DPM job move question - urgent - need experienced input. Please and thank you!

[Feli]

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Your administration does not know your value then. They have zero interest in you seeing nails if they actually want to make money and want you to be happy. Yes I consider myself very lucky.

Yo man... not every powe die a tryst can just bust out cavus recons, trimalls, salvage Achilles stuff.

...Yeah, the hospitals that are smart will turn the podiatry clinic into a mini F&A ortho... crossed with WCC and amputation station. It makes sense to do the most procedures possible when you own the POS where they are being done and own most of the referring docs/facilities. Nails barely moves the needle.

Most hospitals will have DPMs doing at least some nail care to fill out the schedule, though. That's a mistake (unless the DPM is not trained much for surgery or the area doesn't have enough) , but try telling them that. VAs and IHS will have a lot of nail care by their patient population, but the pods there have little/no bonus... so that's another story.

 

[nnjjj]

cannot bill new pt if already seen by another provider in the group, its an est. pt. at least where i am at now.

Can anyone break down the RVU per pt - 1.5/1.8
Since i will be new to RVU billing, i know its new pts, procedures, surgery etc and try to prn the things as said above

But what would be the breakdown of a solid RVU billing per patient for a few common pathologies one might encounter?
New pt/est pt
xray
injection
orthotics - OTC vs custom better or worse?
referrals to vasc, rheum, PT etc..? - does that do anything for you specifically, maybe level 4 instead of level 3, or just overall helps the hospital?
MRI/CT
CPN/TT nerve block
ingrown
DME - cam boot, ASO brace
preop appointment visit ->extra visit to bill, or waste of appointment?
below knee splint
etc....thanks!!

 

[Steveington]

This website is good to find out what the RVU for each CPT code

RVU Calculator - AAPC Relative Value Units

CPT® RVU calculator provides a quick analysis of the work relative value units associated with a certain volume of CPT or HCPCS codes.

www.aapc.com

 

[Bluecollarmed]

Most things as an employed doc will fall into your E/M. Obviously you get procedure CPTs and E/M codes for certain things but you aren't billing the xrays separately, that will be included in your E/M complexity/MDM along with prescriptions, referrals, etc. I would check with the hospital to find out about DME. As a CAH we can't have our own DME and thus use a 3rd party so none of that dispensing is billed from my end or the hospitals. The hospital will collect a facility fee for everyone who walks through the door though which is why they do quite well on top of the RVU production. Orthotics, depends if you're just referring out for molding or doing it yourself. I send out customs and have patient's order powersteps depending on which I think would benefit them most. If you can own stuff like the inserts and even-up devices etc and make a little margin on it (hospitals money not yours) then that would be a nice addition. If you're seeing a good amount of MSK stuff its easy to have a higher number of level 4 visits, especially if you're getting advanced imaging on follow ups. Telehealths don't pay well and have gone through many changes so get people in the door if possible (facility fee $$).

 

[dtrack22]

orthotics - OTC vs custom better or worse?

OTC, refer out/Rx customs. You won’t get credit for doing them yourself in a wRVU system. Your employer could create a dummy CPT code and you could get credit for molding/dispensing in theory. It’s not worth it, I promise.

DME - cam boot, ASO brace

You won’t get credit for any of it. Use them as appropriate.

preop appointment visit ->extra visit to bill, or waste of appointment?

It’s a 0 wRVU visit. It’s an unfortunately necessary appointment IMO, but I’m sure you will get some people on here who claim they bill for them, and others who do everything day of surgery. The former is fraudulent, the latter is not great for the patient and will lead to more same day cancellations than you would like unless your employer has a really good PAS process/team.

but you aren't billing the xrays separately, that will be included in your E/M

You might be billing the professional fee. We do when they are taken in our (ortho) clinic as the radiology group does not read those, we do. But that’s .16 wRVU so pretty meaningless.

