Local only in OR?

[air bud]

I am tired of people getting ridiculous hospital bills for stuff that j could have done under local. We do it plenty of times for amps on super unhealthy people, why not on elective for healthy? No reason can't do some basic hammertoes under local only. Then saves patient from visit to PCP to be cleared, cxr ekg, anesthesia bill. I have even done a few other simpler cases with just having some conscious sedation in pre op to knock patient out so I can get a good ankle block then gone into OR. Obviously have to select right people that aren't going to freak out, but i don't think that's hard. Thoughts? Hell, I would love to do some this in office but afraid of medical legal stuff with opening joints

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[PeaJay]

I do small stuff like tenotomies in the office all the time (to bad it doesn’t count for boards). In training we did hardware removals, exostecomies, and tons of other stuff including amputations in office. Boffelli has some papers on in office distal symes, so the literature is there to back it.

 

[heybrother]

My office's philosophy towards sterilization is such that flexor tenotomies is as far as as I think I'll ever be able to take it. For private practice people they do have a nice mark-up in your own clinic. We actually have an enormous room previously used as an OR forever decades ago where we do matrixectomies (haha).

I've seen people do distal symes amputations in their clinic - I think that would be viable (haha - Peajay posted while I was writing this - I watched Boffelli do a distal symes on my 1st rotation and his paper on them is solid).

Theres an F&A orthopedist in my area who does 5th digit arthroplasties in his office. Jokingly, my suspicion is he does them with a bone cutter as quickly as he possibly can because on the spectrum of floppy they are practically deboned little nubbins. I've actually been inundated with people who could benefit from one recently. Would love to be able to offer it without the cost of the OR.

 

[air bud]

Yeah we did 5th digit arthroplasty in office in residency. No big deal. I use a bone cutter almost all the time on old people when just doing arthroplasty and don't need edges well approximated. Anyone doing plantar fasciotomy? I know Rush does and some friends that trained there that have on own.

 

[air bud]

And I don't think we should be even counting flexor tenotomy that's literally a stab incision.....although my note says an incision was made and bill open flexor.....but as bofelli says " an incision is an incision. Doesn't matter how small it is for me to get the job done.

 

[PeaJay]

I do not think anyone should be caught up on what should and should not be counted as in office surgery. The general surgeon that works 5 feet from me does “surgery” in office all day... it is no scale vasectomies, cysts, skin cancer, wounds, biopsies, etc. The vasectomies are equivalent to flexor T’s, the cysts are equivalent to ingrowns, and wounds/biopsies are mundane. We do surgery in office day in and out. Most of us just don’t beat our chests about it because it is our job.

 

[DYK343]

I regularly amputate in my office. At least once a week. It's so much better than going and waiting for my case to start at the local hospital. I can take that toe off in 5 minutes but if I go to the hospital its an hour and a half at minimum (on a good day) and its just not worth it to me.

I have had zero fail to date (the real bad ones I send to the hospital).

 

[heybrother]

May I ask - within the toe or to the level of the MPJ? Just lesser digits or hallux too?

Would anyone do a TAL in their clinic?

 

[air bud]

I would totally do an isolated perc tal in office now that I thinka bout it. Elevate leg for 2 mins to let blood drain out then do it.

@DYK343 are you just using a glove and hemostat for a tourniquet?

So what's the most you would do? Ganglion on dorsal foot that you could do a field block with epi? Or is that pushing it?

 

[air bud]

So if patient already on IV antibiotics? How do you deal with that part? If on oral thats good enough? I guess the argument is that dude jta already infected, is it going to get more infected because skin opened more?

 

[DYK343]

I have done IPJ disarticulations, MPJ disarticulations, and hallux amps at the MTPJ. The first hallux amp I did was on an uninsured patient. It healed fine... so I've done 2 more of them since. No issues but for the hallux my sample size is relatively low.

I sterily prep it. Sterile gloves/instruments/drape. I put a mask on. No tourniquet. I've done so many amputations I really do not need a tourniquet. Its all by feel at this point. They usually dont bleed that bad. I primarily close them with nylon.

But again the real bad ones w proximal spreading cellulitis I send to the hospital. The ones I do in my office are the chronic wounds with X-ray evidence osteomyelitis. Possible I get myself into trouble someday doing this but until them I am going to continue doing it.


I had an uninsured guy that I considered in my mind doing a TAL on. I didnt do it but the thought did cross my mind...

