer?

I find it easier to plane the lateral side with a burr than a saw. Easier to get down into the plantar aspect to make sure I'm not leaving a flare/shelf of bone and dorsiflexing the met. I'm not worried about the subchondral bone - I drill it and then beat the F out of it with an osteotome.

 

[DYK343]

leaving a flare/shelf of bone and dorsiflexing the met

THis is the key to a speedy lapidus. Recognizing that plantar lateral shelf.

I like the burr idea. I would be afraid to accidently chew up the 2nd met but im sure it works quite well

 

[air bud]

The one time I tried I burr I was like nope that **** is too aggressive and bad things are going to happen.. as Feli stated. You are shortening the 1st ray no matter what. Why are we crying over an extra 1 or 3 mm.

 

[Pronation]

The one time I tried I burr I was like nope that **** is too aggressive and bad things are going to happen.. as Feli stated. You are shortening the 1st ray no matter what. Why are we crying over an extra 1 or 3 mm.

Did you use an egg burr? I think they are too big and unwieldy inside the TMT. Also, as you said, they cut way too aggressively.

I use the Tapered cross cut fissure burr.

Cutting accessories

www.stryker.com

 

[HardRoadPaved]

Why are we crying over an extra 1 or 3 mm.

Bc if you're sitting for BC case review they'll ding you

 

[air bud]

Bc if you're sitting for BC case review they'll ding you

Yes, even with patient happy and satisfied and returned to full activity....Don't get me started on that...

 

[Podstar]

Scrubbed a lapiplasty with an outside attending this past week and he threw the intercuneiform screw. He told me to make sure I put in my dictation that we prepped the joint when we didn’t even touch it…

 

[heybrother]

Scrubbed a lapiplasty with an outside attending this past week and he threw the intercuneiform screw. He told me to make sure I put in my dictation that we prepped the joint when we didn’t even touch it…

I've done 2 since we started this thread. Both times I sat there for a moment during each case looking at these intervals thinking what a b*tch it would be to prepare them. Here's how absurd this is. Treace goes on FOREVER about preparing the 1st TMTJ interval. Removing cartilage. Minimal bone cuts. Drilling - never a kwire - and pulling the graft into the space. Irrigating before drilling so you don't wash out your bone. But how do we fuse the extra joints - we throw a screw across them.

 

[dtrack22]

I've done 2 since we started this thread. Both times I sat there for a moment during each case looking at these intervals thinking what a b*tch it would be to prepare them. Here's how absurd this is. Treace goes on FOREVER about preparing the 1st TMTJ interval. Removing cartilage. Minimal bone cuts. Drilling - never a kwire - and pulling the graft into the space. Irrigating before drilling so you don't wash out your bone. But how do we fuse the extra joints - we throw a screw across them.

Treace has to get their $8,000 kit into surgery centers somehow…

 

[ExperiencedDPM]

Scrubbed a lapiplasty with an outside attending this past week and he threw the intercuneiform screw. He told me to make sure I put in my dictation that we prepped the joint when we didn’t even touch it…

That is 100% insurance fraud. I sure hope you didn’t dictate a part of the procedure that never happened.

 

[ExperiencedDPM]

Treace has to get their $8,000 kit into surgery centers somehow…

That’s the roadblock they are running into. Surgical centers are not allowing this set due to cost. Unlike hospitals, the surgery centers can’t bill for these sets. They want to use the least expensive stuff out there.

The surgeons panic, since the insurance company wants the surgery done at an ASC vs hospital due to cost savings, but the ASCs won’t allow the set. The panic starts when these surgeons realize that they have no idea how to perform a free hand Lapidus.

I have NO problem with the Lapiplasty set. However, it has created a huge increase in billing fraud.

I’ve been consulted to review more of these cases than any other product with the exception of the thieves who bill a STJ arthrodesis or ORIF of a talo tarsal dislocation for performing an arthroereisis.

 

[Podstar]

That is 100% insurance fraud. I sure hope you didn’t dictate a part of the procedure that never happened.

I didn’t but I went back and checked the co-sign and addendum and it was added in by the attending. Frustrating because the attending went on to show and teach me how to bill for that afterwards and if I wasn’t on here as a resident I really wouldn’t have known better at this point.