 

[air bud]

I don't even know what a pre-op appointment is. Whenever you talk to the patient and schedule surgery talk risk benefits complications there you go that's a level four. Why do you need to see the patient again before surgery?

 

[deleted1235332]

I don't even know what a pre-op appointment is. Whenever you talk to the patient and schedule surgery talk risk benefits complications there you go that's a level four. Why do you need to see the patient again before surgery?

I think it’s for people who rightfully don’t schedule electives first time meeting a patient. There’s been many times where I realize a patient was crazy the second visit but it was never noted on the first. Usually first visit I will try something conservative like a toe sleeve, spacer, insert, “wide shoes”, whatever. Basically just from a medical legal standpoint, and so I get one more visit to talk about things I might’ve missed first visit.

I’m sure a more seasoned practitioner doesn’t need that second visit but I do preop visits

 

[Bluecollarmed]

I’ll book a preop visit if patient is scheduling more than 3 months out from the last time we’ve met. It’s a quick visit or telehealth to discuss the procedure and any questions they’ve had from the previous visit. RN goes over pre and post op packet, makes sure all orders and labs are done then and makes sure PT is scheduled if needed etc.

Dtrack my clinic is hospital based so radiology reads it all. But yes if you’re in a separate clinic then you might as well get all your dollars.

 

[air bud]

I think it’s for people who rightfully don’t schedule electives first time meeting a patient. There’s been many times where I realize a patient was crazy the second visit but it was never noted on the first. Usually first visit I will try something conservative like a toe sleeve, spacer, insert, “wide shoes”, whatever. Basically just from a medical legal standpoint, and so I get one more visit to talk about things I might’ve missed first visit.

I’m sure a more seasoned practitioner doesn’t need that second visit but I do preop visits

I mean you talk to a patient about a bunion they give it some consideration and then they make an appointment come back and they say hey I want to do this bunion so you talk about wrist benefits complications That's just an appointment then you scheduled them for surgery

 

[air bud]

I’ll book a preop visit if patient is scheduling more than 3 months out from the last time we’ve met. It’s a quick visit or telehealth to discuss the procedure and any questions they’ve had from the previous visit. RN goes over pre and post op packet, makes sure all orders and labs are done then and makes sure PT is scheduled if needed etc.

Dtrack my clinic is hospital based so radiology reads it all. But yes if you’re in a separate clinic then you might as well get all your dollars.

Telehealth sure. RN can do all that stuff on their own time. Not going to waste an appointment for that. But yeah if you haven't seen him in three or four months I understand talking to him on the phone for 5 minutes at the end of the day and not billing for that

 

[Adam Smasher]

Pre op visits are absolutely necessary and absolutely billable.

1) I am in the middle of an insurance audit. My preop visits have stood up to scrutiny.
2) I've caught flak for doing this here but I'll do my own preop clearances in healthier pts with minor cases. Doing your own clearance is billable.
3) Discussing a post op pain management regimen is a billable counseling service separate and distinct from the surgery
4) Often there are other perioperative medical considerations ("hold your ozempic this week")
5) If you haven't seen this person for months it is medically necessary to re-examine and re-XR the pt. I'm in the middle of appealing my decisions not to re-do XR on a stable bunion, but that's what the auditors wanted to see.

 

[air bud]

Yeah I still dont understand why you have to bring a patient in to do any of that. It's other people's job to tell him which medications to start and stop. You've already talked to him about post-op You're going to tell him about post-op at the time of surgery. How is post-op pain management separate and distinct when they're literally only going to have pain because of a surgery that you're going to do that you've already billed for.

 

[air bud]

Billable yes..... Necessary no. If you need patienta and need to fill up your schedule then sure do it.

 

[Adam Smasher]

Yeah I still dont understand why you have to bring a patient in to do any of that.

You're right. I could create docu-sign consents and do everything via telehealth and the nurses and managers that I have all the facility money in the world to pay salaries would collect this information. But this is a poor substitute in the patient's eyes for a face-to-face consultation.

