"Big stuff doesn't pay much anyways ... you won't do much RRA after residency"

[Feli]

This gets debated or echoed all of the time on here (and in podiatry in general):

"The big stuff doesn't pay," "surgery doesn't pay well," "you make more by not doing surgery," "you make most of your money in the office," etc.

The numbers and the logic don't support this... at all:

https://apma.cms-plus.com/files/2018%20Practice%20Survey%20Results_FINAL.pdf

or
www.acfas.org/compensation/

I think that it's best to have as much to offer your patients and the community as possible. Mainly, you need to be able to tell referral sources like PCPs, ERs, Urgent Cares, specialists, etc that they can send you whatever. This applies to any practice situation, esp PP. I've never had an ER call me to ask me if I can do a metatarsal fracture... and the reason for that is just that I tell them when I start at that hospital "I can handle pretty much anything below the knee." If they ever sent me a tib/fib or something I didn't want, I simply refer it promptly, but they want to know they can just send me anything and I can do 99.5% of it or refer the 0.5% out quick and appropriately. That barely ever happens, though. Whatever an office or ER calls with, I just say "send it," and the only ones I've ever not been able to handle were due to PAD or the patient personality/psych... and even those still get E&M and I was able to help them.

We often fail to realize that those who get strong training and do full F&A surgery can also still do the conservative injects, bracing, orthotics, testing, etc. It's not like since I do the triple I couldn't do the 3 injections and the Arizona brace and PT refer first. The only difference is that having the surgical skills lets you see patients through to the end.. which is great for practice rep, patient trust, and many other things. Obviously, surgery doesn't pay zero either. Even in the global, the XR, the casts, the DME, complications, other problems to break the global, etc all pay you. Those are the reasons all of the surveys have the surgically trained and certified DPMs making more income on average.

Lastly, if you want employed jobs (ortho, hospital, MSG, etc), those will by and large prefer surgically trained DPMs since they will usually have plenty of them in the application pool. For PP, it can be more variable, but good training helps to protect you from being limited... and can give you improved negotiation power also.

Bottom line: don't sell yourself short on training. Don't listen to the noise that it's fine to settle, fine to not try for boards, etc. Try to achieve your potential. You can duck the cases but you lying to patients that they don't need surgery is something you can't escape. Don't miss out on gaining skills... you won't be able to go back later. There are plenty of Harvard trained attorneys who don't work a bigshot govt or Fortune 100 job, but there are hardly any Podunk Law School attorneys who are competitive for major firms or trials. Podiatry is no different. Training matters... it translates into results - for you and for your patients.

...Without “superstars” our profession will remain stagnant. Without “superstars” our profession will always be followers and not leaders...

Those who don’t perform major rearfoot, reconstructive and ankle surgery ... are always preaching how you really can’t make any money doing those cases.

Sure, you can make lots of money hawking $700 orthoses when the majority of those patients would have equal success with a pair or $50 PowerSteps.

Sure, you can convince a patient to have laser surgery for nails for lots of money, knowing that it won’t have any beneficial effect.

Sure, you can sell antifungal nail polish at your front counter, knowing you’ve REALLY helped patients with that crap.

Sure, you can sell vitamins to “cure” their neuropathy, knowing they can buy the same ingredients at Target.

... Is it all about how much more you can make in your office or is about offering and providing the best care, regardless of reimbursement?

And for what it’s worth, I know lots of well trained DPMs who perform a LOT of major cases and are doing VERY well financially...

Yeah, I trimmed a lot of this post quoted above, but it is all pretty spot-on.

It is good to be able to offer as many services as possible, and it does statistically pay more to be doing RRA and surgery... and to be board certified.

/rant

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[NobodyDPM]

The APMA article you cited has a sample size of about 500. There are roughly 14K Podiatrists in the USA. Do you consider what the APMA published a representative sample of our profession? Just to do the math, the APMA article represents about 3.6% of the Podiatrists in this country. If in residency you had a journal club, they should have discussed statistical significance and sample size with you. Did they?

I don't have my ACFAS account info on me so I can't check out the other article. I'll check it out at lunch time.

I can tell you absolutely, that where I practice, you make far more money in your office, than in the OR. And despite what others may say, or think, I can do "the big stuff".

How about this. Get the best training you can get. Then use what you are comfortable with. THE BOTTOM LINE is that the only people this should be important to is YOU and YOUR PATIENTS. Not some random nobody know it all on some internet forum.

 

[Shiyuan]

My dremel is more powerful than your blade will ever be!!! 😜

 

[HardRoadPaved]

My dremel is more powerful than your blade will ever be!!! 😜

Well my Stryker TPS is even more powerful than your nail salon device!!!

How about this. Get the best training you can get. Then use what you are comfortable with. THE BOTTOM LINE is that the only people this should be important to is YOU and YOUR PATIENTS. Not some random nobody know it all on some internet forum.

At the end of the day, not everyone is going to get a good residency. Also think about how awful some of your classmates were with their hands, academics, personality... but if you have all three then its such a shame to waste three years of training at a country club residency.

Surgery pays well when you're not in a PP situation and can rely on RVU. Go get awesome training and get the best job you can.

