Elective and Non-Elective Cases

[podfam3008]

Hey everyone, I'm thinking about focusing more on doing non-elective surgeries like I&D's, amputations, foreign body removals, fracture repairs, etc. I am already board-certified in ABFAS. Of course, I won't turn down anyone that still wants to have a bunion or hammertoe repaired because I don't want to limit myself on patients. However, I find that the most job satisfaction for me comes from patients who I do non-elective surgery. The patients are often so much more grateful, and its great to see someone feel so much better after resolving an infection they had. Patients who have elective surgery are grateful too but I find that there are a lot more complaints (ex: "why does my foot still have swelling a month after a bunion?" Even though we discussed this at length preop), headaches, etc. and now that we can bill after an amputation and there's no global, that's an extra plus. Of course, there are downsides to doing mostly non-elective surgery, including taking more hospital call, rounding, etc. which is a pain and takes more time away from the family. Has anyone ever felt this way or considered this themselves? Pros and cons? Thanks.

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[air bud]

I had an attending who said he would rather do pus than a bunion. Well trained. Now does almost exclusively limb salvage ex fix stuff. He made it work and is happy. Limits your options but if you can make it work then hell yeah. I would have no problem doing that job.

 

[hotpoddy]

If you can start a limb salvage fellowship I would 100% be behind this. That will limit your wasted time in the hospital rounding and taking call.
While it can be easier, it is also a headache when bombs show up in the office on a Friday. Stank wounds showing up in the office and you have to shut down one of your treatment rooms half the day trying to remove the stench.
You are correct that they don't complain as much, but it's because they don't listen to anything you say treatment wise.

 

[podfam3008]

If you can start a limb salvage fellowship I would 100% be behind this. That will limit your wasted time in the hospital rounding and taking call.
While it can be easier, it is also a headache when bombs show up in the office on a Friday. Stank wounds showing up in the office and you have to shut down one of your treatment rooms half the day trying to remove the stench.
You are correct that they don't complain as much, but it's because they don't listen to anything you say treatment wise.

I agree, we don't even have Podiatry residents at our hospital 😩. They are hours away, so I do all my own rounding/consults etc. However, I don't mind if it's just more full-filling in the long run.

 

[HardRoadPaved]

now that we can bill after an amputation and there's no global, that's an extra plus

toe amp = $200..... I'd rather do a P&A which is ~$175 and see that in 2 weeks than waste time amputating a toe in a hospital and dealing with hospital "compliance"

including taking more hospital call, rounding, etc. which is a pain and takes more time away from the family.

exactly why hospital work blows. Consults dont pay that much. Take a ton of charting time and coordinating with other doctors. Also better pray the patient has insurance and pays the bill. If they come into your office you can collect copays/deductibles

 

[DYK343]

I've thought about concentrating exclusively on limb salvage once my loans are finally gone. Work in a WHC 2 days a week and take hospital consults. Make enough to be happy and not have to work as many hours.

The biggest catch would be trying to do this solo. Wounds dont care that you have a vacation next week to Disneyworld with the family. It is inevitable that 1 hour before your flight to florida with the family the ER will call with gas gangrene of one of your regular patients that needs emergent attention with no one else around.

If you do this you would have to have a partner to cover.

 

[podfam3008]

toe amp = $200..... I'd rather do a P&A which is ~$175 and see that in 2 weeks than waste time amputating a toe in a hospital and dealing with hospital "compliance"

exactly why hospital work blows. Consults dont pay that much. Take a ton of charting time and coordinating with other doctors. Also better pray the patient has insurance and pays the bill. If they come into your office you can collect copays/deductibles

I agree!!!

 

[podfam3008]

I've thought about concentrating exclusively on limb salvage once my loans are finally gone. Work in a WHC 2 days a week and take hospital consults. Make enough to be happy and not have to work as many hours.

The biggest catch would be trying to do this solo. Wounds dont care that you have a vacation next week to Disneyworld with the family. It is inevitable that 1 hour before your flight to florida with the family the ER will call with gas gangrene of one of your regular patients that needs emergent attention with no one else around.

If you do this you would have to have a partner to cover.

Luckily I am not solo, nor am I hospital employed, thank god!

 

[podfam3008]

Luckily I am not solo, nor am I hospital employed, thank god!

I mean I don't take hospital call, unless I want to

 

[podfam3008]

I've thought about concentrating exclusively on limb salvage once my loans are finally gone. Work in a WHC 2 days a week and take hospital consults. Make enough to be happy and not have to work as many hours.

