Favorite Wart Treatments

[CutsWithFury]

Yes this is a very TFP topic but I was curious to know what guys and gals are currently doing for their wart patients. For me personally I loathe plantar warts. I typically freeze them with liquid nitrogen but I have had some complications with patients blistering if they are too active after treatment (despite patient education). I used to use the laser in residency which I thought was pretty nifty but obviously there is wound management that still needs to be done. Cantharidin is another option but not readily available and can still lead to a lot of patient discomfort.

Recently I have been pushing for excision in the OR and with rotational skin plasty with a Schrudde flap. I have had patients healed after two weeks. Yes they have to be non weight bearing which seems overkill for a plantar wart but honestly I feel it is worth to them rather than struggle with all of the above and still not eradicating the wart. Stretching the treatment over several weeks or even months leading to patient dissatisfaction.

What say you podiatrists.

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[josebiwasabi]

In office we use monochloroacetic acid followed by salicylic acid. For people with numerous/bilateral lesions I have also added oral cimetidine.

Surgical excision for large/deep/recalcitrant ones. I recently did a bilobe flap on a toe for one and the patient healed very well after 3 weeks.

I think rotational/advancement flap is a good idea, as I have seen some follow-ups from patients who had large verruca surgically excised and they have developed painful scar tissue.

 

[DYK343]

Cantharidin is my go to but I agree... Warts are difficult to treat.

I am too afraid to flap. If it fails then its worse. Not saying its wrong. But I dont have the confidence in my patients to be compliant. Especially since a lot of them are kids.

 

[CutsWithFury]

Cantharidin is my go to but I agree... Warts are difficult to treat.

I am too afraid to flap. If it fails then its worse. Not saying its wrong. But I dont have the confidence in my patients to be compliant. Especially since a lot of them are kids.

Good point about kids. I’ve never taken a kid to the OR for this. I’ve only done schrudde flaps on adults with great success.

I have my patients follow up with me in wound care clinic instead of regular clinic. If my frenulum dies or has necrosis I have collagen dressings accessible to expedite wound healing.


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[CutsWithFury]

In office we use monochloroacetic acid followed by salicylic acid. For people with numerous/bilateral lesions I have also added oral cimetidine.

Surgical excision for large/deep/recalcitrant ones. I recently did a bilobe flap on a toe for one and the patient healed very well after 3 weeks.

I think rotational/advancement flap is a good idea, as I have seen some follow-ups from patients who had large verruca surgically excised and they have developed painful scar tissue.

I have issues getting salicylic acid covered by insurance plans therefore I don’t bother ordering it anymore.

What’s your dosing for oral cimetidine and how long are you giving it for? Any contraindications? Giving it to only adults or kids too?


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[air bud]

always had pretty good luck with cantharidin and then covered with a compound cream of like 40 something percent salycilic acid and something else I can't remember (last job). Leave on for between 12 and 24 hours depending on age, location etc.

rarely did laser in residency will never do now I don;t know enough about it and have experience that I would trust it. I rarely treat warts anymore (I rarely see patients...) but my protocol is cantharidin and if that doesn't work then cut out in OR and bovie the crap out of it.

 

[air bud]

I have issues getting salicylic acid covered by insurance plans therefore I don’t bother ordering it anymore.

What’s your dosing for oral cimetidine and how long are you giving it for? Any contraindications? Giving it to only adults or kids too?


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i also did cimetidine on kids, I dont remember the dosage. I never felt like it actually did anything

 

[G0dFather]

Recently I have been pushing for excision in the OR and with rotational skin plasty with a Schrudde flap.

WOW... for a wart? i guess itll be great $ if pt is out of net LOL

 

[CutsWithFury]

WOW... for a wart? i guess itll be great $ if pt is out of net LOL

I'm hospital employed. RVUs is my language

In all seriousness...it works and its fast and they don't come back. If the patient has any contraindications such as DM2, PVD, nicotine use, etc etc etc I am not doing this. I just wanted to put that out there

 

[G0dFather]

i feeling it ... great thinking out of the box man ! derm and plastics combined

 

[Scrantonicity]

I just debride, freeze, put them on cimetidine 800mg BID (for adults--I make adjustments for kids according to their weight), and prescribe imiquimod cream. I was never a huge believer in cimetidine until I put someone on it (just to try it) and the patient reported that the warts on their fingers disappeared even though I was only treating the ones on their feet.

