Favorite Wart Treatments

[Pronation]

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

Which portion?

---

Members don't see this ad.

 

[air bud]

I take full credit


Sent from my iPhone using SDN

Long live the king

 

[G0dFather]

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

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

Nothing wrong with this... a 99213 is a LOW complexity visit 2 of 3 EnM components required and they are very simple to hit in your note .... time can or cannot be used, not a requirement.... but know that time is never on your side as you are a limited scope practitioner

 

[dtrack22]

Nothing wrong with this... a 99213 is a LOW complexity visit 2 of 3 EnM components required and they are very simple to hit in your note .... time can or cannot be used, not a requirement.... but know that time is never on your side as you are a limited scope practitioner

I see a bigger problem with the initial visit where a new patient e/m and a procedure are billed. Without a complaint separate from the wart you wouldn’t pass that part.

As for the level 3 f/u, the history would be easy, you couldn’t get complexity/mom points so it comes down to physical exam. What 6 bullet points are you using?

 

[GreenHousePub]

Back on topic I use verrusol with some decent results. If it fails that typically then do in office excision.

 

[CutsWithFury]

Back on topic I use verrusol with some decent results. If it fails that typically then do in office excision.

What do you do for wound care after you excise in office under local? What is your treatment algorithm post procedure?


Sent from my iPhone using SDN

 

[GreenHousePub]

What do you do for wound care after you excise in office under local? What is your treatment algorithm post procedure?


Sent from my iPhone using SDN

I try not to go too deep, aiming for almost a split thickness skin graft style wound. Compression and a little epi-soaked gauze. Remove after a few hours. Afterwards just basic triple abx ointment, light amount of gauze. Change twice a day to daily, keep wound clean and dry until I see them back.

I don't know if I'm doing anything wrong but it has worked for me.

 

[Creflo]

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.

Regarding healthy 12 year old with wart, as for MDM you need two of risk/problem point/data point. In my opinion you don't have the data points, but you have moderate MDM (99202 is straightforward MDM). The risk is moderate because you have "new illness with complicated/uncertain progression. The problem points add up to 3 because you have "new problem with no additional workup planned." So I'm not sure why they are saying 99202? Is it because of the exam portion?

 

[air bud]

Regarding healthy 12 year old with wart, as for MDM you need two of risk/problem point/data point. In my opinion you don't have the data points, but you have moderate MDM (99202 is straightforward MDM). The risk is moderate because you have "new illness with complicated/uncertain progression. The problem points add up to 3 because you have "new problem with no additional workup planned." So I'm not sure why they are saying 99202? Is it because of the exam portion?

I would think because there is already an EM component built into the wart treatment code?

 

[Creflo]

I would think because there is already an EM component built into the wart treatment code?

So for new patients with a procedure are people not including an e&m? Let's say you do a wart procedure on the new patient, with no other problems, are you billing an e&m alone or an e&m along with 17110?

 

[air bud]

So for new patients with a procedure are people not including an e&m? Let's say you do a wart procedure on the new patient, with no other problems, are you billing an e&m alone or an e&m along with 17110?

Yes. I was getting some things confused, don't mind me and my old age

 

[CutsWithFury]

Yes. I was getting some things confused, don't mind me and my old age

He's not very busy these days. He has forgotten how to podiatrist. He should do an ACFAS fellowship so he can reinvent himself into a "Fellowship trained Foot and Ankle Surgeon" on LinkedIn but....he/she has a DPM behind their name.

 

[air bud]

He's not very busy these days. He has forgotten how to podiatrist. He should do an ACFAS fellowship so he can reinvent himself into a "Fellowship trained Foot and Ankle Surgeon" on LinkedIn but....he/she has a DPM behind their name.

not very busy is a relative term....haven't you done more in the last 2 months than I did all last year?

Also, you never now, maybe things will change or pick up

 

[Apolo106]

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.

Check out this article, I have never tried Bleomycin though.

What I Learned From A Recent Malpractice Case On Warts

I recently had the opportunity to participate as a defense expert in a malpractice case. The jury returned a verdict in favor of the defendant podiatrist, determining that the plaintiff was 75 percent responsible for damages and the defendant was 25 percent responsible. However, the case was in...

www.podiatrytoday.com

 

[air bud]

Check out this article, I have never tried Bleomycin though.