The biggest catch would be trying to do this solo. Wounds dont care that you have a vacation next week to Disneyworld with the family. It is inevitable that 1 hour before your flight to florida with the family the ER will call with gas gangrene of one of your regular patients that needs emergent attention with no one else around.

If you do this you would have to have a partner to cover.

Also, why did you consider doing only limb salvage surgery? Same reason as me?

 

[DYK343]

Also, why did you consider doing only limb salvage surgery? Same reason as me?

Im looking to cut back at some point in my near future. Im grinding HARD right now and I cant do it forever. Once I am debt free I am going to re evaluate. If I could work 1-2 days a week in a wound healing center and take hospital consults and still make a decent living I would jump on that. But I wouldnt do it alone. Need cross coverage. Wound care is very unpredictable.

 

[DYK343]

I mean I don't take hospital call, unless I want to

If you want to run a non elective practice youre (almost certainly) going to have to start taking a lot of call. How else would you feed the schedule?

 

[HardRoadPaved]

If you want to run a non elective practice youre (almost certainly) going to have to start taking a lot of call. How else would you feed the schedule?

Sit in a busy ED and wait for cases to walk in unlike this....

 

[DYK343]

toe amp = $200..... I'd rather do a P&A which is ~$175 and see that in 2 weeks than waste time amputating a toe in a hospital and dealing with hospital "compliance"

exactly why hospital work blows. Consults dont pay that much. Take a ton of charting time and coordinating with other doctors. Also better pray the patient has insurance and pays the bill. If they come into your office you can collect copays/deductibles

Inpatient consults really should pay more. They are a lot of work and the reimbursement is usually not worth it. Most consults do come with a procedure which increases the worth. But still.... Friday night "can you come look at this and tell me if its serious or not" when you are out to dinner with the family. Not worth it.

 

[NatCh]

I say do whatever is going to give you the most job satisfaction or at least whatever is going to be the least soul-sucking. This career is long and arduous enough without having to get beat down all day long. At this point my favorite surgery is arthrodesis for hallux rigidus since it's so damned reliable. My workday is mostly in-office procedures though. The luster of surgery has dulled a bit over time.

 

[wakaflocka88]

I say do whatever is going to give you the most job satisfaction or at least whatever is going to be the least soul-sucking. This career is long and arduous enough without having to get beat down all day long. At this point my favorite surgery is arthrodesis for hallux rigidus since it's so damned reliable. My workday is mostly in-office procedures though. The luster of surgery has dulled a bit over time.

This is truth right here. When will new grads and fellows realize this 😂

 

[air bud]

toe amp = $200..... I'd rather do a P&A which is ~$175 and see that in 2 weeks than waste time amputating a toe in a hospital and dealing with hospital "compliance"

exactly why hospital work blows. Consults dont pay that much. Take a ton of charting time and coordinating with other doctors. Also better pray the patient has insurance and pays the bill. If they come into your office you can collect copays/deductibles

28002 and 28003 also no more global (but reimbursement down 200 bucks). But now you can at least bill for rounding the following day.

 

[Feli]

Elective has the highest overall standards... no question. Pt expectations are high, and difficulty is medium-to-high.
This is why I picked the training I did (adequate trauma with much elective - and not a trauma-heavy one). Some of the expectations can be managed with pt selection and counseling for elective stuff, but you still need solid planning and good execution. The deformities and post-trauma recon are tough to get right. Luckily, your cases are planned, banker hours are cream puff and payers are chocolate sauce... compared to taking a lot of ER call or floor consults for infections and wounds.

Trauma is probably the hardest technically, but he expectations are low.
Pt can't walk... wants to walk again. Very hard to fix some of them, but injury can always be blamed for almost any of your bad outcomes.

The I&Ds and amps and stuff are easy (both technically and little/no pt expectations).
That is why those are "first year cases." It still takes good judgment and skill to do them well. I would never want to do only that stuff, but that's just me. I don't like the late case add-ons, urgent infection cases, tons of DME shoe/filler paperwork to get best outcomes (which are not helpful to your collections in PP), etc.

...as was said, do what you like and what you get good results, good income, and good life quality from. I think it's best to welcome whatever ppl need... you never know when a competitor for clinic/consult/ER pts will come in. You can always encourage some pathologies and discourage others (I say this as I dink around on SDN and procrastinate on a couple hospital consults that came in yesterday).