I just have them put a dot of the imiquimod cream and some duct tape on the warts every day.

With this combo, I have found that many kids under 12 years old only need 1-2 treatments--I see them back and they are gone, and I'm always amazed.

I do have plenty of adult patients that don't seem to respond to the treatment, or the progress is very slow--I usually end up surgically excising them--haven't tried a flap yet, but I am not usually excising any huge warts. I just have to remind the patient about the likelihood of scarring, and possible keloid, yada yada yada.

If I excise it in the office, I just numb them up and cut a hole in their foot and scoop it out with a curette...cauterize with silver nitrate and phenol, flush it out really well...silvadine dressings every day for about 2 weeks. Warn about recurrence and scarring.

 

[DYK343]

Its been a few years since I read about it but last I read Cimetidine didnt hold up well against placebo in larger trials. No benefit. I have not used it for this reason since I graduated residency.

 

[DYK343]

I have a patient with a wart about the size of a dime or nickel. Very painful and not budging. I might excise and flap...

 

[CutsWithFury]

I have a patient with a wart about the size of a dime or nickel. Very painful and not budging. I might excise and flap...

If no risk factors I def would. I also excise chronic diabetic foot ulcers and do rotational skin flaps often if they are failing conventional wound care.

 

[NatCh]

Yes this is a very TFP topic...

Nice backhand! Takes a swipe then asks for help, lol.

 

[CutsWithFury]

Nice backhand! Takes a swipe then asks for help, lol.

Meh

 

[Scrantonicity]

Its been a few years since I read about it but last I read Cimetidine didnt hold up well against placebo in larger trials. No benefit. I have not used it for this reason since I graduated residency.

Meh, placebo or not--it's probably going to be in my bag of tricks for the foreseeable future. I'm a believer in placebo effects for warts anyways--there have been studies about that as well (the whole mind over matter thing). Anyways, it seems to work for me.

 

[NatCh]

Meh

Ha. Best of luck to you.

 

[CutsWithFury]

Ha. Best of luck to you.

I’m doing fine. Excise and rotational flap.


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[josebiwasabi]

I have issues getting salicylic acid covered by insurance plans therefore I don’t bother ordering it anymore.

What’s your dosing for oral cimetidine and how long are you giving it for? Any contraindications? Giving it to only adults or kids too?


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Adults 800mg BID until warts resolve
Kids weight based, up to 40mg/kg/day until warts resolve

Contraindications are renal and hepatic disease

 

[air bud]

What is highest OTC salicylic bacid goes?

 

[dtrack22]

I give patients the option of several essentially painless cantharone treatments (12-14 days apart) with some OTC home salicylic acid products in between, or excision in clinic which is a single treatment that's going to hurt more but the problem is typically resolved in 1 visit.

I've only taken 1 wart to the OR in the last 2-3 years.

 

[MilknCheerios]

What is highest OTC salicylic acid goes?

Pharmacist here. I think it's 40%. I usually recommend Dr. Scholl products instead of storebrand generics. If the patient has already tried that for a few weeks with no improvement, I will then recommend the freeze away stuff. And if that doesn't work, I recommend seeing one of you or rubbing the area with a banana peel (just kidding).

 

[CutsWithFury]

I give patients the option of several essentially painless cantharone treatments (12-14 days apart) with some OTC home salicylic acid products in between, or excision in clinic which is a single treatment that's going to hurt more but the problem is typically resolved in 1 visit.

I've only taken 1 wart to the OR in the last 2-3 years.

I didn’t know you operate still. Get a job you bum


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[ExperiencedDPM]

Blow torch. Haven’t had one recurrence.

 

[GeauxT]

I give patients the option of several essentially painless cantharone treatments (12-14 days apart) with some OTC home salicylic acid products in between, or excision in clinic which is a single treatment that's going to hurt more but the problem is typically resolved in 1 visit.

I've only taken 1 wart to the OR in the last 2-3 years.

This our basically our procedure as well. We apply cantherone, then the pt keeps the area covered and dry for 3 days. After that they apply an OTC acid (we use wart stick) daily for the remainder of 2 weeks. I would estimate 80% or more are healed in 2 weeks.

