Is Anyone Doing Total Contact Casts?

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Dermato Fight Club

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I feel like a lot of the time a total contact cast is the only thing that will work in the patient that does not want to face the fact that if they continue to walk their wound will note heal.

I recently closed a wound that had been opened about a year (on a former nurse) in about 6 weeks with a TCC. After it was closed I recommended referral to the nearest residency program for a charcot reconstruction (sub cuboid ulcer) or live in a CROW walker. She fought with me stating she never had a charcot on this foot and she didn't want any surgery or to live in a CROW walker.

She came back 3 weeks later with the wound opened again.

I looked at my reimbursement for a TCC and it is about $140. The TCC system that I use (TCC-ez) costs about that much. Maybe like 10 dollars cheaper.

I see that she is on my schedule tomorrow but I really do not want to continue applying the TCC on her without any financial benefit. I find it frustrating that the one thing that actually works in these patients we are discouraged from doing duetot the financial repercussions.

Is anyone doing anything different that I am not?

Should I just refer to the nearest wound care center?

Should I guess be applying a 1500 skin substitutes with the TCC?
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CAM boot w/ Coban over it ala Armstrong.

If she actually cared enough she would do it.

Another option.... diabetic shoe/insole heavily modified w/ felt offloading (double depth one like Apis or Orthofeet).

Surgically... Maybe just plain it down to get it flush with ground. Should help bypass the whole recon crap.
 
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Some papers say as long as the patient is in the boot that the success is the same as a TCC. I had a couple people not healing who I believe were compliant (would see them around in the boot etc), and I put them in the ez TCC and both said that it locked them up more than the boot and with in 4 weeks they were healed. So I do like the TCC, but I'm paid on RVUs and the nurse puts it on so I don't worry about the cost. But I would maybe try a boot and then cast them into it, not around the foot, and see how the wound heals.
AttackNME said:
I just use regular cast padding and 5 rolls of fiberglass, takes same amount of time as the EZ but cheaper
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How long to you let them sit before letting them go? Cause I think I read somewhere it takes about an hour for fiberglass to get as hard as it is going to get. At that point do you let them walk right on it? I tried with one patient and she kept breaking the cast so I quit.
 
AttackNME said:
I just use regular cast padding and 5 rolls of fiberglass, takes same amount of time as the EZ but cheaper
Click to expand...
That's my method. Use a peg on the bottom as well. Way cheaper than the EZ. I leave them on for a week. Our reimbursement for them is around 180. Absolutely worth doing along with a 11042.
 
Hell yea I put everybody in a TCC. Gives the cast tech something to do.
 
Dermato Fight Club said:
The TCC system that I use (TCC-ez) costs about that much.
Click to expand...

There’s your problem. You’re using the most expensive product on the market. Cheaper kits aren’t much better. Just use cast padding, foam, 5 rolls of fiberglass if you want to save money.

I use TCC when patients aren’t healing in boot or offloading shoe. Usually because of non compliance. I do wound care in a wound care clinic and nurses apply felt offloading to virtually every wound. I’m also wRVU based so cost of casting material is meaningless to my reimbursement. In the last year I’ve only TCC’d 3 different patients. All have gone on to heal. One of them on two different occasions…
 
Dermato Fight Club said:
I feel like a lot of the time a total contact cast is the only thing that will work in the patient that does not want to face the fact that if they continue to walk their wound will note heal.

I recently closed a wound that had been opened about a year (on a former nurse) in about 6 weeks with a TCC. After it was closed I recommended referral to the nearest residency program for a charcot reconstruction (sub cuboid ulcer) or live in a CROW walker. She fought with me stating she never had a charcot on this foot and she didn't want any surgery or to live in a CROW walker.

She came back 3 weeks later with the wound opened again.

I looked at my reimbursement for a TCC and it is about $140. The TCC system that I use (TCC-ez) costs about that much. Maybe like 10 dollars cheaper.

I see that she is on my schedule tomorrow but I really do not want to continue applying the TCC on her without any financial benefit. I find it frustrating that the one thing that actually works in these patients we are discouraged from doing duetot the financial repercussions.

Is anyone doing anything different that I am not?

Should I just refer to the nearest wound care center?