 

[Shiyuan]

Well my Stryker TPS is even more powerful than your nail salon device!!!

Ouch... well, as it was stated before, back to the ol’ nail jail...

 

[NobodyDPM]

Well my Stryker TPS is even more powerful than your nail salon device!!!

At the end of the day, not everyone is going to get a good residency. Also think about how awful some of your classmates were with their hands, academics, personality... but if you have all three then its such a shame to waste three years of training at a country club residency.

Surgery pays well when you're not in a PP situation and can rely on RVU. Go get awesome training and get the best job you can.

Bolded mine.

If you look at the limited data shown in the APMA article cited, you will see that only about 40% are not in a private practice situation. So the majority of us, have to deal with the PP situation. And the majority of you will be as well. If you want to look at data analysis of only 3.6% of practicing podiatrists, that is. Food for thought.

 

[NobodyDPM]

Sample size of the ACFAS data is less than 400.

2.9% of all Podiatrists in the USA. Representative sample? I personally don't think so. YMMV.

What's also important and vacant from this data is demographics. Where do these practitioners work? What state? What city? Cost of living plays a huge role in pay. If they are all in CA, they need to be making that kind of money for cost of living purposes. It's not just "ZOMG, I make a quarter million dollars a year!!!". Economics 101, folks.

 

[GreenHousePub]

I got paid 648 to do a calcaneal osteotomy. Then it's free follow ups for the next 90 days.

 

[Feli]

I got paid 648 to do a calcaneal osteotomy. Then it's free follow ups for the next 90 days.

Correct (with some payers), but you would have gotten zero if you didn't have the rep to get that referral and skill to do the case, right?

And the correct way to look at that patient can also be new pt eval with XR set and pre-fabs, f/u eval with orthotics, f/u eval for brace, f/u with surgery discussion and CAM boot and crutches, patient goes out to get labs and MD visit which spreads your name around the community, you bill surgery codes (648), then many XRs at f/u visits, possibly orthotics post-op if architecture changed... I would guess that's more like $5k+ than just 648 there from that pathology. Also, that person might even become your possible patient for life who could have other procedures/injuries later or refer others down the line.

The crux of this is that idea is that those schedule slots where RRA patients go or would go don't automatically fill in with new patient warts and ingrowns when we don't or can't do the real surgical procedures. It's best to have as many offerings as we can. I comes back to you in many ways.

...At the end of the day, not everyone is going to get a good residency...
...Go get awesome training and get the best job you can.

Yes.

 

[heybrother]

Should you do right by people? Yes
Should you try to get good training? Yes
Should you understand the foot and ankle to the best of your ability? Yes
Should you offer full service for things you are accomplished at and is it probably good for business, referrals? Yes
Does being ortho or hospital employed pay well? Yes

Otherwise its a battle.

-I got paid $593 by a commercial insurance plan to do an Achilles tendon the other day.
-Real procedures from "decent" insurance does pay money, but it doesn't pay amazing money by any means. ie. a Blue Cross lapidus is $1100, ankle fusion is $1700, evans is $1200, ATFL repair $1200.
-All of the above surgeries can be better tolerated if secondary procedures are added that don't greatly change the recovery.
-Essentially if you are going to operate you must do everything you can to prevent complications, choose your patients carefully, and manage the post-op.
-The global is in truth 45 days too long and presumes every patient is a healthy 15 year old.
-If you see these patients above weekly for 90 days that's a hell of a lot of visits.
-My wife has had 2 c-sections. The first Obgyn saw her twice. The second saw her once. A flexor tenotomy gets more follow-up.

Now for the dirty. Non-payment. As in no payment at all. Reviews after the fact. Having to submit every document again. Claiming no prior authorization is required and then demanding a prior authorization after the fact. Challenging any procedure with a plural number of hammertoes. Bundling things together that clearly aren't the same procedure ie. paying 1/2 the procedures. A few months ago I had not been paid for half the surgery I had done. Like we're 90+ days after the fact and nothing has paid.

I like to ask staff, scrub people etc - what do you think we get paid for doing this. The answers are 3-10x higher than what we get paid.

I enjoy operating. I enjoy doing the right thing for people. I'd rather make $160 doing an outpatient practice with a mix of clinic, surgery, etc than grind out $300K at a nursing home. But surgery is put up on a pedestal.

The less follow-up the patient requires from surgery the more tolerable surgery is. I got like $850 for a dorsal exostectomy awhile back. The patient told me at the 2nd visit/suture removal they'd call me. Its hard to argue with that.

Insurance that kills rates produces a situation where there is no win. Regardless of if you have these great visits, DME, whatever before hand - you're just a grunt grinding it out. Bad insurance pays Sub-$100 for a 99214. It pays less than $25 an x-ray. There is no winning there.

True freedom is to be busy enough to drop everything except Medicare and Blue Cross or to tell crappy commercial payors you won't accept anything less than 165% or something like that for surgery.

 

[NobodyDPM]

Correct (with some payers), but you would have gotten zero if you didn't have the rep to get that referral and skill to do the case, right?