What I Learned From A Recent Malpractice Case On Warts

I recently had the opportunity to participate as a defense expert in a malpractice case. The jury returned a verdict in favor of the defendant podiatrist, determining that the plaintiff was 75 percent responsible for damages and the defendant was 25 percent responsible. However, the case was in...

www.podiatrytoday.com

Lol smoking was essential to her life because of personal stress..

 

[GreenHousePub]

Check out this article, I have never tried Bleomycin though.

What I Learned From A Recent Malpractice Case On Warts

I recently had the opportunity to participate as a defense expert in a malpractice case. The jury returned a verdict in favor of the defendant podiatrist, determining that the plaintiff was 75 percent responsible for damages and the defendant was 25 percent responsible. However, the case was in...

www.podiatrytoday.com

What I learned is that in a patient who is desperate for a cash grab she can find any unscrupulous idiot willing to destroy another's reputation. **** that guy who was the expert witness for the plantiff.

 

[CutsWithFury]

What I learned is that in a patient who is desperate for a cash grab she can find any unscrupulous idiot willing to destroy another's reputation. **** that guy who was the expert witness for the plantiff.

There are a lot of podiatrists who are just willing to testify against anyone just for the pay check. They have no soul.


Sent from my iPhone using SDN

 

[heybrother]

So - stupid question. I'm always curious if there's some sort of shady motivation to everything people do. The J code reimbursement for bleomycin is like $25 bucks per Medicare. You use like 0.1cc which is way less than chemo 15 unit amount. Is some part of the motivation for bleomycin the ability to hit the J9040 repeatedly?

I'm less informed about J codes than I should be. My residency clinic used them and they were a b&tch to enter and seemed to be worth pennies for all the additional clicks. We used dex and kenalog and the Medicare J code fee schedule is very low for these - especially dex. I asked my employer if I could put J codes in since we currently carry betamethasone and kenalog in our clinic and betamethasone appears to reimburse at $7 for 3mg which seems like it might be worth a click or 2 to capture. Presumably it reimburses higher because we are paying more for it. I don't particularly enjoy the click game but turning a $50 injection into a $50 injection and $10 of supplies seems worth it... unless I'm completely missing something. Anyway, never happend.

 

[dtrack22]

Your note needs to corroborate the number of units billed for the J code. You know more about this particular J code than I do, but it’s my understanding that if you bill “1 unit,” you need to have used “1 unit” of the medication in question.

we had an attending in residency who would use bleomycin but he charged the patient cash for it. He made it sound like it was due to the cost of the medication vs reimbursement. Not sure if that’s kosher with insurance contracts or not.

 

[heybrother]

What's interesting about coding stuff is trying to find the ultimate source you can use. So I typed in some variation of "Bleomycin J code". Found a 2017 discussion where someone says if you use less than a unit you always round up. But the reference is to some dermatology document I don't have. So I type in "round up to the unit J code" or something like that into Google. Someone references a CMS document.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf

Hospitals must report all appropriate HCPCS codes and charges for separately payable drugs, in addition to reporting the applicable drug administration codes. Hospitals should also report the HCPCS codes and charges for drugs that are packaged into payments for the corresponding drug administration or other separately payable services. Historical hospital cost data may assist with future payment packaging decisions for such drugs. Drugs are billed in multiples of the dosage specified in the HCPCS code long descriptor. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit based on the HCPCS long descriptor for the code in order to report the dose provided. If the full dosage provided is less than the dosage for the HCPCS code descriptor specifying the minimum dosage for the drug, the provider reports one unit of the HCPCS code for the minimum dosage amount.


So that's something - at least its a CMS document, but is it the most up to date CMS - I don't know. Its just always funny in coding stuff trying to figure out what is the true "source" for reliable information. I went to the ACFAS coding course and they said a whole bunch of stuff. I summarized it for some friends, but I thought - if they said to me - says who this is the case, I don't have the actual source material to back anything up.

 

[air bud]

I was under the impression bleomycin was done for the money. as a secondary treatment though, I never knew anyone doing it as a primary treatment

 

[air bud]

Maybe try bleach or disinfectant to get rid of warts? Maybe UV light?

 

[ExperiencedDPM]

Maybe try bleach or disinfectant to get rid of warts? Maybe UV light?

I am now recommending my patients with arthritis and joint stiffness start drinking 10W40 motor oil to lubricate their joints.

 

[Pronation]

Maybe try bleach or disinfectant to get rid of warts? Maybe UV light?

Crank the thermostat to 90, use the power of heat.