Should I guess be applying a 1500 skin substitutes with the TCC?
Click to expand...
The last 3 I have put on came back with $hit running down the inside of the cast. No more.
Shiyuan said:
CAM boot w/ Coban over it ala Armstrong.
Click to expand...
...They gonna take that thing off. At least 80% of the diabetics I treat will.
Shiyuan said:
Surgically... Maybe just plain it down to get it flush with ground. Should help bypass the whole recon crap.
Click to expand...
This is the way. I am 100% dehiscence on these but also 100% healed. THe whole "total charcot recon or nothing" mentality is industry fueled and/or ego fueled crap. Shave that plantar protruding bone. With ORIF/fusion they just recharcot out, get infected, weightbear against advice, etc. Its a disaster everytime. These people are not making good and healthy decisions to get to this point. They wont change. I can make a pretty xray for 1-2 weeks before its back to where it was.
GreenHousePub said:
That's my method. Use a peg on the bottom as well. Way cheaper than the EZ. I leave them on for a week. Our reimbursement for them is around 180. Absolutely worth doing along with a 11042.
Click to expand...
I think a 11042 included in the reimbursement for a TCC
 
DYK343 said:
...They gonna take that thing off. At least 80% of the diabetics I treat will.
Click to expand...
My diabetics are more compliant than your diabetics, brotato chip...

1687320351905.jpeg
 
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I love total contact casting. If you're efficient about it, you can do it in 15 min with MA help. If you're smart about it, you can source your supplies for under $20/cast.

Problems they don't talk about in the literature:
  • No one with right foot wounds will agree to them, because they can't drive their car.
  • Most people with ulcers can't work in a cast so be prepared to sign off on FMLA forms.
  • If you don't address the underlying root cause to the ulcer (bumpectomy/tenotomy), they will reulcerate.
Once you're done, you can prescribe them a pair of magic shoes, however...
 
Adam Smasher said:
I love total contact casting. If you're efficient about it, you can do it in 15 min with MA help. If you're smart about it, you can source your supplies for under $20/cast.

Problems they don't talk about in the literature:
  • No one with right foot wounds will agree to them, because they can't drive their car.
  • Most people with ulcers can't work in a cast so be prepared to sign off on FMLA forms.
  • If you don't address the underlying root cause to the ulcer (bumpectomy/tenotomy), they will reulcerate.
Once you're done, you can prescribe them a pair of magic shoes, however...
Click to expand...
I totally LOL’d at your new icon and description.
 
Most PP folks don't apply total contact casts in their clinic in my area. They send it to wound care centers. This is financially driven.

I use TCC all the time. I am in hospital setting and our PA puts it on. we use a different kit with fiberglass rolls instead of TCC EZ due to cost.

My understanding is that you can't bill debridement AND application of TCC. You can't bill it if RN or MA applied it.

Literature supports use of TCC specially for forefoot and midfoot ulcers.
 
While I did a lot of TCC in residency I find them to be headaches in PP. I am not a fan of closed casting ulcers particularly in noncompliant (nonhygeinic) patients with multiple comorbidities.

What often happens is the cast becomes soiled and you have a wound festering in an enclosed space with bodily fluids and closed off from wound dressing changes for a week. There is of course the occasional issue with swelling and having to cut the cast off. I’d rather document the patient being noncompliant and not listening to what I say when I tell them to NWB than risk them getting septic with a wound I can’t see and can’t monitor on a regular basis by home health dressing changes or daily changes at home.

I’m definitely more of a CAM booter person.
 
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billBOB213 said:
I use the football dressing

The football: an intuitive dressing for offloading neuropathic plantar forefoot ulcerations - PMC

A reproducible, affordable, efficacious and safe modality for offloading neuropathic plantar foot ulcerations was previously presented in a pilot study. A follow‐up retrospective multicentre analysis of the football dressing is now presented. Wound ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Shiyuan said:
S

Same. Great for the right patient!
Click to expand...
I sometimes use it too.
It can work quite well in the right patient.
 
I can't find any simple and time efficient way to do that in PP. I CAM boot those ulcers but I can wrap all the fiberglass and coban around that boot that I want those people take it off as soon as they leave the office and walk around as if nothing ever happened.
 
Anyone have a good resource for making own TCC? Let's just say casting is not my specialty
 
What made the cast and e/m separate visit... Did you order and review xr? If you just popped a cast off and go "it's healing continue casting" then no
 
HardRoadPaved said:
What made the cast and e/m separate visit... Did you order and review xr? If you just popped a cast off and go "it's healing continue casting" then no
Click to expand...

Yeah what I am reading is a lot of unbundling and over billing. Unless you are doing something above and beyond or unrelated no e/m is billable and if you look up NCCI edits you cannot bill debridement and TCC application together. You are better with the application and supplies billed in private practice but you still would probably do better reimbursement wise billing a debridement no TCC vs what you make after supply costs with TCC application. Yes it isn’t fair and it shouldn’t be that way because we all know the TCC isn’t also debriding the wound. You really should be allowed to bill the TCC and supplies because we all know it’s above and beyond a debridement. This being said I do it as a service to my patient if nothing else works, if you have a system down in your office it should provide little disruption but make sure you are the one rolling the fiberglass on if your billing it.
 