 

[heybrother]

28002 and 28003 also no more global (but reimbursement down 200 bucks). But now you can at least bill for rounding the following day.

Thank you for this.

 

[HardRoadPaved]

HOLY HELL! Bring back the global period. My locality is down $400 on 28003!

 

[air bud]

Thank you for this.

@ExperiencedDPM guess where I learned this....so what if publicly disclosed info I need someone to point it out to me.

 

[heybrother]

I was totally on top of the toe amp global last year, but somehow missed this one. Sadly, had I read TPMA's blast in December I would also have noticed this.

Call me crazy, but if they are going to do this they need to do it for all of the infection type codes ie. 28124, abscess codes (10060-10061) etc. I get we get less money but I have insurances that will not pay -anything- during a global even if its a new bone infection on the other foot.

In other news though:

Article - Billing and Coding: Surgical Treatment of Nails (A52998)

Use this page to view details for the Local Coverage Article for Billing and Coding: Surgical Treatment of Nails.

www.cms.gov

 

[podfam3008]

Inpatient consults really should pay more. They are a lot of work and the reimbursement is usually not worth it. Most consults do come with a procedure which increases the worth. But still.... Friday night "can you come look at this and tell me if its serious or not" when you are out to dinner with the family. Not worth it.

I knowww that's how I feel! Like wtf an hour to write my note and see the patient? No thanks.

 

[podfam3008]

Elective has the highest overall standards... no question. Pt expectations are high, and difficulty is medium-to-high.
This is why I picked the training I did (adequate trauma with much elective - and not a trauma-heavy one). Some of the expectations can be managed with pt selection and counseling for elective stuff, but you still need solid planning and good execution. The deformities and post-trauma recon are tough to get right. Luckily, your cases are planned, banker hours are cream puff and payers are chocolate sauce... compared to taking a lot of ER call or floor consults for infections and wounds.

Trauma is probably the hardest technically, but he expectations are low.
Pt can't walk... wants to walk again. Very hard to fix some of them, but injury can always be blamed for almost any of your bad outcomes.

The I&Ds and amps and stuff are easy (both technically and little/no pt expectations).
That is why those are "first year cases." It still takes good judgment and skill to do them well. I would never want to do only that stuff, but that's just me. I don't like the late case add-ons, urgent infection cases, tons of DME shoe/filler paperwork to get best outcomes (which are not helpful to your collections in PP), etc.

...as was said, do what you like and what you get good results, good income, and good life quality from. I think it's best to welcome whatever ppl need... you never know when a competitor for clinic/consult/ER pts will come in. You can always encourage some pathologies and discourage others (I say this as I dink around on SDN and procrastinate on a couple hospital consults that came in yesterday).

I agree Feli. Trauma expectations overall are low. "Well I couldn't walk before, and I'm better now at least." Same with infection "I felt lethargic and sick before the I and D/amp". Patient's are so much more well rested and happy the next day. It's just instant gratification. I had a foreign body I removed the other day on a patient and her family was so grateful you would've thought I cured cancer or something. It's so nice to be appreciated sometimes, instead someone being upset that they feel some numbness from a hammertoe repair... I don't know. Positives and negatives to both. Hate rounding and hate late night consults.

 

[podfam3008]

28002 and 28003 also no more global (but reimbursement down 200 bucks). But now you can at least bill for rounding the following day.

What exactly are you billing the next day? Do you have to get a post op xray to be able to bill an established visit code? Or is dressing change/reviewing labs enough?
So...
What code do you bill for initial hospital consults?
And what code do you bill for the following visits?

 

[air bud]

What exactly are you billing the next day? Do you have to get a post op xray to be able to bill an established visit code? Or is dressing change/reviewing labs enough?
So...
What code do you bill for initial hospital consults?
And what code do you bill for the following visits?

I would Bill the specified code for a inpatient based on what I did. I would bill the specified inpatient follow up visit based on what I did. The is black and white. It is not 10 ways to code a bunion.