 

[PointyNippers]

Hello all,

My office is looking into starting cantharone treatments. Can someone direct me to a place we can order from at a decent price? Our current supplier doesn't keep it in stock

 

[dtrack22]

Hello all,

My office is looking into starting cantharone treatments. Can someone direct me to a place we can order from at a decent price? Our current supplier doesn't keep it in stock

Good luck. Dormer Laboratories in Canada was out of cantharone plus last time my employer checked. But they did get me the regular cantharone which seems to work, but has been consistently less effective requiring 1 more visit in most cases. I know iped Facebook group podiatrists have also had luck with local compounding pharmacies making them some sort of cantharone/salicylic acid combo.

Price should not be an issue. You can use the vial many times and it pays well enough to justify just about any price anyone could charge.

 

[heybrother]

A lot of places listed Cantharone / Cantharone Plus but it seems Dormer was essentially everyone's actual source. I've used Cantharone "Regular" extensively and have it on my shelf taking up space- I've unfortunately had basically zero success with it. Maybe 1 patient with 5 warts have 1-2 resolve but ten other people it did nothing on. Hilariously I got a small wart on my finger and applied cantharone regular 5 times without ever developing a blister though it fell off after the last treatment which I guess is a success. Never saw a patient blister from it. My partner also never could get anyone to blister and went back to excisions. I had way too much residency experience with warts and we used cryo (actual tank and applicator gun), Aldara, 5-FU. Mixed bag. Bunch of patients I never saw success on. Recently had someone try adapalene. No luck. Cantharone plus was the best experience I've ever had in my career for treating warts. I feel like some sort of scumbag testimonial person - it made me like treating warts. I had so much success with it. I had like 3-4 kids come in with 20+ warts each on both feet that resolved them all. I've posted about this before - when I had Cantharone Plus I thought the Swift wart people were the dumbest people in the world. One bottle of Cantharone is $100. People with good commercial insurance were paying me $160-225 a treatment and I was getting in 2-3 treatments a person, multiple people, and still on the same vial. It was like a bottle of gold and yet people are off buying a $10,000+ device with probes that you have to replace every single time.

Anyway. I called Dormer a week ago. The person I spoke to said they had no time, date, estimate, etc. They also fully conceded to me that Cantharone Plus is better than Cantharone regular.

I miss you Cantharone Plus.

 

[ExperiencedDPM]

Okay, that seals the deal. I’m opening a beetle farm and will soon be the number one supplier of beetle juice in the the universe. I will supply all who need it at a grossly inflated price. I will cure the world’s warts.

 

[NatCh]

Hello all,

My office is looking into starting cantharone treatments. Can someone direct me to a place we can order from at a decent price? Our current supplier doesn't keep it in stock

Contact a local compounding pharmacy to make their own version of it. I'd give you the contact info for the pharmacy that I use but I don't want them running out of stuff. Make sure it has the podophyllin component (the "plus" part of Cantharone Plus), otherwise it won't do squat.

 

[NatCh]

Okay, that seals the deal. I’m opening a beetle farm and will soon be the number one supplier of beetle juice in the the universe. I will supply all who need it at a grossly inflated price. I will cure the world’s warts.

Can I get an application to be a beetle squeezer?

 

[Shiyuan]

Go Efudex. Works great and well tolerated.

 

[ExperiencedDPM]

Can I get an application to be a beetle squeezer?

Only if you have a CAQ in that area.

 

[Feli]

Contact a local compounding pharmacy to make their own version of it. I'd give you the contact info for the pharmacy that I use but I don't want them running out of stuff. Make sure it has the podophyllin component (the "plus" part of Cantharone Plus), otherwise it won't do squat.

Most of the pharmacies won't or can't make cantharidin anymore. Supply issues or FDA lack of approval are what they state, but it's probably they just don't have enough margin or demand, or whatever.... cost went up and up, now it's very hard to find.

Cantharidin is decent stuff, but for anyone who hasn't used it, you WILL lose patients if you use it on the weightbearing portions of the foot and don't warn them.

I think good debride + sal acid always was and always will be the standard. It doesn't hurt too much, it works, and it beats everything else in EBM (particularly cryo). I do occasional cantharidin or cimetidine PO... ultra-rare surgical excision (OR).

Cryo is the most useless treatment imo: if you don't leave it on long enough, it does noting... too long = frostbite and blood blister. PAD patient? Could be even worse. Crazy.

 

[Pronation]

As a total toenail replacement surgeon, I find this discussion absolutely fascinating.