And the correct way to look at that patient can also be new pt eval with XR set and pre-fabs, f/u eval with orthotics, f/u eval for brace, f/u with surgery discussion and CAM boot and crutches, patient goes out to get labs and MD visit which spreads your name around the community, you bill surgery codes (648), then many XRs at f/u visits, possibly orthotics post-op if architecture changed... I would guess that's more like $5k+ than just 648 there from that pathology. Also, that person might even become your possible patient for life who could have other procedures/injuries later or refer others down the line.

The crux of this is that idea is that those schedule slots where RRA patients go or would go don't automatically fill in with new patient warts and ingrowns when we don't or can't do the real surgical procedures. It's best to have as many offerings as we can. I comes back to you in many ways.


Yes.

Bolded mine.

Sorry friend, but that's not what your OP says nor alludes to.

You can get the exact outcome if you do a bunion procedure, which pays about the same with good insurance. Patient for life, orthotics, blah, blah, blah.

Also, you aren't taking into account the post operative resources needed to care for someone who had a calcaneal osteotomy vs someone who had an Austin bunionectomy.

 

[NobodyDPM]

Should you do right by people? Yes
Should you try to get good training? Yes
Should you understand the foot and ankle to the best of your ability? Yes
Should you offer full service for things you are accomplished at and is it probably good for business, referrals? Yes
Does being ortho or hospital employed pay well? Yes

Otherwise its a battle.

-I got paid $593 by a commercial insurance plan to do an Achilles tendon the other day.
-Real procedures from "decent" insurance does pay money, but it doesn't pay amazing money by any means. ie. a Blue Cross lapidus is $1100, ankle fusion is $1700, evans is $1200, ATFL repair $1200.
-All of the above surgeries can be better tolerated if secondary procedures are added that don't greatly change the recovery.
-Essentially if you are going to operate you must do everything you can to prevent complications, choose your patients carefully, and manage the post-op.
-The global is in truth 45 days too long and presumes every patient is a healthy 15 year old.
-If you see these patients above weekly for 90 days that's a hell of a lot of visits.
-My wife has had 2 c-sections. The first Obgyn saw her twice. The second saw her once. A flexor tenotomy gets more follow-up.

Now for the dirty. Non-payment. As in no payment at all. Reviews after the fact. Having to submit every document again. Claiming no prior authorization is required and then demanding a prior authorization after the fact. Challenging any procedure with a plural number of hammertoes. Bundling things together that clearly aren't the same procedure ie. paying 1/2 the procedures. A few months ago I had not been paid for half the surgery I had done. Like we're 90+ days after the fact and nothing has paid.

I like to ask staff, scrub people etc - what do you think we get paid for doing this. The answers are 3-10x higher than what we get paid.

I enjoy operating. I enjoy doing the right thing for people. I'd rather make $160 doing an outpatient practice with a mix of clinic, surgery, etc than grind out $300K at a nursing home. But surgery is put up on a pedestal.

The less follow-up the patient requires from surgery the more tolerable surgery is. I got like $850 for a dorsal exostectomy awhile back. The patient told me at the 2nd visit/suture removal they'd call me. Its hard to argue with that.

Insurance that kills rates produces a situation where there is no win. Regardless of if you have these great visits, DME, whatever before hand - you're just a grunt grinding it out. Bad insurance pays Sub-$100 for a 99214. It pays less than $25 an x-ray. There is no winning there.

True freedom is to be busy enough to drop everything except Medicare and Blue Cross or to tell crappy commercial payors you won't accept anything less than 165% or something like that for surgery.

Well written, sir! You get it. Bravo!

 

[wakaflocka88]

Every new fresh grad from residency needs to listen to the advice here. 100% get the best training you can get because you want to offer every patient your most honest, ethical, professional opinion. I tell every patient of mine - yes, surgery is always an option on the table but let's try ABCD-Z first. I've even offered patients to go get a 2nd opinion and they don't want to because they trust me.

Yes - surgery pays "well" all depending on the insurance mix and as HeyBrother mentioned, lots of subtle nuances because all of the follow up ancillary stuff (DME, casts, splints) still gets paid. But most importantly, you earn your patient's trust. Priceless. But at the same time, sometimes you have to wonder if doing a 3-5 hour triple/ankle fusion/charcot recon/cavus foot recon is worth the $<1500 you get reimbursed. I find that new grads want to do everything, but forget to ask themselves - are they ready to deal with everything in the post-op phase?

 

[NobodyDPM]

Every new fresh grad from residency needs to listen to the advice here. 100% get the best training you can get because you want to offer every patient your most honest, ethical, professional opinion. I tell every patient of mine - yes, surgery is always an option on the table but let's try ABCD-Z first. I've even offered patients to go get a 2nd opinion and they don't want to because they trust me.

Yes - surgery pays "well" all depending on the insurance mix and as HeyBrother mentioned, lots of subtle nuances because all of the follow up ancillary stuff (DME, casts, splints) still gets paid. But most importantly, you earn your patient's trust. Priceless. But at the same time, sometimes you have to wonder if doing a 3-5 hour triple/ankle fusion/charcot recon/cavus foot recon is worth the $<1500 you get reimbursed. I find that new grads want to do everything, but forget to ask themselves - are they ready to deal with everything in the post-op phase?