 

[heybrother]

I'm exploring trying to get cantharidin/a variant for our office. Seems like you can get multi-use vials on line through various labs.

In residency we did cryotherapy (we told the patients it would take 5-7 applications and I definitely saw it take more). They applied salicylic acid + initially 5-FU under duct tape and followed up at 2 weeks for repeat. We eventually switched to Aldara in lieu of 5-FU and I personally thought it had a better effect. Pediatrics got cimetidine. Did excisions for solo/2-3 lesions in clinic infrequently- healed by secondary intention. Large scale (15+) excisions in the OR, again without flaps.

I'll be crass and discuss $. During residency, my presumption is we billed 17110 for the vast majority of wart applications. Medicare values this in my area at about $110. At 7 or more visits that adds up. I believe we billed the size based benign skin lesion excision code for excisions. If experiencedDPM is still reading I strongly suspect he will have something to say about that. I may be looking at this all wrong, but the funny thing to me is that cryo seems ... "overpaid" for its difficulty. If you look at all the things 17110 entails - 30-60 seconds of application of cold spray pays the same as more involved things ie. numbing/cutting

Out of residency my clinic does not have cryotherapy. We do have some sort of historic device that can destroy tissues with soundwave via an application probe. I've never used it. I believe my partner uses it after the excision is already performed.

I offer patients:

(a) medication therapy - go home and put salicylic acid + duct tape + aldara on the lesions. Follow-up 2-3 weeks and I'll redebride down to the lesion and you continue. Most patients who present for pain seem to be alleviated by the first f/u but it takes a long time for resolution - like 2 months of applications. Most of these visits are very quick but unless I'm missing something they are 99212s. I'm not changing the plan/MDM. They are continuing to improve.
(b) go find someone who has cryotherapy
(c) excision

I saw a ton of warts in residency. My current practice really only has them infrequently. If you are doing repeat cryo every 2 weeks even having a handful of patients though is going to generate regular encounters since the patients come back so much. My intention/hope via adding cantharidin is to give my patients something effective/much more rapid as opposed to having to follow-up them for 2 months essentially hoping the problem will resolve. I'm also under the impression I should be able to bill 17110 for this procedure (a online coding site stated this code applies to chemosurgery though that may be out of date information) which would be improvement for the practice over 99212. My office manager claims private insurance will frequently not pay for this code in our area as they view it as cosmetic- perhaps she is wrong or perhaps it is only some plans. Perhaps this makes it an opportunity to offer an effective cash pay service/something that is not already being offered in the area.

I'm open to feedback.

 

[air bud]

I think that chemo surgery is for bleomycin and yes pays very well.

3 days seems like a long time to leave cantharidin on. I never left on for more than 24 hours.

Cryo and doing 5 to 7 in this day and age is robbery.

 

[heybrother]

Cryo and doing 5 to 7 in this day and age is robbery.

This is why I'm always curious to hear what other people have to say. I had no idea what those visits cost in residency. We did something along the lines of 60 seconds of application from cryo-gun - off and on, blanch till the patient says it hurts, stop/dethaw, repeat. I've had some dermatology residents come through my office and their feeling was that if the patient didn't blister like crazy it wasn't going to work. The above regimen inconsistently produces blistering. If you aren't on ...Medicaid the above adds up quickly.

In the spirit of robbery, we dispensed DME at my residency for sprains and fractures and trauma and what not. A $65? brace here. A presumably $200+ CAM boot there. My patient's out of residency have commercial insurance and we don't dispense DME in the office (yet). When patient's hear what the price of the DME at the store is they buy from Amazon. I look back and wonder - was anyone actually paying the cost for those items?

 

[air bud]

I love not being able to dispense DME. It is through a 3rd party med supply down the street. I tell people we can go through insurance and I have no idea what will cost, or buy this surgical shoe for 13 bucks on Amazon. Granted it takes longer since I live in the middle of nowhere..... obviously don't do for trauma but stress fracture or tendonitis? Yeah a few days more is fine. Patients love that I give them the option and most importantly makes them think I am not the bad guy when it comes to their bill.

 

[heybrother]

Are you so remote your patients can't get a Hoka? Cause that would be bad.

 

[G0dFather]

my presumption is we billed 17110 for the vast majority of wart applications. Medicare values this in my area at about $110.