 

[ExperiencedDPM]

I didn’t but I went back and checked the co-sign and addendum and it was added in by the attending. Frustrating because the attending went on to show and teach me how to bill for that afterwards and if I wasn’t on here as a resident I really wouldn’t have known better at this point.

I would urge you to never take advice from this attending again and distance yourself from him/her. There is never a way to rationalize pure fraud.

An operative report is a medical record and legal document. Documenting something in an op report that never happened is criminal.

I assure you that if this attending did this in this case, he or she practices fraud on a regular basis. There is no one who is partially honest. Either you’re a thief or you aren’t. And this doctor is a thief, a criminal and a fraud.

And he/she has placed you in jeopardy. If this was ever reviewed or audited in a lawsuit, you would be called to testify and you would have no choice but to tell the truth.

Sorry, this stuff pisses me off big time. And you can thank these types of a-holes for screwing it up for the rest of us. His/her actions are NOT benign.

 

[HardRoadPaved]

And he/she has placed you in jeopardy. If this was ever reviewed or audited in a lawsuit, you would be called to testify and you would have no choice but to tell the truth.

Technically they didnt dictate that the portion happened and the attending added it in. All the person has to do is say "I did hundreds of cases as a resident. Well if its not in the medical record I put in, then I dont have any other additional comment as I have no further recollection."

I was deposed as a resident in a case and I just used that explanation when the plaintiffs lawyer wanted to trap me bad mouthing. Things you say in a deposition can be brought in future suits by the way so its best not to talk too much in a case.

 

[ExperiencedDPM]

Technically they didnt dictate that the portion happened and the attending added it in. All the person has to do is say "I did hundreds of cases as a resident. Well if its not in the medical record I put in, then I dont have any other additional comment as I have no further recollection."

I was deposed as a resident in a case and I just used that explanation when the plaintiffs lawyer wanted to trap me bad mouthing. Things you say in a deposition can be brought in future suits by the way so its best not to talk too much in a case.

I have been hired as an expert in MANY cases and know how the system works

Even though the addending added the addendum, the resident has already admitted awareness of the fraud. So it’s too late to comment that he/she did hundreds of cases, etc. The attending has put the resident in a very precarious situation. It’s not months or years later, the resident already knows and admits his or her knowledge of what was performed and what was dictated.

Saying anything but the truth at a deposition or trial is simply lying.

 

[air bud]

That’s the roadblock they are running into. Surgical centers are not allowing this set due to cost. Unlike hospitals, the surgery centers can’t bill for these sets. They want to use the least expensive stuff out there.

The surgeons panic, since the insurance company wants the surgery done at an ASC vs hospital due to cost savings, but the ASCs won’t allow the set. The panic starts when these surgeons realize that they have no idea how to perform a free hand Lapidus.

I have NO problem with the Lapiplasty set. However, it has created a huge increase in billing fraud.

I’ve been consulted to review more of these cases than any other product with the exception of the thieves who bill a STJ arthrodesis or ORIF of a talo tarsal dislocation for performing an arthroereisis.

How is michael graham still a thing?

 

[ExperiencedDPM]

How is michael graham still a thing?

They dude has dodged so many bullets. When his product first came out, he told docs to bill it as a 28725 (subtalar arthrodesis) with a 52 modifier as a reduced service. I attended a lecture where he said this and I asked a question. I asked how you can bill a reduced service when you haven’t performed ANY part of the procedure. Dropping that blob of metal in the sinus tarsi doesn’t even expose the STJ let alone fuse any portion of it, etc, etc.

That crap went on for years and he finally got slapped around. Then he renamed it an “extra osseous” blob and told people to bill a 28585 as an ORIF of a talo tarsal dislocation. I can ASSURE you that he and all his disciples have never even seen a talo tarsal dislocation. More pure fraud.

So then he sends out a “manuscript” discussing how it’s a dislocation and quoted Webster’s dictionary. More BS and fraud. A dislocation is not a subluxation and a subluxation is not a dislocation. And some hypermobility is not a dislocation.

Then he was called out again on that BS (even though many of his disciples still bill it fraudulently) so he now tells people to do it in the office and charge the patient.

His product gained some popularity in Europe and they don’t deal with insurance so he didn’t have to spew his BS there.