Very well said.

Bolded mine.

Here's what I'd like all the new grads to do. Spend one year only doing "the big stuff". And during that year, work on percentage reimbursement only. I think people would be shocked at how low their take home would be in that scenario. Not only because of how little they are actually getting paid for those procedure, based on time spent in the OR actually doing them, but then on these patients' post operative courses and how much time and effort goes into that. You want to do tons of surgery? More power to you. You then fill up your office with non paying visits. The "bigger" the surgery, the more involved those visits are. And the more visits will be required before discharge.

I don't give a hoot if people on these forums believe or even consider what I have to say. Get in there and do it. Then report back and tell us your experience. I'm just telling you mine. Take it or leave it. Makes no difference to me at all.

 

[DYK343]

I can do 5 quick forefoot cases in a day.
Or I can do 1-2 recons in a day.
Ill take the quick and easy any day and make more $$ doing it.
I do big cases. I dont turn them away. But I love my easy surgery center block days.
Hospital block days are always more headache, less income, and lower reimbursements.

RVU system is where it is at with big cases as they are typically multiple high RVU procedures. A lot of hospital employed DPMs get 100% RVU value for multiple procedures. Evans, calc slide, Cotton, TAL. 4 procedures with 100% RVU reimbursement each. Thats $$ right there. Not all hosptial DPMs get the 100% reimbursement but many do. Snag that position if you can get it.

 

[heybrother]

MUE for calcaneal osteotomy is 1. A PP pod would know that because the insurance would pay them zero for the whole thing until it was sorted out

When I first heard about all this I would have said how can a hospital pay full RVU. But when you think about how much more the hospital gets paid for everything they do it totally makes sense...

 

[G0dFather]

This gets debated or echoed all of the time on here (and in podiatry in general):

"The big stuff doesn't pay," "surgery doesn't pay well," "you make more by not doing surgery," "you make most of your money in the office," etc.

The numbers and the logic don't support this... at all:

https://apma.cms-plus.com/files/2018%20Practice%20Survey%20Results_FINAL.pdf

or
www.acfas.org/compensation/

I think that it's best to have as much to offer your patients and the community as possible. Mainly, you need to be able to tell referral sources like PCPs, ERs, Urgent Cares, specialists, etc that they can send you whatever. This applies to any practice situation, esp PP. I've never had an ER call me to ask me if I can do a metatarsal fracture... and the reason for that is just that I tell them when I start at that hospital "I can handle pretty much anything below the knee." If they ever sent me a tib/fib or something I didn't want, I simply refer it promptly, but they want to know they can just send me anything and I can do 99.5% of it or refer the 0.5% out quick and appropriately. That barely ever happens, though. Whatever an office or ER calls with, I just say "send it," and the only ones I've ever not been able to handle were due to PAD or the patient personality/psych... and even those still get E&M and I was able to help them.

We often fail to realize that those who get strong training and do full F&A surgery can also still do the conservative injects, bracing, orthotics, testing, etc. It's not like since I do the triple I couldn't do the 3 injections and the Arizona brace and PT refer first. The only difference is that having the surgical skills lets you see patients through to the end.. which is great for practice rep, patient trust, and many other things. Obviously, surgery doesn't pay zero either. Even in the global, the XR, the casts, the DME, complications, other problems to break the global, etc all pay you. Those are the reasons all of the surveys have the surgically trained and certified DPMs making more income on average.

Lastly, if you want employed jobs (ortho, hospital, MSG, etc), those will by and large prefer surgically trained DPMs since they will usually have plenty of them in the application pool. For PP, it can be more variable, but good training helps to protect you from being limited... and can give you improved negotiation power also.

Bottom line: don't sell yourself short on training. Don't listen to the noise that it's fine to settle, fine to not try for boards, etc. Try to achieve your potential. You can duck the cases but you lying to patients that they don't need surgery is something you can't escape. Don't miss out on gaining skills... you won't be able to go back later. There are plenty of Harvard trained attorneys who don't work a bigshot govt or Fortune 100 job, but there are hardly any Podunk Law School attorneys who are competitive for major firms or trials. Podiatry is no different. Training matters... it translates into results - for you and for your patients.


Yeah, I trimmed a lot of this post quoted above, but it is all pretty spot-on.

It is good to be able to offer as many services as possible, and it does statistically pay more to be doing RRA and surgery... and to be board certified.

/rant

OH NO .... JUST NO ... podiatry is its own thing, its has its own formula and is backwards as ever ... the more trained you are the more screwed you get moneywise ... this is very evident and hard to debate man ... the money in this profession is in having ownership/equity stake in something

 

[G0dFather]

And the correct way to look at that patient can also be new pt eval with XR set and pre-fabs, f/u eval with orthotics, f/u eval for brace, f/u with surgery discussion and CAM boot and crutches, patient goes out to get labs and MD visit which spreads your name around the community, you bill surgery codes (648), then many XRs at f/u visits, possibly orthotics post-op if architecture changed... I would guess that's more like $5k+ than just 648 there from that pathology. Also, that person might even become your possible patient for life who could have other procedures/injuries later or refer others down the line.