 

[NatCh]

Most of the pharmacies won't or can't make cantharidin anymore. Supply issues or FDA lack of approval are what they state, but it's probably they just don't have enough margin or demand, or whatever.... cost went up and up, now it's very hard to find.

In that case I'm DEFINITELY not telling you guys where I get mine from.

 

[DYK343]

Go Efudex. Works great and well tolerated.

As long as you debride well and have patient debride daily with pumice this works miracles.
Problem is getting insurance to cover it.

 

[dtrack22]

As long as you debride well and have patient debride daily with pumice this works miracles.
Problem is getting insurance to cover it.

I do have my patients perform self debridement and use compound w in between visits. I also am very honest with patients and tell them that they can treat it themselves if they are patient enough. I had one on my finger in high school. I never even used a topical and after years worth of trauma from sports (it would get damaged, ripped, bled, etc. frequently at football practice and during track season), the dead skin just fell off one day and there was normal healthy skin underneath. Irritate the tissue routinely enough and long enough, absent a compromised immune system, the body will take care of it. Luckily for us, most folks aren’t patient enough for OTC salicylic acid.

But maybe my home care routine is the real reason I feel like cantharone regular (blue label) has still worked, just less effective.

 

[heybrother]

We should probably start a verruca-podiatry-dermatology-fellowship to better understand this, but there is I think definitely a difference between a patient show shows up asking "what is this" and has done nothing and a patient who is a 3rd opinion, did 3 months of salicylic acid, had new expansive lesions, got a painful cryo sessions from their PCP and then was injected with antigen by dermatology. The latter is frustrated, scared, hurting, etc and obviously in danger of having something stupid and expensive done to them in a podiatry office.

Interestingly, no podiatry problem can be discussed without hearing about someone somewhere doing something bizarre. Another podiatrist in my town kept applying something to people and telling them to leave the bandaid on for weeks. I figured it was cantharone though I still didn't understand the time table... "did you blister underneath, did it hurt, did he tell you what would happen, did you reapply something?" Turns out it was just salicylic acid. Thank you for the undertreated patient, I guess.

 

[DYK343]

We should probably start a verruca-podiatry-dermatology-fellowship to better understand this, but there is I think definitely a difference between a patient show shows up asking "what is this" and has done nothing and a patient who is a 3rd opinion, did 3 months of salicylic acid, had new expansive lesions, got a painful cryo sessions from their PCP and then was injected with antigen by dermatology. The latter is frustrated, scared, hurting, etc and obviously in danger of having something stupid and expensive done to them in a podiatry office.

Interestingly, no podiatry problem can be discussed without hearing about someone somewhere doing something bizarre. Another podiatrist in my town kept applying something to people and telling them to leave the bandaid on for weeks. I figured it was cantharone though I still didn't understand the time table... "did you blister underneath, did it hurt, did he tell you what would happen, did you reapply something?" Turns out it was just salicylic acid. Thank you for the undertreated patient, I guess.

I believe @NatCh once posted about "auto innoculation". There is an article out of india on it. I had a 20ish year old patient with massive mosaic warts both feet. I didnt know what to do as both plantar feet were basically 70% wart. So I took a 2-3mm punch biopsy and punched a central nasty looking area. Flipped it around and steri stripped it down with mastizol. Patient reported 10/10 pain for about 7 days at biopsy site but came back at 3-4 weeks and every wart was gone. It was a miracle.

So I obviously tried it on anther patient with much smaller problem and it didnt work at all.

Havent tried it since.

 

[DYK343]

I do have my patients perform self debridement and use compound w in between visits. I also am very honest with patients and tell them that they can treat it themselves if they are patient enough. I had one on my finger in high school. I never even used a topical and after years worth of trauma from sports (it would get damaged, ripped, bled, etc. frequently at football practice and during track season), the dead skin just fell off one day and there was normal healthy skin underneath.

But maybe my home care routine is the real reason I feel like cantharone regular (blue label) has still worked, just less effective.

I believe most of wart care with topical keratolytics is just exposing the wart to the immune system. Once the immune system knows its there its over. Game of hide and seek. Turn the light on in the closet and its game over (see my post about auto innoculation above).

 

[Shiyuan]

Try oral zinc 50mg PO TID w/ food. Some good literature out on it.

 

[Pronation]

Is there anything expensive I can sell to the patient instead?

 

[wakaflocka88]

Real talk. This swift machine thing. Sounds like it costs $10k but how do you bill for this? Cash pay only?