And I was contacted last week by an insurer to review 3 op reports from a provider who is doing Lapiplasty’s. He unbundled the procedures to a 28292 and 28740 AND billed for an ORIF of a tarsal metatarsal joint (for the met cun joint). This guy will be paying back big bucks because he’s billed this way for his last 32 cases.

I should send him a thank you note. He just paid for my new carbon road bike.

 

[heybrother]

I've said this before - I still don't understand how it makes it this far. BCBS literally has me in purgatory on a CMT case with a calcaneal osteotomy where they won't pay until they get the note. Meanwhile, some other guy has been paid 32 times for an unbundled bunion.

 

[ExperiencedDPM]

I've said this before - I still don't understand how it makes it this far. BCBS literally has me in purgatory on a CMT case with a calcaneal osteotomy where they won't pay until they get the note. Meanwhile, some other guy has been paid 32 times for an unbundled bunion.

I understand your frustration. It’s all based on whether your case gets pulled for review.

I was at a seminar a few years ago and there was a DPM from some hick town in NJ who was lecturing on HyProCure. Apparently he does them for anyone with a pulse. He “bragged” that he does them ALL the time and bills for an ORIF of a talo tarsal dislocation and gets paid all the time.

As someone who knows the industry pretty well, I’m amazed he’s never been flagged, considering the fact that he bills this all the time and that most DPMs (and MDs) rarely if ever actually bill the CPT code 28585, since few of us really see true talo tarsal dislocations.

Since he must be way off the charts compared to his peers billing code, it’s incredible he hasn’t been audited. He’s statistically way off compared to peers and that is what usually triggers concern.

 

[HardRoadPaved]

He’s statistically way off compared to peers and that is what usually triggers concern.

It's all public luckily with CMS data

Centers for Medicare & Medicaid Services Data

data.cms.gov

 

[Feli]

I didn’t but I went back and checked the co-sign and addendum and it was added in by the attending. Frustrating because the attending went on to show and teach me how to bill for that afterwards and if I wasn’t on here as a resident I really wouldn’t have known better at this point.

You have no liability as a resident... no worries.

You obviously don't want to ever falsify medical records, and I agree that "sometimes you learn what NOT to do" during residency. Still, any malpractice or insurance audit or etc etc would go on the attending who is supervising the case/clinic or the facility that employs you. Residents are pretty much immune unless it's gross misconduct on their part, which would just get them probation, suspension, fired, etc. As mentioned, you could potentially get deposed or interviewed or whatever regarding malpractice or an audit related to your residency, but even that's pretty unlikely since any suit or audit would probably be years after you graduate training. You just keep quiet and play the 'I was under supervision and doing as I was told' card.

Don't sweat any dumb stuff attendings do would ever pin to you. You aren't the one boarding the cases or submitting the billing. Associate is a whole other story, though... fraud billing, fraud DME, balance billing, upcoding, etc by the ownership can be very risky to the associate.

 

[ExperiencedDPM]

It's all public luckily with CMS data

Centers for Medicare & Medicaid Services Data

data.cms.gov

Only with Medicare cases.

 

[ExperiencedDPM]

You have no liability as a resident... no worries.

You obviously don't want to ever falsify medical records, and I agree that "sometimes you learn what NOT to do" during residency. Still, any malpractice or insurance audit or etc etc would go on the attending who is supervising the case/clinic or the facility that employs you. Residents are pretty much immune unless it's gross misconduct on their part, which would just get them probation, suspension, fired, etc. As mentioned, you could potentially get deposed or interviewed or whatever regarding malpractice or an audit related to your residency, but even that's pretty unlikely since any suit or audit would probably be years after you graduate training. You just keep quiet and play the 'I was under supervision and doing as I was told' card.

Don't sweat any dumb stuff attendings do would ever pin to you. You aren't the one boarding the cases or submitting the billing. Associate is a whole other story, though... fraud billing, fraud DME, balance billing, upcoding, etc by the ownership can be very risky to the associate.

I never said the resident would get in trouble or be liable. I said it would put the resident in a precarious situation.

Attendings like the one described are the scum of our profession. They are too stupid and brazen to realize that now their fraud is known to the residents, etc.

Yep, I have zero tolerance for this kind of crap. Thank these docs for decreased reimbursements to offset fraudulent claim losses.