 

[dtrack22]

exactly why hospital work blows. Consults dont pay that much. Take a ton of charting time and coordinating with other doctors. Also better pray the patient has insurance and pays the bill. If they come into your office you can collect copays/deductibles

It blows if you are not employed by the hospital…

I had a gas consult at lunch. I walked down the hallway to the ED, looked at the foot, told the patient they needed an amp and walked out. On the way out I told the PA in the ED to have hospitalist team admit the patient. I walked down the hallway to my clinic and told my MA to call the OR and let them know I had an amp to add on after I was done in clinic. I dictated into the templated consult note saying patient had gas and osteo and needed surgery today, took a couple minutes before I saw my first afternoon clinic patient. I finished clinic, walked down the hallway to the OR where patient was waiting, went to OR and amped some rays and threw on a wound vac and was walking out 45 min later to head home. 17 wRVU later and a little over $900 will go towards my next paycheck. I have no idea if the patient was insured or not. Doesn’t matter. I get paid regardless and it took maybe an extra hour of my time. I’ll happily do an hours worth of work for an extra $900.

Wounds dont care that you have a vacation next week to Disneyworld with the family. It is inevitable that 1 hour before your flight to florida with the family the ER will call with gas gangrene of one of your regular patients that needs emergent attention with no one else around.

Meh, this is a mindset thing. It isn’t necessary. You tell the ED you aren’t on call. General surgery or ortho gets to do the thing they are being paid to do.

I guess I don’t understand the thought process of “I need to be available for my patients 24 hours a day.” You don’t. I’ve worked for podiatrists who thought like that. Nobody else in medicine really does. There is ALWAYS someone around who can do what we do. The above scenario isn’t your problem and shouldn’t even begin to mess with your Disney vacation.

I was out of town this weekend and gas/osteo came in. My ortho partner called me and I let him know I was out of town, he amped the toe and took the met head and I took over monday. They all know they can call me and that I will often times come in when not on call, as long as I’m in town and not busy. But if I’m not listed on call, I have ZERO obligation to do anything about a foot problem in the hospital.

 

[podfam3008]

Again...
What code do you guys bill for initial hospital consults? 99221?
And what code do you bill for the following subsequent visits?

 

[podfam3008]

It blows if you are not employed by the hospital…

I had a gas consult at lunch. I walked down the hallway to the ED, looked at the foot, told the patient they needed an amp and walked out. On the way out I told the PA in the ED to have hospitalist team admit the patient. I walked down the hallway to my clinic and told my MA to call the OR and let them know I had an amp to add on after I was done in clinic. I dictated into the templated consult note saying patient had gas and osteo and needed surgery today, took a couple minutes before I saw my first afternoon clinic patient. I finished clinic, walked down the hallway to the OR where patient was waiting, went to OR and amped some rays and threw on a wound vac and was walking out 45 min later to head home. 17 wRVU later and a little over $900 will go towards my next paycheck. I have no idea if the patient was insured or not. Doesn’t matter. I get paid regardless and it took maybe an extra hour of my time. I’ll happily do an hours worth of work for an extra $900.



Meh, this is a mindset thing. It isn’t necessary. You tell the ED you aren’t on call. General surgery or ortho gets to do the thing they are being paid to do.

I guess I don’t understand the thought process of “I need to be available for my patients 24 hours a day.” You don’t. I’ve worked for podiatrists who thought like that. Nobody else in medicine really does. There is ALWAYS someone around who can do what we do. The above scenario isn’t your problem and shouldn’t even begin to mess with your Disney vacation.

I was out of town this weekend and gas/osteo came in. My ortho partner called me and I let him know I was out of town, he amped the toe and took the met head and I took over monday. They all know they can call me and that I will often times come in when not on call, as long as I’m in town and not busy. But if I’m not listed on call, I have ZERO obligation to do anything about a foot problem in the hospital.

What an awesome set-up you have!

 

[air bud]

It blows if you are not employed by the hospital…

I had a gas consult at lunch. I walked down the hallway to the ED, looked at the foot, told the patient they needed an amp and walked out. On the way out I told the PA in the ED to have hospitalist team admit the patient. I walked down the hallway to my clinic and told my MA to call the OR and let them know I had an amp to add on after I was done in clinic. I dictated into the templated consult note saying patient had gas and osteo and needed surgery today, took a couple minutes before I saw my first afternoon clinic patient. I finished clinic, walked down the hallway to the OR where patient was waiting, went to OR and amped some rays and threw on a wound vac and was walking out 45 min later to head home. 17 wRVU later and a little over $900 will go towards my next paycheck. I have no idea if the patient was insured or not. Doesn’t matter. I get paid regardless and it took maybe an extra hour of my time. I’ll happily do an hours worth of work for an extra $900.



Meh, this is a mindset thing. It isn’t necessary. You tell the ED you aren’t on call. General surgery or ortho gets to do the thing they are being paid to do.