The one not doing the sx can get all of that minus the 648 .... and in the TOTAL time itll take you to do the case they can make at LEAST make another 2k seeing pts /doing quick minor office procedures without all the stress/risk and headache and global .. i just dont see a scenario where foot sx makes sense financially unless tied to a sx center incentive ... we have been fed garbage from day one in school the more i run and grow my business each day i realize this more and more... every pod school catalog has an ex fix on the cover ... what a joke

 

[G0dFather]

-I got paid $593 by a commercial insurance plan to do an Achilles tendon the other day.
-Real procedures from "decent" insurance does pay money, but it doesn't pay amazing money by any means. ie. a Blue Cross lapidus is $1100, ankle fusion is $1700, evans is $1200, ATFL repair $1200.
-All of the above surgeries can be better tolerated if secondary procedures are added that don't greatly change the recovery.
-Essentially if you are going to operate you must do everything you can to prevent complications, choose your patients carefully, and manage the post-op.
-The global is in truth 45 days too long and presumes every patient is a healthy 15 year old.
-If you see these patients above weekly for 90 days that's a hell of a lot of visits.
-My wife has had 2 c-sections. The first Obgyn saw her twice. The second saw her once. A flexor tenotomy gets more follow-up

I agree with all this ... just look at the money tied to these case ... is this something you would want to get paid knowing the years of training, expertise, skill, difficulty, and effort that goes into getting a positive result ? These case should be reimbursed WAY more for the skill it takes to deliver and see these through to the end... you get shafted and short change yourself taking innetwork fees for these case, you can make money with certian procedures that would come as close as possible to high ticket items in podiatry ( for now at least) .... a perc. tenotomy gets about 400 bucks.. which would you line up all day ?

 

[G0dFather]

I can do 5 quick forefoot cases in a day.

Legendary

 

[DYK343]

Legendary

Youre comments about surgery not being able to make $ are incorrect in my opinion (or at least situation). I make good money on my surgery days. Especially at the surgery center where I book 5+ cases a day.

Im not going to schedule two quick cases in a day. Thats a waste of my time and I would make more $ in the office in that time considering the follow ups and global. But I will schedule 5+ cases and go in and knock them all out in a day. I make pretty decent cash doing that. I skip some weeks (and take the day for myself) because I dont have the volume that week to make it worth my time. I run a fairly solid MSK practice so I can typically generate the volume.

I dont think I really make much money doing the bigger cases at the hospital actually operating at least for the stress and training behind it involved. But I make a lot of $ getting those patients referred to me. I dont just sign everyone up for surgery. 3-4 visits with injections, AFO, casting, etc. Thats where I make the $ off the big cases. Its before I even operate on them. When you take the injections, AFO brace or CAM boot, and 3-4 office visits before the surgery now it starts to add up

But as i basically just said i agree clinic is king in terms of cash reimbursement. I do an insane amount of injections and huff phenol all day. Thats easy stress free $ right there.

 

[dtrack22]

I can do 5 quick forefoot cases in a day.
Or I can do 1-2 recons in a day.
Ill take the quick and easy any day and make more $$ doing it.
I do big cases. I dont turn them away. But I love my easy surgery center block days.
Hospital block days are always more headache, less income, and lower reimbursements.

RVU system is where it is at with big cases as they are typically multiple high RVU procedures. A lot of hospital employed DPMs get 100% RVU value for multiple procedures. Evans, calc slide, Cotton, TAL. 4 procedures with 100% RVU reimbursement each. Thats $$ right there. Not all hosptial DPMs get the 100% reimbursement but many do. Snag that position if you can get it.

Yeah I did 2 cases one morning that were worth 41-42 wRVU for me. That’s almost 20 clinic patients worth of wRVU.

And I’d rather spend 4-6 hours working in the OR than seeing 20 patients in clinic and doing all of the documentation that goes along with them…

“Hey, don’t you know you could see 8 patients in clinic and make as much money as you did on that surgery? So instead of operating why don’t you spend more time doing thing you hate most in all of podiatry (medicine, really)?”

but yes, the numbers are much less favorable for those with bad commercial contracts or a lot of Medicare. Individuals who have surgical wRVU’s cut to 50% for multiple procedures are going to find surgical reimbursements disappointing too.

 

[HardRoadPaved]

And I’d rather spend 4-6 hours working in the OR than seeing 20 patients in clinic and doing all of the documentation that goes along with them…

Did you sign the H&P update? Did you make sure to put in the ancef order to follow our new hospital protocol even though it's a quick non-implant procedure? Did you make sure to do the pre-op checklist on the front of the patient's chart and sign your name before they can be brought back in the room because our new initiative is patient safety? Did you enter in your orders in EPIC properly because you held them but you needed to hit sign and held?! You didnt enter in the PDMP verification before you sent that narc rx, so make sure you do that because we want all our docs e-rx their narcs!? Also that path specimen needs a paper signature too in addition to the order to ensure the circulator entered it in as you described. And before you go, you need to do a brief OP note in the paper chart, yes yes I know you are going to dictate your note now but we require this quick little write up in the room.

Don't worry the documentation train shares in the headache in facilities. OR Circulators are now data entry specialists. Thanks JHCAO!