This has and continues to make derms and pods very wealthy, I love it ..... WHAT you should be billing when they come back every 2 weeks for debridement of the lesion is 17110 not 99212 ( your loosing alot of money!) because that is what your doing, even if say on the 3rd visit your evaluating the progression of the wart, it doesnt matter there is an E&M component built into the procedure code ..... YOU ALREADY E&Med it on the visit that they first came in and you dx a wart if you also debirded it on that first visit then you can also tack on the 17110, its within your right ... but when they come back the next 3 visits ( for example) and ALL you are doing is debriding the wart and evaluating it then you should just bill 17110 ONLY .... unless they have something else that is "separately identifiable" then you can bill 99213/12 according to how thorough your EM

 

[dtrack22]

I didn’t know you operate still. Get a job you bum


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I’m living my best life. Like @NatCh but with even less work...and unfortunately a little less skiing I’d bet.

Though I got the best of both worlds in CO last weekend. Epic storm that brought a ton of snow (and lift lines even at Mary Jane, thank god I wasn’t at Vail) on Friday and then a bluebird day with great corduroy and a few untouched stashes in the trees on Saturday.

 

[Pronation]

visit 1: 99203 + 17110 - canthrone. f/u 2 wks
visit 2: resolved? 99213. not resolved? 17110 - canthrone. f/u 2 wks
visit 3: resolved? 99213. not resolved? 99213 + 17110 - cathrone plus add in aldara and cimetidine. f/u 4 wks
visit 4: This stupid wart has persisted for 2 months now... Discuss excision and rotational flap

 

[CutsWithFury]

visit 1: 99203 + 17110 - canthrone. f/u 2 wks
visit 2: resolved? 99213. not resolved? 17110 - canthrone. f/u 2 wks
visit 3: resolved? 99213. not resolved? 99213 + 17110 - cathrone plus add in aldara and cimetidine. f/u 4 wks
visit 4: This stupid wart has persisted for 2 months now... Discuss excision and rotational flap

Where do you buy your canthrone?


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[msuDPM]

visit 1: 99203 + 17110 - canthrone. f/u 2 wks
visit 2: resolved? 99213. not resolved? 17110 - canthrone. f/u 2 wks
visit 3: resolved? 99213. not resolved? 99213 + 17110 - cathrone plus add in aldara and cimetidine. f/u 4 wks
visit 4: This stupid wart has persisted for 2 months now... Discuss excision and rotational flap

I recommend an E/M course.

 

[heybrother]

Got beat to posting this - If an "established problem, stable or improving" is worth 1 point, how do you get to level 3 established on a "cya" visit? MDM is the heart of valuing the visit and it requires 2 columns of MDM - problem, data, risk etc

I'm not trying to ask that aggressively. My "training" from this is reading E&M university so maybe I'm not seeing it.

By that logic, a person with completely resolved plantar fasciitis is a level 3 also. Now I'm muddying the warts because the heart of the matter to me is its really about what you discussed and additionally plantar fasciitis could be presenting with 3 other mechanical problems.

At the ACFAS billing course the other day they said a healthy 12 year old with a wart is a 99202. The real question is - what did you say to their parents. If you walk in, take a glance and say "Its a plantar wart, its likely to go away on its own, don't worry about it" - it doesn't seem like there's a lot going on though I'll concede there are other conditions where lack of treatment doesn't mean lack of thought or decision making. But if you discuss - look, you were referred here because it didn't resolve - I'm going to definitively treat this - I have multiple treatment modalities - I can canth, freeze, excise, prescribe aldara, cimetidine, 5-FU. Here are the ups and downs. Aldara can irritate the skin. Cantharidin - blah blah blah - you've covered a lot of ground. Similarly - if a person with plantar fasciitis is resolved, but its there 5th episode in a year and you intend to discuss something more - sure, but add relevant problems.

Call me terrible, but I sort of regret attending the ACFAS billing conference the other day. The heart of their E&M section was "you all need to bill higher level codes" along with a fight over the classic can I bill a matrixectomy and a 203 together. Eruption. A dive into true multi-part MDM discussion, what is risk, etc was not done.