I guess I don’t understand the thought process of “I need to be available for my patients 24 hours a day.” You don’t. I’ve worked for podiatrists who thought like that. Nobody else in medicine really does. There is ALWAYS someone around who can do what we do. The above scenario isn’t your problem and shouldn’t even begin to mess with your Disney vacation.

I was out of town this weekend and gas/osteo came in. My ortho partner called me and I let him know I was out of town, he amped the toe and took the met head and I took over monday. They all know they can call me and that I will often times come in when not on call, as long as I’m in town and not busy. But if I’m not listed on call, I have ZERO obligation to do anything about a foot problem in the hospital.

I miss the good old days like this. This is EXACTLY how hospital employed podiatry goes....

 

[air bud]

Again...
What code do you guys bill for initial hospital consults? 99221?
And what code do you bill for the following subsequent visits?

Google "inpatient cpt codes" and I bet you find your answer. While you are the there I am guess you should read up more on them besides what is the correct code.

 

[air bud]

I was totally on top of the toe amp global last year, but somehow missed this one. Sadly, had I read TPMA's blast in December I would also have noticed this.

View attachment 351549

Call me crazy, but if they are going to do this they need to do it for all of the infection type codes ie. 28124, abscess codes (10060-10061) etc. I get we get less money but I have insurances that will not pay -anything- during a global even if its a new bone infection on the other foot.

In other news though:

Article - Billing and Coding: Surgical Treatment of Nails (A52998)

Use this page to view details for the Local Coverage Article for Billing and Coding: Surgical Treatment of Nails.

www.cms.gov

View attachment 351550

It is only for certain MACS, yours being one of them @heybrother

 

[Feli]

Again...
What code do you guys bill for initial hospital consults? 99221?
And what code do you bill for the following subsequent visits?

99221 or 99222 usually... plus any procedures. F/u are 99231 or 99232.

You can use 99252 family of codes for non-MCR payers if you want (can't remember my last inpt consult that was not MCR age). You can't use those for MCR anymore as of a year or two ago. I try to inpt work so few and far between that I need to check the codes to see if they've changed 😛

 

[dtrack22]

99221 or 99222 usually... plus any procedures. F/u are 99231 or 99232.

You can use 99252 family of codes for non-MCR payers if you want (can't remember my last inpt consult that was not MCR age). You can't use those for MCR anymore as of a year or two ago. I try to inpt work so few and far between that I need to check the codes to see if they've changed 😛

Just remember these codes are only for those patients that have already been admitted to the floor and don’t apply if you see the patient in the ED before admission.

What code do you guys bill for initial hospital consults? 99221?

99222 primarily. I would only do 99221 if it was non surgical though I couldn’t tell you the last time I’ve had an inpatient consult that didn’t require surgery. We have wound care nurses and a wound care center in our hospital, who do pretty much everything wound related on the floor. I can even have the nurses come down to the OR to put the vac on for me after the cutting is done. So I’m not getting called unless hospitalist is thinking amputation or wound care nurses think it need debridement in the OR.

Follow ups depend on the global really. Assuming they aren’t in the global then it’s generally 99232 on a day where I can document the decision to go back to the OR (staged debridement/amps) and 99231 on most other days. Time isn’t worthwhile because inpatient codes are still based on face to face time with over 50% being counseling and coordination of care. 25 min (99232) is a long time to be in an inpatient room unless you’re a sadist.

 

[DYK343]

I was out of town this weekend and gas/osteo came in. My ortho partner called me and I let him know I was out of town, he amped the toe and took the met head and I took over monday. They all know they can call me and that I will often times come in when not on call, as long as I’m in town and not busy. But if I’m not listed on call, I have ZERO obligation to do anything about a foot problem in the hospital.

Exactly like I said. You need someone around when you are gone to help manage things that pop up when you are gone. All I said was it would be hard to do it alone.Not that its impossible. But hard.

Im sure its regional. Where I am, I dont have a lot of backup. And if youre going to cater the ER for a non elective practice you will have to be reliable or have someone reliable to back you up when gone.

 

[dtrack22]

You need someone around when you are gone to help manage things that pop up when you are gone. All I said was it would be hard to do it alone.Not that its impossible. But hard.

What hospital doesn’t have an orthopedic surgeon and a general surgeon on call?

It’s no different than when I was solo in the same town, before joining the hospital. If I wasn’t on call it didn’t matter who the patient was. I had no obligation to come in and whoever the hospital was paying to be on call had to take care of the patient regardless. It isn’t hard at all.