Or just apply the TCC the day after "hemostasis of the wound is controlled" 🤣
 
apollofx said:
Yeah what I am reading is a lot of unbundling and over billing. Unless you are doing something above and beyond or unrelated no e/m is billable and if you look up NCCI edits you cannot bill debridement and TCC application together. You are better with the application and supplies billed in private practice but you still would probably do better reimbursement wise billing a debridement no TCC vs what you make after supply costs with TCC application. Yes it isn’t fair and it shouldn’t be that way because we all know the TCC isn’t also debriding the wound. You really should be allowed to bill the TCC and supplies because we all know it’s above and beyond a debridement. This being said I do it as a service to my patient if nothing else works, if you have a system down in your office it should provide little disruption but make sure you are the one rolling the fiberglass on if your billing it.
Click to expand...
Depends on the MAC that covers your state, but it’s true some states can’t bill for both, it’s bonkers how dumb that is
GreenHousePub said:
Confirmed we can bill 11042 along with the TCC. And the day is mine.
Click to expand...
You can buy me a beer at the next SDN anonymous conference with all the money you’re gonna collect
 
I utilize total contact casting quite frequently in my clinics. Get your nurses trained on how to do them and you will fly through them. They pay well and reimburse good amount via RVU system. They work great for plantar foot ulcers.

You know what doesn't work? Diabetic shoes or cut out padding. Sorry that doesn't work for a 300lbs diabetic woolly mammoth
 
Technically for the TCC you only have to be present for part of the cast application. So have the staff do everything and then you roll on the last roll of fiberglass, then have the staff finish the job.
 
Does anyone use those peg-assist post op shoes? Do you know how much they run and so they reimburse much?
 
billBOB213 said:
Does anyone use those peg-assist post op shoes? Do you know how much they run and so they reimburse much?
Click to expand...
I use the ones I get free from samples. I don't order them. I want to say $10-20 or so for the honeycomb inserts (doesn't include shoe... which is about $5). They are not a custom thing, so I'm not sure how they'd be reimbursed by insurance... cash pt pay if anything. I'm not sure they do anything a 1/4 inch felt and post op shoe +/- memory foam insole in doesn't do. As mentioned, nothing really works for Two Ton Tessie or Dunlap disease Don.

Convos like this bring back memories. I am so glad to be in an educated area where gyms and parks and trails are full, obesity and DM are relatively rare (and Wegovy and RD consult is also insurance-covered or affordable to local ppls).
 
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Feli said:
I use the ones I get free from samples. I don't order them. I want to say $10-20 or so for the honeycomb inserts (doesn't include shoe... which is about $5). They are not a custom thing, so I'm not sure how they'd be reimbursed by insurance... cash pt pay if anything. I'm not sure they do anything a 1/4 inch felt and post op shoe +/- memory foam insole in doesn't do. As mentioned, nothing really works for Two Ton Tessie or Dunlap disease Don.

Convos like this bring back memories. I am so glad to be in an educated area where gyms and parks and trails are full, obesity and DM are relatively rare (and Wegovy and RD consult is also insurance-covered or affordable to local ppls).
Click to expand...
Something to be said for practicing in this type of location....I see a ton of people that I won't operate on between their job, their lifestye, their diabetes or smoking....
 
billBOB213 said:
Not to derail but everytime I visit a buc-ee’s I think about what it could be like with no student loans and a manager salary like this


So anyways, back to TCC’s

View attachment 374876
Click to expand...

My total net earnings are very similar to the General Manager salary at buc-ees. My practice is very busy and I tend to do a lot of nail care. I think being a manager at one of these locations is much more demanding compared to my current practice style. The fellowship trained guys start out very similar to a Food service manager at my practice, but they also take on a lot of complex surgical cases. My loans are almost paid off after 10+ years in practice, but once they are I can consider applying for a position at buc-ees. Maybe my DPM degree will hold some negotiation power when applying.

Anyone have any experience with this? Thank you
 
BubbaWub said:
My total net earnings are very similar to the General Manager salary at buc-ees. My practice is very busy and I tend to do a lot of nail care. I think being a manager at one of these locations is much more demanding compared to my current practice style. The fellowship trained guys start out very similar to a Food service manager at my practice, but they also take on a lot of complex surgical cases. My loans are almost paid off after 10+ years in practice, but once they are I can consider applying for a position at buc-ees. Maybe my DPM degree will hold some negotiation power when applying.

Anyone have any experience with this? Thank you
Click to expand...
Huge negotiation power. You can open a Buc-ee’s Medi-spa to maintain your unique skillset.
 
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