Other small thing - data points. Unless you work for a hospital where you can easily review charts, labs, etc - I don't think I really ever hit higher level visits on datapoints. I sometimes hear people say - you'll need another set of X-rays to get you there. Its 2 points for independent review of tracing.

 

[heybrother]

Where do you buy your canthrone?


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Appreciate the answer to this also,

I've started exploring this. Options I"ve seen so far.

-Dorner (sp) labs in Canada.
-Edge Pharma- something like that
-There may be other places, but some of them seem to just buy from Dorner and then sell you a marked up price.

I called Edge and they claim to be an American compounding laboratory within the states. They sell 0.7% and 1% (with some other stuff) - variations of these are usually marketed as Canth-something and Something PLUS. Edge claims that the Dorner product is illegal and shouldn't be allowed to be purchased in the states. I have not explored this- seems to be something pertaining to how the FDA has treated canth through the years. Edge also requires you to buy at least 2 at a time so you are looking at a minimum cost at just over $200 (I'm not saying this is outrageous - I'm just saying the price ain't the price of 1 vial and you work your way through it). They told me they test its viability out to 3 months.

Just to try and lighten the mood in this thread - I asked Edge who buys their products and they told me its incredibly popular with old podiatrists. They love it and can't get enough of it. I almost dropped the phone laughing.

Appreciate godfather's feedback above. Regardless of whether I'm coding my 17110 wrong - I reviewed all the billing for my practice concerning this code and variations of it - and we don't get paid for it. I actually looked through the billing chain of submission and response and the claims get trapped in hell forever ultimately to be rejected with a non-covered service. We got paid handsomely ($175-$225) twice, $50 a few times, and $0 dollars/written off after awhile. So I can start billing these but I don't think I'm going to get paid. Interestingly, my clinic has the fee schedule code for this set at almost $400 which is funny... god, if I had to block and dig out 14 warts with a blade that still wouldn't be enough.

 

[air bud]

visit 1: 99203 + 17110 - canthrone. f/u 2 wks
visit 2: resolved? 99213. not resolved? 17110 - canthrone. f/u 2 wks
visit 3: resolved? 99213. not resolved? 99213 + 17110 - cathrone plus add in aldara and cimetidine. f/u 4 wks
visit 4: This stupid wart has persisted for 2 months now... Discuss excision and rotational flap

Visit 2 - problem resolved, no medication - how are you billing a level 3? you really spending 15 mins with them?

 

[ExperiencedDPM]

visit 1: 99203 + 17110 - canthrone. f/u 2 wks
visit 2: resolved? 99213. not resolved? 17110 - canthrone. f/u 2 wks
visit 3: resolved? 99213. not resolved? 99213 + 17110 - cathrone plus add in aldara and cimetidine. f/u 4 wks
visit 4: This stupid wart has persisted for 2 months now... Discuss excision and rotational flap

Can you spell A-U-D-I-T??!

 

[josebiwasabi]

Got beat to posting this - If an "established problem, stable or improving" is worth 1 point, how do you get to level 3 established on a "cya" visit? MDM is the heart of valuing the visit and it requires 2 columns of MDM - problem, data, risk etc

I'm not trying to ask that aggressively. My "training" from this is reading E&M university so maybe I'm not seeing it.

By that logic, a person with completely resolved plantar fasciitis is a level 3 also. Now I'm muddying the warts because the heart of the matter to me is its really about what you discussed and additionally plantar fasciitis could be presenting with 3 other mechanical problems.

At the ACFAS billing course the other day they said a healthy 12 year old with a wart is a 99202. The real question is - what did you say to their parents. If you walk in, take a glance and say "Its a plantar wart, its likely to go away on its own, don't worry about it" - it doesn't seem like there's a lot going on though I'll concede there are other conditions where lack of treatment doesn't mean lack of thought or decision making. But if you discuss - look, you were referred here because it didn't resolve - I'm going to definitively treat this - I have multiple treatment modalities - I can canth, freeze, excise, prescribe aldara, cimetidine, 5-FU. Here are the ups and downs. Aldara can irritate the skin. Cantharidin - blah blah blah - you've covered a lot of ground. Similarly - if a person with plantar fasciitis is resolved, but its there 5th episode in a year and you intend to discuss something more - sure, but add relevant problems.