You don’t need a partner or associates. You have no obligation to come into the hospital when you aren’t on call. Zero. Zip. Nada. This is why ortho and Gen surg get paid $1000+ per day to have their phone on. The hospital has to have coverage and it isn’t your responsibility to provide it, outside of what staff bylaws require for privileges or outside of what your employment contract dictates.

 

[DYK343]

What hospital doesn’t have an orthopedic surgeon and a general surgeon on call?

It’s no different than when I was solo in the same town, before joining the hospital. If I wasn’t on call it didn’t matter who the patient was. I had no obligation to come in and whoever the hospital was paying to be on call had to take care of the patient regardless

The point of the argument was OP wants to open a non elective practice. If he wants to do that he will need to be available for the ER and doing it alone would be difficult.

Every time I try to leave the ER calls me and asks "well who is your backup" "You have to have an alternate"

Its frustrating to say the least because my MSG only employs 1 DPM and thats me. Its great because I get all the cases. Its bad because i'm always essentially on call. There is no backup DPM wise for me.

Im surprised your orthos will amp toes. Would almost certainly send out around here but im sure its regional. General surgery would do it in a pinch but i dont think they have touched the foot in many years.

 

[dtrack22]

OP wants to open a non elective practice. If he wants to do that he will need to be available for the ER and doing it alone would be difficult.

He/she can be available for the ER for however many days staff bylaws require or as many as he/she wants. The practice situation doesn’t change that fact nor does it change the difficulty level.

Every time I try to leave the ER calls me and asks "well who is your backup" "You have to have an alternate"

You don’t have to have anything. Your ED providers need educated on their own jobs apparently. It is their job to stabilize the patient. They are licensed to treat the patient in the ED if they feel anything procedural is necessary. If they feel the patient is safe for discharge they can do that. If the patient needs admitted then they have other people on call who have privileges to amputate a toe or do an I&D. If there is nobody on call who can do that then they are to arrange transfer for the patient to a higher level of care.

The reality is that you’re being bullied into doing work you are neither ethically nor legally required to do. Personally I would have put a stop to that long ago but at least you’re getting paid when you go in…

Would almost certainly send out around here

Then you need to go on vacation and tell them to send it out the next time they consult you.

The old podiatrist in town has never taken call/inpatient consults, so ortho has done amps here for years. Probably because they aren’t frequent. I have 2 inpatients at the same time for the first time in over a year. I can go a month (or two) without an inpatient. So it’s not like they were chopping off toes every week. And we all still send stuff out, so he would have if he really wasn’t comfortable with it or didn’t want to come in for it. Ortho sent a GSW to the foot across the state because he wasn’t sure what exactly to do with it and didn’t want to wake me up at 1am on a Saturday. And I didn’t need the money enough to be upset about that. I thanked him for not waking me up but also made sure to let him know not to feel bad if he did, I would have come in to help out had he asked. It is possible to draw a line and say “no” while still playing nice and at least offering to be helpful when you can

 

[podfam3008]

99221 or 99222 usually... plus any procedures. F/u are 99231 or 99232.

You can use 99252 family of codes for non-MCR payers if you want (can't remember my last inpt consult that was not MCR age). You can't use those for MCR anymore as of a year or two ago. I try to inpt work so few and far between that I need to check the codes to see if they've changed 😛

Thanks for answering the question, our group has been using those exact codes (minus 99252). Last I checked, those were appropriate for admitted patients. Thanks for confirming.

 

[HardRoadPaved]

36:54 into the video Lehrman explain why you should be careful with those level 2 new codes unless you are billing for time.

99222 : Inpatient hospital visits: Initial and subsequent initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.

I am not doubting you can get to the moderate MDM, but good luck getting that comprehensive H&P portion.

 

[josebiwasabi]

Not sure why a comprehensive history and PE would be hard to achieve?

The history is easy and the EMR template will pull everything for you for PMH/PSH/FH/SH/MEDS/ALL/ROS. The only thing you need to do is list the chief complaint and 4 elements of NLDOCAT.

For the PE, you can do almost everything from a visual exam. You need 9 systems and 2 items per system.

Choose any 5 of 7 from the following plus our usual 4 system extremity exam and you're done.