It's other people's job to tell him which medications to start and stop. You've already talked to him about post-op You're going to tell him about post-op at the time of surgery.

I have had PCPs/internists shrug and literally tell me "You're the surgeon, you decide."

How is post-op pain management separate and distinct when they're literally only going to have pain because of a surgery that you're going to do that you've already billed for.

A lot of it is basic pharmacology for us, but advising pt's on side effects of narcotic analgesics or how to coadminister with NSAIDs is medical advice that I believe we deserve compensation for providing. Obviously we have our go-to pain management protocol, but I think you understand we need to deviate from this when tailoring the protocol to a pt's needs. Example, I had a lady recently on suboxone who had a gastric bypass.

 

[josebiwasabi]

i am based out of a county safety-net hospital.

i am booked 3 months out for elective surgery. if i were to see a surgical candidate, book them for surgery today in April and tell them "hey your surgery is July 20th, see you the morning of surgery!" my no-show rate/cancellation rate would be through the roof.

our service has the lowest surgery cancellation rate in the entire hospital. we are also the only service that sees our surgical patients within 3 weeks of the date of surgery for a preop visit. you probably did a thorough job on a prior visit explaining the surgery and postop course but the literature shows that patients retain maybe 10-20% of what we tell them in a visit. another visit to reinforce our instructions especially with their family member or whoever will be helping them postop has helped improve my postop instruction compliance rate and therefore reduced my postop complications in a relatively sick population.

the other thing is that other specialties can more easily bring someone in if there's a last minute cancellation because they don't have the lengthy NWB and return-to-work restrictions that are inherent to foot and ankle surgical procedures. it is not easy for a blue collar worker to tell their employer "hey actually my surgery will be this week instead of in 4 weeks like we discussed, i will be out for 3 months starting this friday!"

if you work in a more affluent area with higher health care literacy rates and better home support systems this may not be as necessary. but for my practice it absolutely is needed.

 

[air bud]

You're right. I could create docu-sign consents and do everything via telehealth and the nurses and managers that I have all the facility money in the world to pay salaries would collect this information. But this is a poor substitute in the patient's eyes for a face-to-face consultation.

I have had PCPs/internists shrug and literally tell me "You're the surgeon, you decide."

A lot of it is basic pharmacology for us, but advising pt's on side effects of narcotic analgesics or how to coadminister with NSAIDs is medical advice that I believe we deserve compensation for providing. Obviously we have our go-to pain management protocol, but I think you understand we need to deviate from this when tailoring the protocol to a pt's needs. Example, I had a lady recently on suboxone who had a gastric bypass.

Those medications are being stopped for anesthesia this is your surgery center or whoever else telling who to stop medications.

The whatever medical clearance you did at the time of booking the surgery

The pain control is still part of the surgery and you talk about it after the surgery and remind them. They would not be taking pain medications without you booking a surgery

You're not doing anything that is not separate and distinct

 

[air bud]

I don't know, whatever. If you get paid for those visits then sure do them if you don't just talk to the patient on the phone

 

[Toenail]

I try to avoid pre op visits as much as possible. Every pre op visit is another new surgical patient I could have seen. I can understand how these types of visits are “important” in private practice though.

 

[dtrack22]

From the AMA:

“If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package.”

And no, airbud, your NP doesn’t get to bill for your pre-ops or post-ops because they have a different taxonomy code lol

One day soon I won’t have to see patients, I’ll just get paid by CMS and commercial insurers to comb through all of the incorrect billing from various hospitals and podiatrists.