Call me terrible, but I sort of regret attending the ACFAS billing conference the other day. The heart of their E&M section was "you all need to bill higher level codes" along with a fight over the classic can I bill a matrixectomy and a 203 together. Eruption. A dive into true multi-part MDM discussion, what is risk, etc was not done.

Other small thing - data points. Unless you work for a hospital where you can easily review charts, labs, etc - I don't think I really ever hit higher level visits on datapoints. I sometimes hear people say - you'll need another set of X-rays to get you there. Its 2 points for independent review of tracing.

Theoretically for a return visit you dont even need to factor in the MDM component.

Return patients only require 2 of 3 of HISTORY, EXAM and MDM.

 

[heybrother]

Theoretically for a return visit you dont even need to factor in the MDM component.

Return patients only require 2 of 3 of HISTORY, EXAM and MDM.

I don't disagree with you that this is what's written all over the "guidance". I've been trying to do some reading on how to do this right and here's my problem. Yeah, he could just drop a level 3 establish history # of points, a level 3 physical exam # of points and be done with it. But the way you are supposed to code an encounter as I'm reading online is - define the MDM of the visit and then document it (HPI or PE) accordingly. Documenting established level 4 points of HPI/PE isn't how we're supposed to get to 4. The MDM comes first and then the rest of the documentation is line with it. It should (but doesn't) read 2 of the 3, but always including MDM.

Once you recognize the MDM of the visit is "cya" the HPI/PE becomes what it should be - very, very short. And I sadly overdocumented the hell out of these during residency.

Just one additional thing - I thought it was interesting during the conference - a patient presents with worsening plantar fasciitis. How do you get that visit to a 3. 15 minutes or ...MDM but MDM will require an additional problem ie. you start documenting equinus or instability or what not because otherwise you won't have enough problem points.

***Anyway, I want to come back around to the fact that - you are saying what the online guidance says. I'm not disagreeing with that.

 

[air bud]

I don't disagree with you that this is what's written all over the "guidance". I've been trying to do some reading on how to do this right and here's my problem. Yeah, he could just drop a level 3 establish history # of points, a level 3 physical exam # of points and be done with it. But the way you are supposed to code an encounter as I'm reading online is - define the MDM of the visit and then document it (HPI or PE) accordingly. Documenting established level 4 points of HPI/PE isn't how we're supposed to get to 4. The MDM comes first and then the rest of the documentation is line with it. It should (but doesn't) read 2 of the 3, but always including MDM.

Once you recognize the MDM of the visit is "cya" the HPI/PE becomes what it should be - very, very short. And I sadly overdocumented the hell out of these during residency.

Just one additional thing - I thought it was interesting during the conference - a patient presents with worsening plantar fasciitis. How do you get that visit to a 3. 15 minutes or ...MDM but MDM will require an additional problem ie. you start documenting equinus or instability or what not because otherwise you won't have enough problem points.

***Anyway, I want to come back around to the fact that - you are saying what the online guidance says. I'm not disagreeing with that.

worsening is worth 3 points so don't need an additional problem right? then rest of MDM may help get to a level 3

 

[air bud]

Got beat to posting this - If an "established problem, stable or improving" is worth 1 point, how do you get to level 3 established on a "cya" visit? MDM is the heart of valuing the visit and it requires 2 columns of MDM - problem, data, risk etc

I'm not trying to ask that aggressively. My "training" from this is reading E&M university so maybe I'm not seeing it.

By that logic, a person with completely resolved plantar fasciitis is a level 3 also. Now I'm muddying the warts because the heart of the matter to me is its really about what you discussed and additionally plantar fasciitis could be presenting with 3 other mechanical problems.

At the ACFAS billing course the other day they said a healthy 12 year old with a wart is a 99202. The real question is - what did you say to their parents. If you walk in, take a glance and say "Its a plantar wart, its likely to go away on its own, don't worry about it" - it doesn't seem like there's a lot going on though I'll concede there are other conditions where lack of treatment doesn't mean lack of thought or decision making. But if you discuss - look, you were referred here because it didn't resolve - I'm going to definitively treat this - I have multiple treatment modalities - I can canth, freeze, excise, prescribe aldara, cimetidine, 5-FU. Here are the ups and downs. Aldara can irritate the skin. Cantharidin - blah blah blah - you've covered a lot of ground. Similarly - if a person with plantar fasciitis is resolved, but its there 5th episode in a year and you intend to discuss something more - sure, but add relevant problems.