GEN: Well appearing, NAD, AAOx4
HEENT: NC/AT, MMM, EOMI
NECK: supple, neg thyromegaly
CV: RRR, CFT<2s
RESP: atraumatic chest wall, non labored breathing
ABD: obese, soft, NT/ND
PSYCH: normal affect, normal speech

 

[NobodyDPM]

I'll take your bunions and hammertoes, and you can have all my pus balls. Gladly. And twice on Sunday.

 

[newfeet]

Hey everyone, I'm thinking about focusing more on doing non-elective surgeries like I&D's, amputations, foreign body removals, fracture repairs, etc. I am already board-certified in ABFAS. Of course, I won't turn down anyone that still wants to have a bunion or hammertoe repaired because I don't want to limit myself on patients. However, I find that the most job satisfaction for me comes from patients who I do non-elective surgery. The patients are often so much more grateful, and its great to see someone feel so much better after resolving an infection they had. Patients who have elective surgery are grateful too but I find that there are a lot more complaints (ex: "why does my foot still have swelling a month after a bunion?" Even though we discussed this at length preop), headaches, etc. and now that we can bill after an amputation and there's no global, that's an extra plus. Of course, there are downsides to doing mostly non-elective surgery, including taking more hospital call, rounding, etc. which is a pain and takes more time away from the family. Has anyone ever felt this way or considered this themselves? Pros and cons? Thanks.

Same. I would prefer to do non elective surgeries.

 

[DYK343]

He/she can be available for the ER for however many days staff bylaws require or as many as he/she wants. The practice situation doesn’t change that fact nor does it change the difficulty level.


You don’t have to have anything. Your ED providers need educated on their own jobs apparently. It is their job to stabilize the patient. They are licensed to treat the patient in the ED if they feel anything procedural is necessary. If they feel the patient is safe for discharge they can do that. If the patient needs admitted then they have other people on call who have privileges to amputate a toe or do an I&D. If there is nobody on call who can do that then they are to arrange transfer for the patient to a higher level of care.

The reality is that you’re being bullied into doing work you are neither ethically nor legally required to do. Personally I would have put a stop to that long ago but at least you’re getting paid when you go in…



Then you need to go on vacation and tell them to send it out the next time they consult you.

The old podiatrist in town has never taken call/inpatient consults, so ortho has done amps here for years. Probably because they aren’t frequent. I have 2 inpatients at the same time for the first time in over a year. I can go a month (or two) without an inpatient. So it’s not like they were chopping off toes every week. And we all still send stuff out, so he would have if he really wasn’t comfortable with it or didn’t want to come in for it. Ortho sent a GSW to the foot across the state because he wasn’t sure what exactly to do with it and didn’t want to wake me up at 1am on a Saturday. And I didn’t need the money enough to be upset about that. I thanked him for not waking me up but also made sure to let him know not to feel bad if he did, I would have come in to help out had he asked. It is possible to draw a line and say “no” while still playing nice and at least offering to be helpful when you can

I agree with much of what you said above. Especially about the bullying part because its true.

But you're also only carrying 2 inpatients in a several month time span and go several months without an inpatient. I have 5-6 patients in the hospital at any given time. Its very rare for me not to have an inpatient.

Being busy in a non elective practice would be very difficult to do alone. Im going to have to stand by that. We disagree on this issue but if you have patients in the hospital you cant just leave without an alternate.

If you're running a non elective practice solo and have no alternate what do you do 3-5 days before your vacation? Just stop accepting consults because you're going to be out of town? Thats a lot of lost revenue.

Like I said above im really grinding hard at my current position. Its not sustainable long term but my loans will be gone soon. I do feel trapped and leaving is not easy given I have no real alternate to help when I am away. Its a hole I did somewhat create myself in the name of greed. My advice to OP is find a solution to this problem before it becomes a problem. Not answering the ER calls, telling them no thanks not this time, or leaving patients in the hospital for a week without followup is not advised if youre going to thrive in a non elective practice.

 

[PTPuser]

I have a question. So theoretically speaking, if I have a patient who walked into my office on Monday with gas whom I take to the OR for amp / I&D that Monday night, goes home but have complications on Wednesday and I happen to be off from call that night, am I obligated to see them when I am solo PP that night? Or like dtrack22 said, patient will have to be stabilized by whoever is call and I'll be notified of it the next day I'm back in office?

I'm trying to understand if our field is similar to what the PCP/Hospitalist model is like. But I'm getting confused between what DYK343 and dtrack22 is saying.