 

[dtrack22]

i am based out of a county safety-net hospital.

i am booked 3 months out for elective surgery. if i were to see a surgical candidate, book them for surgery today in April and tell them "hey your surgery is July 20th, see you the morning of surgery!" my no-show rate/cancellation rate would be through the roof.

our service has the lowest surgery cancellation rate in the entire hospital. we are also the only service that sees our surgical patients within 3 weeks of the date of surgery for a preop visit. you probably did a thorough job on a prior visit explaining the surgery and postop course but the literature shows that patients retain maybe 10-20% of what we tell them in a visit. another visit to reinforce our instructions especially with their family member or whoever will be helping them postop has helped improve my postop instruction compliance rate and therefore reduced my postop complications in a relatively sick population.

the other thing is that other specialties can more easily bring someone in if there's a last minute cancellation because they don't have the lengthy NWB and return-to-work restrictions that are inherent to foot and ankle surgical procedures. it is not easy for a blue collar worker to tell their employer "hey actually my surgery will be this week instead of in 4 weeks like we discussed, i will be out for 3 months starting this friday!"

if you work in a more affluent area with higher health care literacy rates and better home support systems this may not be as necessary. but for my practice it absolutely is needed.

This is exactly why you have elective surgery patients come in for a pre-op.

 

[Adam Smasher]

From the AMA:

“If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package.”

Hmm. Interesting. I stand corrected.

A few observations:

1) for every surgery my family members and I have undergone, there was a preoperative consult, and there was a bill. I know, many wrongs do not make a right.

2) my residency director did not do preoperative visits. He also had many many same-day cancelations, at least 1-2 a day.

3) just my opinion, but I think it's a bad look medical legally to indicate a pt in January for surgery, and they want to schedule it in July, and you don't lay your hands on them at all until the operative day.

4) and this goes back to my audit (which i will absolutely write about when the dust all settles). They didn't care about the preoperative visits, they cared that I didn't repeat the entire exam. This is more defensive charting than anything else, but for a lay person, they want to know that the justification for surgery is still there and the exam still supports it.

5) and so while a rote preoperative exam may not be billable, a follow up reassessment surely would be

 

[deleted1235332]

So another reason elective surgeries don’t pay well especially in private practice.. can’t even bill for a preop visit.. then 90 day global….. on a patient that isn’t happy because their bunion isn’t perfectly straight…………

 

[air bud]

So another reason elective surgeries don’t pay well especially in private practice.. can’t even bill for a preop visit.. then 90 day global….. on a patient that isn’t happy because their bunion isn’t perfectly straight…………

Sorry buddy. You are a surgeon. The APMA says so. Start surgerizing

 

[deleted1235332]

Sorry buddy. You are a surgeon. The APMA says so. Start surgerizing

I’m a boot.

and you’re a dog

 

[nnjjj]

aside from whether or not its billable or length of time between considering surgery and booking, since i have several attorneys in the family and my brother is a med mal defense attorney i am too educated for my liking on that side of things, and I prefer to over document and over explain. and i find a preop appointment and consent signing helps with that, whether it was a week ago they made the decision for surgery or esp when they call 3 months later saying 'im finally ready to schedule my sx we talked about'. For me its just good repetition for the patients. never underestimate the lack of common sense of 99% of the population, even in the very well educated ppl. you dont need any medical knowledge to know RICE after an ankle sprain, that just shows u never played sports as a kid, but we all have those pts that need their hand held even though youd like to tell them to walk it off and will be fine in a week or 2.... but if you are doing surgery, you are the surgeon and are responsible for that patient, and most need help and reinforcement with even the most basic of instructions ('take a daily aspirin as dvt ppx, ice, elevate, NWB, tylenol for baseline pain control, yes youll be in a splint for x amount of time, yes we talked about this all 12 times already, etc") - Not all do of course, some are totally with it and understand after one explanation....but more often than not i find patients need things explained 20 times (at least in all my areas of practice so far, even highly educated ones..) med legally its good practice if youre operating. and i find patients really like when i sit down and draw out and explain things thoroughly sometimes more than just once. just my worthless $0.02.