 

[heybrother]

Did you sign the H&P update? Did you make sure to put in the ancef order to follow our new hospital protocol even though it's a quick non-implant procedure? Did you make sure to do the pre-op checklist on the front of the patient's chart and sign your name before they can be brought back in the room because our new initiative is patient safety? Did you enter in your orders in EPIC properly because you held them but you needed to hit sign and held?! You didnt enter in the PDMP verification before you sent that narc rx, so make sure you do that because we want all our docs e-rx their narcs!? Also that path specimen needs a paper signature too in addition to the order to ensure the circulator entered it in as you described. And before you go, you need to do a brief OP note in the paper chart, yes yes I know you are going to dictate your note now but we require this quick little write up in the room.

Don't worry the documentation train shares in the headache in facilities. OR Circulators are now data entry specialists. Thanks JHCAO!

Ha. That made me laugh. I was slightly spoiled. One of my main places my OM fills out a paper chart with orders ahead of time and I check boxes on a paperchart of my own design when I leave. And then they changed the paperwork person and suddenly I had to sign every piece of paper in the world. Sheets that didn't even have signature lines. And dates and times too. I was coming back the week after surgery to a pile of charts covered in red sticky notes demanding more and more signatures. Now I sign everything like a neurotic little biotch ahead of time.

 

[HardRoadPaved]

. Now I sign everything like a neurotic little biotch ahead of time.

Don't worry at JHCAO, state, hospital board meeting's next review they'll make some new forms to keep you on your toes.

 

[G0dFather]

Youre comments about surgery not being able to make $ are incorrect in my opinion (or at least situation). I make good money on my surgery days. Especially at the surgery center where I book 5+ cases a day.

I think we are basically saying the same thing here ... i group all cases now to the last friday of the month and its always a full day .... you are making money doing surgery but the whole argument is it being worth everything it comes with ... have you looked into your avg innetwork reimbursement for A case ... ours is around 700 bucks ( this is all big and small cases) ... 700 bucks !? this is way i had to find other things to make it worth it ... prior to sx center profit sharing, doing about 15 cases a month would generate about 120k/yr ... 120k is a joke for all the risk, skill, expertise etc that you undertook for ALL those cases !!! Just one or two lawsuit ( and it could be the most petty thing that a pt/lawyer comes after to you for ) that stick from any of those cases that year will set you back WAY more than that in just increased yearly malpractice premiums this is the point im trying to make that many will come to realize... 120k is a drop in the bucket when it comes to running a busy practice.... out of net sx is a different story and the avg case amount goes up significantly but they dont come in as often and we dont do that bait and switch crap with the patients

 

[dtrack22]

Did you sign the H&P update?

Yes, took 4 keystrokes to get .dtrackinterval to populate into the H&P interval section

Did you make sure to put in the ancef order to follow our new hospital protocol even though it's a quick non-implant procedure?

My MA does all that, pre-op nurses will put it in if missed

Did you make sure to do the pre-op checklist on the front of the patient's chart and sign your name before they can be brought back in the room because our new initiative is patient safety?

that sounds made up, so no, I didn’t…

Did you enter in your orders in EPIC properly because you held them but you needed to hit sign and held?!

My MA does that, but even if they didn’t I can give verbal orders for everything

You didnt enter in the PDMP verification before you sent that narc rx, so make sure you do that because we want all our docs e-rx their narcs!?

Not required

Also that path specimen needs a paper signature too

No it doesn’t

Documentation required for a single OR case is significantly less onerous and time consuming than the equivalent number of clinic patients (from a wRVU standpoint)

 

[NobodyDPM]

Yeah I did 2 cases one morning that were worth 41-42 wRVU for me. That’s almost 20 clinic patients worth of wRVU.

And I’d rather spend 4-6 hours working in the OR than seeing 20 patients in clinic and doing all of the documentation that goes along with them…

“Hey, don’t you know you could see 8 patients in clinic and make as much money as you did on that surgery? So instead of operating why don’t you spend more time doing thing you hate most in all of podiatry (medicine, really)?”

but yes, the numbers are much less favorable for those with bad commercial contracts or a lot of Medicare. Individuals who have surgical wRVU’s cut to 50% for multiple procedures are going to find surgical reimbursements disappointing too.

Bolded mine.

I don't understand those that complain about doing their medical records. I created templates within our EMR system, and I use those exclusively.

Nail care notes take me about 30 seconds. H&P and E&M visit notes take me about a minute and half. Everything is templated, and all I have to do is click. Unless I have to do MIPS, and that extends it to about three minutes. If you aren't doing this in your practice, you are seriously behind the 8 ball.

 

[air bud]

MUE for calcaneal osteotomy is 1. A PP pod would know that because the insurance would pay them zero for the whole thing until it was sorted out

When I first heard about all this I would have said how can a hospital pay full RVU. But when you think about how much more the hospital gets paid for everything they do it totally makes sense...

lol MUEs for life...yeah that is why i have never done a calc slide...Did just do a bone biopsy on a chronic calcaneal abcess. 3 separate incisions, 3 separate codes because the MUE is 3....at least that is what I remember from the Bofelli/acfas course.

edit - why I will never do calc slide in private practice going forward...