 

[heybrother]

Real talk. This swift machine thing. Sounds like it costs $10k but how do you bill for this? Cash pay only?

Cash only. The machine has some big upfront cost but its less than I thought it was. They used to have a calculator on their website and I wondered if you could reverse engineer the cost from it but you can't ie. someone on Iped called and was given an exact number and it was lower than what I calculated. Maybe something like $10-14K or something like that. Could call and ask but its more than cantharone so f7*( it.

-You have the lease (or the cost) of the machine
-You have probes you have to use everytime. They are thrown away afterwards.
-I listened to the Tracy V-derm lady talk about it at TPMA - my take from her talk was she liked it but she implied that if the patient had a lot of lesions the "probes" would die before you could complete all the lesions. My suspicion is the company was somehow concerned you'd line a bunch of people up and use the same probe over and over again to save costs.
-I was under the impression the probes are like $60-80 a piece or something like that. So apart from the lease you have a cost everytime.

So - the company walks this bull**** line. Essentially if you look up the code 17110 (17111) it says "Destruction of wart/lesion by any means eg. curettage, chemical, cryo, electrical - whatever." I don't remember the exact wording but I believe you can use this code both for warts and mollusciosum or something like that but obviously we use it for warts 99% of the time.

The company claims that because the listing doesn't include "microwave" - therefore the code doesn't apply to them and therefore its unique/special, uncovered and cash pay. Its garbage. The code is the code for destruction of warts ie. its clearly intended to be a covered service if you are using some sort of means to destroy warts. Secondly "eg" means for example. It doesn't mean "only these techniques". If you are destroying warts - you use this code. And it doesn't matter whether the microwave truly destroys or not because all of the destruction techniques are somewhat variable on whether they actually destroy at that moment or in time. Cryo doesn't actually destroy at the moment applied.

Its all in all very podiatry. Its like Treace. Turn it into something it isn't and make it more expensive than it should be. Destroying warts is a covered service. They've created something incredibly expensive and therefore the patient is to be talked into a $500+ treatment.

If you use this service and bill insurance ie. 17110 you will get slaughtered financially. Medicare pays like $110 for 17110. BCBS pays like a 1.5ishx multiplier where I am so $160-170ish. I've got a rare but awesome plan that pays 165%. I've got a rarer one still that pays about $200. But in the end - all of these are losers if you have a $60-80 equipment cost everytime you use it. However, they are all perfectly adequate if you have a straight forward destruction technique that works.

 

[Feli]

Is there anything expensive I can sell to the patient instead?

 

[Feli]

I believe most of wart care with topical keratolytics is just exposing the wart to the immune system. Once the immune system knows its there its over. Game of hide and seek. ...

Yes, that's the start and end of it. ^^

I think a lot of PCPs and even Derms or DPMs fail on plantar foot since they don't debride aggressive enough before applying whatever. Cantharidin mostly "works" just because it gets down to the basement membrane to destroy the lesion blood supply, trigger immune system, makes any subsequent tx work better. Many things can work if the callus is removed and lesions are properly exposed, immune system is triggered (hence even pumice + duct tape adhesive can do the immune trigger for kids).

 

[NatCh]

Real talk. This swift machine thing. Sounds like it costs $10k but how do you bill for this? Cash pay only?

I thought about buying one but right after I made contact with them they came at me with the hard sell. Emails and phone calls wouldn't stop. That put me off. The quote was around $20K for outright purchase. I chatted with a colleague who owns a machine and she said that it works but only a small portion of her patients opt to use it because it's pay out of pocket whereas their insurance covers more traditional methods. Also, the disposable tips cost $60 per use, which means that in the end she's netting about the same amount per patient as she was using Cantharone or whatever else.

 

[air bud]

Contact a local compounding pharmacy to make their own version of it. I'd give you the contact info for the pharmacy that I use but I don't want them running out of stuff. Make sure it has the podophyllin component (the "plus" part of Cantharone Plus), otherwise it won't do squat.

Yeah. 60 percent salicylic acid too.

 

[icebreaker32]

Catharone plus works well. It sometimes hurts a lot for a day or two. Not surprisingly more applied and left on much longer works even better, but pain for a day or two then becomes not just possible, but probable.

 

[619]

I think a lot of PCPs and even Derms or DPMs fail on plantar foot since they don't debride aggressive enough before applying whatever.

True, you have to debride down until you see pin point bleeding. A lot of PCPs or Derms don't like to see blood.