 

[air bud]

aside from whether or not its billable or length of time between considering surgery and booking, since i have several attorneys in the family and my brother is a med mal defense attorney i am too educated for my liking on that side of things, and I prefer to over document and over explain. and i find a preop appointment and consent signing helps with that, whether it was a week ago they made the decision for surgery or esp when they call 3 months later saying 'im finally ready to schedule my sx we talked about'. For me its just good repetition for the patients. never underestimate the lack of common sense of 99% of the population, even in the very well educated ppl. you dont need any medical knowledge to know RICE after an ankle sprain, that just shows u never played sports as a kid, but we all have those pts that need their hand held even though youd like to tell them to walk it off and will be fine in a week or 2.... but if you are doing surgery, you are the surgeon and are responsible for that patient, and most need help and reinforcement with even the most basic of instructions ('take a daily aspirin as dvt ppx, ice, elevate, NWB, tylenol for baseline pain control, yes youll be in a splint for x amount of time, yes we talked about this all 12 times already, etc") - Not all do of course, some are totally with it and understand after one explanation....but more often than not i find patients need things explained 20 times (at least in all my areas of practice so far, even highly educated ones..) med legally its good practice if youre operating. and i find patients really like when i sit down and draw out and explain things thoroughly sometimes more than just once. just my worthless $0.02.

Yes you make some good points. One of the nice things about being in these small towns rural is you can spend that time with people. And ultimately what matters is your documentation not what the patient thinks they heard.... The way to think about documentation is talk out loud on a piece of paper

 

[nnjjj]

So another reason elective surgeries don’t pay well especially in private practice.. can’t even bill for a preop visit.. then 90 day global….. on a patient that isn’t happy because their bunion isn’t perfectly straight…………

really!? oops i be billing level 4s for all my preop consent signing appts. all get paid. feel like my time spent and documentation supports it? and they are usually booked more than a month+ from any initial surgery discussion appointment. maybe my billers and group do something with the hospital/insurances, or maybe state or local differences? idk all the partners do it, their PAs do it...oh, but then again they are real doctors... \o/ .....dont forget the never ending complaints about swelling and numbness around my 2 poke hole incisions xD

 

[Weirdy]

really!? oops i be billing level 4s for all my preop consent signing appts. all get paid. feel like my time spent and documentation supports it? and they are usually booked more than a month+ from any initial surgery discussion appointment. maybe my billers and group do something with the hospital/insurances, or maybe state or local differences? idk all the partners do it, their PAs do it...oh, but then again they are real doctors... \o/ .....dont forget the never ending complaints about swelling and numbness around my 2 poke hole incisions xD

Decision for major surgery fits level 4s

Idk if you've already had that discussion 3mo prior and now they're back for same discussion if it'll get reimbursed

 

[Feli]

Decision for major surgery fits level 4s

Idk if you've already had that discussion 3mo prior and now they're back for same discussion if it'll get reimbursed

 

[Adam Smasher]

Decision for major surgery fits level 4s

Idk if you've already had that discussion 3mo prior and now they're back for same discussion if it'll get reimbursed

Maybe the reasons my preop consults got paid is because I never use the expression "preop consult"

Rather, it's a decision to make sure the decision for surgery made 3 months prior is still the right decision. Level 4.

EDIT: The above is more glib than I should have been. In truth, I contend it's entirely appropriate to reassess a patient if their surgery date is > 30 days from date of "decision for surgery." Meaning you elicit a new HPI, as thorough as you think is warranted, re-examine the patient, and recap why the planned procedure is indicated under MDM. Along with other preop stuff. So the emphasis is on the reassessment (billable) and not the preop consent (not billable)

 

[air bud]

Maybe the reasons my preop consults got paid is because I never use the expression "preop consult"

Rather, it's a decision to make sure the decision for surgery made 3 months prior is still the right decision. Level 4.

You're going to spend 30 minutes with the patient reviewing everything documenting etc etc... That's a level for with time who cares what you talk about

 

[Adam Smasher]

You're going to spend 30 minutes with the patient reviewing everything documenting etc etc... That's a level for with time who cares what you talk about

someitmes it's 30 between reviewing and documenting, or I'm rx'ing pain meds, many roads lead to Rome