 

[HardRoadPaved]

I created templates within our EMR system, and I use those exclusively.

Just make sure you have several templates so copy pasting same format into every note is gonna be an easy flag when an insurance asks you to forward random notes for review.

(especially the part where you "checked" pulses on a 15 year old at their 10th follow-up visit)

 

[dtrack22]

Nail care notes take me about 30 seconds. H&P and E&M visit notes take me about a minute and half. Everything is templated, and all I have to do is click. Unless I have to do MIPS, and that extends it to about three minutes.

I don’t do that much nail care and 2-3 minutes per note still means 40-60 minutes of the least favorite part of my job. I have templates and dot phrases but I would still rather do the thing that requires less note writing when compensation is equivalent.

 

[NobodyDPM]

Just make sure you have several templates so copy pasting same format into every note is gonna be an easy flag when an insurance asks you to forward random notes for review.

(especially the part where you "checked" pulses on a 15 year old at their 10th follow-up visit)

I've been through several Medicare/Medicaid audits unscathed. I'm good, thanks.

 

[NobodyDPM]

I don’t do that much nail care and 2-3 minutes per note still means 40-60 minutes of the least favorite part of my job. I have templates and dot phrases but I would still rather do the thing that requires less note writing when compensation is equivalent.

You don't dictate your own OP Notes? Or do the residents you work with do that for you? I don't imagine you trust an MA enough to do those for you.

 

[dtrack22]

You don't dictate your own OP Notes? Or do the residents you work with do that for you? I don't imagine you trust an MA enough to do those for you.

Yes they take a couple minutes a piece. Two dictations is less time documenting than 15-20 clinic notes. By a lot.

 

[NobodyDPM]

Yes they take a couple minutes a piece. Two dictations is less time documenting than 15-20 clinic notes. By a lot.

To each his own, I guess. I'd personally prefer to click away on a computer than dictate an op note. And for me, a well constructed op note on a complex procedure takes more than a couple of minutes. A bunion procedure, sure, but a triple or pan talar fx repair?

 

[HardRoadPaved]

I've been through several Medicare/Medicaid audits unscathed. I'm good, thanks.

Haha several audits? Gee, how'd you trigger that? Most RACs only look at 2% of claims.

 

[NobodyDPM]

Haha several audits? Gee, how'd you trigger that? Most RACs only look at 2% of claims.

I've worked in several different states. I guess once they audit you and you're clean, they figure they must have missed something, LOL.

 

[619]

If you work for a Hospital group, ortho or MSG and get paid per wRVU then doing big RRA cases is profitable. If you are in PP and own equity in a surgery center then doing big RRA cases is profitable. HOWEVER if you are an associate at a pod practice and you are neither paid per wRVU nor have equity in a surgery center then doing big RRA cases is not profitable. It is as simple as that. I will like to hear counter argument to the above statement.

Most big cases pay less than $1500 with a 3 months global. If you see an actual EOB and not what is billed out, then you will know surgery does not pay in comparison to doing procedures in clinic. No one is even talking about wound care grafts that pays thousands of dollars per patient application on a weekly cases. Y'all big shots can have all the big RRA cases, send me the wounds that will be grafted, warts, bunions, hammertoes, ingrown nails, plantar fasciitis, DME etc. I am happy to kick it in clinic and do a few small cases in the OR here and there.

I have zero interest in doing a charcot recon or putting in an IM nail even though I did tons in residency. Further more, doing a big RRA case in residency with many hands to assists in the OR is different when you are out and it's only you and the scrub tech (except if you work with residents). You can still provide the best care to patient with minimal surgery. I have seen patients go from bad to worst after undergoing a big recon case. No one talks about the charcot recon that ends up in BKA 9 months later

In conclusion, money talks. If you are an associate or about to be one and you are doing big RRA cases, at the end of the year, look at you total income. If you are making less than $150K (base and bonus), you need to focus on growing your income. Doing big RRA cases is not going to help with that goal. There is a reason all the older docs send the big cases to the younger associate while the older docs sit in clinic and make the Benjamins.

 

[G0dFather]

I don't understand those that complain about doing their medical records. I created templates within our EMR system, and I use those exclusively.

Nail care notes take me about 30 seconds. H&P and E&M visit notes take me about a minute and half. Everything is templated, and all I have to do is click. Unless I have to do MIPS, and that extends it to about three minutes. If you aren't doing this in your practice, you are seriously behind the 8 ball.

Thats the way man !! this is how you scale !! good stuff

Most big cases pay less than $1500 with a 3 months global. If you see an actual EOB and not what is billed out, then you will know surgery does not pay in comparison to doing procedures in clinic. No one is even talking about wound care grafts that pays thousands of dollars per patient application on a weekly cases. Y'all big shots can have all the big RRA cases, send me the wounds that will be grafted, warts, bunions, hammertoes, ingrown nails, plantar fasciitis, DME etc. I am happy to kick it in clinic and do a few small cases in the OR here and there.

You have what it takes, i like what you said here

 

[ExperiencedDPM]

Very well said.

Bolded mine.