 

[HardRoadPaved]

I have a question. So theoretically speaking, if I have a patient who walked into my office on Monday with gas whom I take to the OR for amp / I&D that Monday night, goes home but have complications on Wednesday and I happen to be off from call that night, am I obligated to see them when I am solo PP that night? Or like dtrack22 said, patient will have to be stabilized by whoever is call and I'll be notified of it the next day I'm back in office?

I'm trying to understand if our field is similar to what the PCP/Hospitalist model is like. But I'm getting confused between what DYK343 and dtrack22 is saying.

Well depends if you round daily on your patients. Now with 28002/3 having global I hope you do or else its not financially worth it.

 

[PTPuser]

Well depends if you round daily on your patients. Now with 28002/3 having global I hope you do or else its not financially worth it.

But does rounding in this scenario counts as being available 24/7 for all immediate complications? Or can rounding / global count for follow up after emergent event?

 

[dtrack22]

Wednesday and I happen to be off from call that night, am I obligated to see them when I am solo PP that night? Or like dtrack22 said, patient will have to be stabilized by whoever is call and I'll be notified of it the next day I'm back in office?

How you are notified depends on your relationship with other docs at the hospital and both written and unwritten hospital policies. But if you aren’t on call and they call you that night there is no reason you have to come in. If the patient needs to urgently go to the OR for some reason there is a surgeon on call who can do it. And if not, the ED should transfer the patient somewhere they can be treated.

We disagree on this issue but if you have patients in the hospital you cant just leave without an alternate.

I never suggested you up and leave with a patient who is receiving active treatment.

I am really struggling with the idea that in the last 5 years you haven’t taken any time off since you don’t have an alternate and have inpatients at all times and respond to all consults from the ED and hospitalists. That sounds awful. How do you get CME if you can’t leave for any conferences? All online?

If you're running a non elective practice solo and have no alternate what do you do 3-5 days before your vacation? Just stop accepting consults because you're going to be out of town?

Yes. That’s exactly what you do. Do you schedule clinic patients and elective surgery the week you are planning on going out of town? Of course not. This is no different.

Thats a lot of lost revenue.

It’s no more lost revenue than shutting down an elective clinic and a handful of elective cases when you go out of town. Vacation is lost revenue for any physician, no matter how you are set up. Ok, vacation is not lost revenue for the podiatry group owner who just takes 10% from all 10 of their associates. But for everyone else…

 

[heybrother]

There is no answer to your question because its going to be entirely dependent on your circumstances and what arrangement you have with your hospital, ED, other podiatrists in town etc. You may also have your own personal preferences ie. perhaps you really never take call but this patient was an elective outpatient surgery turned bad and you are following it trying to clean up your own mess. Dtrack and Dyk have described two different scenarios with different thought processes. There was another residency near mine and a mixture of PP, podiatry-in-ortho, and hospital employed shared call. The interactions I witnessed were friendly/collegial. How common that is - I cannot say. None of the PP podiatrists in my town take hospital call.

 

[Feli]

... None of the PP podiatrists in my town take hospital call.

The way it should be. ^^^

We don't take any formal call in my group, and we won't apply to be on staff or bring our elective to one hospital system that requires all staff DPMs all being on call schedule. They can have their FTE podiatrists do that evening and weekend work; we have plenty of other options in terms of places to do our cases or admissions. A few of the competing PP DPM groups take call to pick up new patients via ER and consults since they are trying to build, and that's their choice. I will do infrequent ER or floor consults at my location within a hospital, but they know there is no guarantee I will respond fast or respond at all since I might be on vaca, other location, or just not interested. I would rather just market and get good results to get patients and keep patients than chase patients wherever they may be.

As was said, if you're a DPM employed at the hospital with clinic at the hospital, it is a much different story... you're already there, and it is an expected part of your job. I have been in both situations, but to try to pick up a lot of inpatients and inpatient cases when you are PP - even if you have a clinic attached to the hospital - is almost never an efficient use of your time (assuming you have anything else productive to do).

In any business, you want clients or deals or buyers or whatever to come to you. You also want fewer clients or deals and more money per deal or client or whatever the business type dictates. As it applies to medicine, this is why you see any PP doc doing a lot of marketing and possibly some call, inpatient, etc in the early going. After they have enough patients, they close or mitigate their office locations with bad payer demographics or under-booked days, they avoid the hospital unless absolutely necessary (patients known to them), and they trim payers. They might narrow their scope. Some of them keep those locations and services and payers... and hire associates to do that work. Regardless, the goal is to increase per patient revenue and patients per day... to maximize per hour income (and max free time).