Call me terrible, but I sort of regret attending the ACFAS billing conference the other day. The heart of their E&M section was "you all need to bill higher level codes" along with a fight over the classic can I bill a matrixectomy and a 203 together. Eruption. A dive into true multi-part MDM discussion, what is risk, etc was not done.

Other small thing - data points. Unless you work for a hospital where you can easily review charts, labs, etc - I don't think I really ever hit higher level visits on datapoints. I sometimes hear people say - you'll need another set of X-rays to get you there. Its 2 points for independent review of tracing.

One of the "upsides" I guess would be that yes, you are able to get 2 points for reviewing x-rays since you are not billing for them (almost all hospitals do not lot providers bill for x-ray because they are paying radiology to read them).

 

[heybrother]

worsening is worth 3 points so don't need an additional problem right? then rest of MDM may help get to a level 3

E&M university seems to indicate a worsening established problem is worth 2.

In regards to the X-rays - I may have worded my comment poorly. Here's where I'm going with that. You are at a follow-up visit. You are like the above - wondering how to get a 2nd column of 3+ since your risk column is already there due to medicine or surgery discussion. People have said to me - you need to take some X-rays to get your visit up to a 3, but the X-rays will only be worth 2 data points so you aren't going to "3" that column with just X-rays. That's sort of what I mean by that. Being in a hospital and being able to review the ED docs notes, labs, etc are points I don't immediately have in my pocket.

I'll give another example - follow-up of a 5th metatarsal avulsion fracture. (Bad news surgeons - it is going to heal.) Anyway, the patient comes in at the 2nd/3rd visit and they are improving - pain from 8 to 5. Swelling is going down. Tenderness decreasing. X-rays are too early to show true healing but they don't show loss of position. Patient is continuing ambulating in a CAM boot. You discuss DVT prevention and using pain and swelling as guides to modulate activity. Maybe they are on aspirin. You arrange a 2 week follow-up visit. Teasing about surgery aside - surgery is potentially still on the table pending improvement/non-union so the risk is there, but your problem points are: ..well unless they had an ankle sprain you only have the same problem. I'm willing to concede it should be a 2 for stable "worsening" because it isn't by any means done. So 2 problem points. 2 data points for tracing your X-ray. So how do people code that visit? I was "taught" following a fracture along its course with X-rays is a level 3 established during the early course, but it doesn't seem in line with the "guidance"***.

***my addendum after writing this - unless of course I document enough HPI and PE to say those decide the visit. And perhaps I should just roll with it as such. I like those visits, but they are certainly not the same as a my plantar fasciitis is completely resolved visit.

 

[DYK343]

THis is the best thread we have had on here in awhile

 

[CutsWithFury]

THis is the best thread we have had on here in awhile

I take full credit


Sent from my iPhone using SDN

 

[josebiwasabi]

Doesn't 99213 only require low complexity for the MDM?

For your improving 5th met base example:

Problem Points
1 point for stable problem, improving

Data Points
2 points for reviewing the XR images independently

Risk
2 points: Rec OTC meds, discuss possible surgery

That's >=2 points in 2 of the 3 categories for MDM. 2 points is low complexity, which is a 99213.

 

[heybrother]

You just made my life a lot better. I've read that damn thing repeatedly and still screwed it up. Thank you.

 

[josebiwasabi]

I think you guys have been talking about trying to bill a 99214 based on the 3+ points you guys have mentioned.

99214 is actually much easier to attain than most people think. I am currently trying to get to around 20% level 4 visits. (I do very little routine foot care.)

Here's an example with a patient who has worsening lateral ankle instability who has failed orthotics, ASO, etc.

Problem Points
Usually you have the main problem they are there for, but often times they have other minor/self limiting dx that you can discuss.
IE if they are here for worsening ankle instability (2 points) but they also have hammer toes (1 point) and a bunion (1 point) that are asymptomatic, you include those dx and write a 1 sentence "continue with wide shoes and accommodative padding"

Data Points
We usually won't get this unless we review labs AND interpret our own xrays. I usually ignore this section.

Risk
Any decision for surgery or prescription given for medication is automatically 3 points

Voila, 99214.