Here's what I'd like all the new grads to do. Spend one year only doing "the big stuff". And during that year, work on percentage reimbursement only. I think people would be shocked at how low their take home would be in that scenario. Not only because of how little they are actually getting paid for those procedure, based on time spent in the OR actually doing them, but then on these patients' post operative courses and how much time and effort goes into that. You want to do tons of surgery? More power to you. You then fill up your office with non paying visits. The "bigger" the surgery, the more involved those visits are. And the more visits will be required before discharge.

I don't give a hoot if people on these forums believe or even consider what I have to say. Get in there and do it. Then report back and tell us your experience. I'm just telling you mine. Take it or leave it. Makes no difference to me at all.

What exactly is the point you’re attempting to make?

 

[ExperiencedDPM]

I've been through several Medicare/Medicaid audits unscathed. I'm good, thanks.

The real question is why you went through several audits. I can tell you factually that it’s not random.

 

[air bud]

Let's just say that in some places (not in the big city....) There are crazy good payers. PP is good.

Recently got paid $1,300 bucks for a 10-minute I and D of a leg from a neglected dog bite. A couple recent BCBS chronic Achilles repairs paid over 8k. A huge recon of a ankle (ligaments tendons scope, exostectomy) paid over 15k. Big cases big bucks. Get the training. Then get lucky like me

 

[ExperiencedDPM]

I've worked in several different states. I guess once they audit you and you're clean, they figure they must have missed something, LOL.

Ummmm…….NOT!

 

[deleted1097413]

Let's just say that in some places (not in the big city....) There are crazy good payers. PP is good.

Recently got paid $1,300 bucks for a 10-minute I and D of a leg from a neglected dog bite. A couple recent BCBS chronic Achilles repairs paid over 8k. A huge recon of a ankle (ligaments tendons scope, exostectomy) paid over 15k. Big cases big bucks. Get the training. Then get lucky like me

After reading your posts the last several years I’ve come to the conclusion that you live in Idaho, montana, south or North Dakota. Wouldn’t rule out the mountains in West Virginia either though

 

[air bud]

After reading your posts the last several years I’ve come to the conclusion that you live in Idaho, montana, south or North Dakota. Wouldn’t rule out the mountains in West Virginia either though

Close to or including that area yes. This world doesn't exist in Miami or NYC.

 

[deleted1097413]

Close to or including that area yes. This world doesn't exist in Miami or NYC.

I agree. I’m going to follow the dollar signs when I finish residency and that may mean I’m somewhere similar.

 

[air bud]

I agree. I’m going to follow the dollar signs when I finish residency and that may mean I’m somewhere similar.

I have plenty of friends however in big cities killing it. Maybe not necessarily in the most popular suburb but on the outskirts the urban sprawl and somewhere and that's a good place to find a healthy in between. Driving three plus hours to Costco is not for everybody

 

[G0dFather]

I’ve come to the conclusion that you live in Idaho, montana, south or North Dakota. Wouldn’t rule out the mountains in West Virginia either though

Driving three plus hours to Costco is not for everybody

My condolences !!! LMAO

 

[ExperiencedDPM]

Let's just say that in some places (not in the big city....) There are crazy good payers. PP is good.

Recently got paid $1,300 bucks for a 10-minute I and D of a leg from a neglected dog bite. A couple recent BCBS chronic Achilles repairs paid over 8k. A huge recon of a ankle (ligaments tendons scope, exostectomy) paid over 15k. Big cases big bucks. Get the training. Then get lucky like me

AirBud,

Unless you are out of network, I can’t fathom how any insurance would pay those rates.

Let’s say your Achilles repair was a 27654. Medicare pays approximately $730 for that procedure. For an insurer to pay more than 10x Medicare is hard to understand.

Another example is your scope, ligament repair and exostectomy.

I don’t know what you billed but if you billed 27698 for the ligament repair, Medicare pays $655, for an extensive scope of 29898, it pays $575 and a 28120 (if that’s what you billed) pays $508.

That’s a total of $1738.00 before a reduction for the secondary procedures.

If you were paid $15,000 for similar procedures, then you should buy lottery tickets, though it sounds like you may have already hit it a few times!

 

[G0dFather]

AirBud,

Unless you are out of network, I can’t fathom how any insurance would pay those rates.

Let’s say your Achilles repair was a 27654. Medicare pays approximately $730 for that procedure. For an insurer to pay more than 10x Medicare is hard to understand.

Another example is your scope, ligament repair and exostectomy.

I don’t know what you billed but if you billed 27698 for the ligament repair, Medicare pays $655, for an extensive scope of 29898, it pays $575 and a 28120 (if that’s what you billed) pays $508.

That’s a total of $1738.00 before a reduction for the secondary procedures.

If you were paid $15,000 for similar procedures, then you should buy lottery tickets, though it sounds like you may have already hit it a few times!

I didnt feel like commenting on this post but now that you said it Yes this is on the money ... id also like to add that even with out of network fees to get these figures many "unbundle" and create more codes than required .. when i hear people tell me they got 10k+ for a bunion out of net its obvious how they most likely billed it (which isnt right and messes it up for everyone overtime)