 

[DYK343]

I wouldnt do a ganglion. They tunnel/wrap around structures and often require fair amount of dissection.

 

[heybrother]

A few times (4 maybe) in residency I had someone with nec fasc in a toe and ascending cellulitis but no attending. So I did a MPJ disarticulation - think hallux twice and lesser toe twice. Raquet with the proximal pole extending where I thought we'd be going. They were always bounding pulses so they bled even with a blood pressure cuff around the ankle. I would say I infinitely prefer doing them in an OR but agree with you it definitely can be done.

5th metatarsal head resection would be an interesting one - definitely pushing it, but very straightforward procedure, no hardware, can be done with a bone cutter, etc.

 

[air bud]

Yeah I wouldn't have problem doing met head resect. I often use an esmarch for a tourniquet anyways when ankle isn't working or patient isnt liking tourniquet. Works fine

 

[ExperiencedDPM]

And I don't think we should be even counting flexor tenotomy that's literally a stab incision.....although my note says an incision was made and bill open flexor.....but as bofelli says " an incision is an incision. Doesn't matter how small it is for me to get the job done.

If you are billing for an open tenotomy with simply a stab incision, that is 100% fraud. That’s why there is a code for a percutaneous tenotomy.


As far as the quote “an incision is an incision” that of course is true. However that doesn’t equate with an OPEN procedure. Even a percutaneous procedure requires at least a stab incision.

I just reviewed a few years worth of tenotomies done in the office by the same doctor. Every case involved a stab incision and every case was billed as on open procedure.

The whistle blower was a patient who was a coder for a large multi specialty group. The insurance did an investigation and the provider was found to have billed fraudulently.

As a provider it is your job to bill accurately and not try little “tricks”. If there is a specific code for what you did, that’s the code you bill.

A stab incision tenotomy is percutaneous. And there IS a code for a percutaneous tenotomy

By the way, the provider had to refund about $47,000.

It doesn’t matter if you’ve done it 100 times and got paid. If your case gets reviewed it won’t be paid and you put yourself on the radar for an investigation.

There is a DPM is from NJ who lectures on HyProCure implants and is proud to tell everyone that he ALWAYS bills it as an ORIF of a talo tarsal dislocation. I can assure you that this guy wouldn’t know the first thing to do for a true talo tarsal dislocation.

This guy gets paid because his cases haven’t been reviewed. When they are someday, he’s gonna be writing a big check back to the insurers.

 

[G0dFather]

There is a DPM is from NJ who lectures on HyProCure implants and is proud to tell everyone that he ALWAYS bills it as an ORIF of a talo tarsal dislocation. I can assure you that this guy wouldn’t know the first thing to do for a true talo tarsal dislocation.

This guy gets paid because his cases haven’t been reviewed. When they are someday, he’s gonna be writing a big check back to the insurers.

I get confused by this ... so someone like this and the person you mentioned earlier get to pay back money but other get thrown in jail for nail debridements ?? How does this get determined, paying back money vs jail time? is it a commercial vs federal insurance or not necessarily ?

 

[DYK343]

I'm so afraid of that kind of stuff. I don't cut nails... like almost none. Not because I am better than that but because 99% of them simply do not qualify.

I have a fair amount of patients/PCPs get upset with me.. Honestly most of it is the PCPs fault. They think of podiatry as toenail doctors and if you're diabetic automatic referral for nail debridements/diabetic shoes. They dont know insurance guidelines for it and that is 100% podiatry's fault as most DPMs find ways to get them covered fraudently. They have been sending their diabetic patients to DPMs for years with no problems. Now the new(ish) guy in town turns them away for not qualifying.

I've had some akward messages from PCPs regarding patients they have referred to me after the patients went back and complained. I just copy/paste medicare guidelines and that has solved that... and future referrals from them which sucks because the rules are the rules. Not everyone gets diabetic shoes and their nails cut by a DPM. Sorry.

Like I've said in the past. I am thinking about cutting out 100% diabetic care. I just do not enjoy it. Whenever I see "diabetic foot care" on a new patient I get frustrated because I know 95% chance it's not going to qualify.

OK that was a bit of a rant and slightly off topic. But its a significant frustration of mine as my negative reviews over it are starting to pile up. Maybe I should just join the gravy train and screw over medicare like everyone else is.

- - -

Edit: Any recommendations on how to better handle this would be appreciated. I am nice about it but straight forward about it. I have medicare guidelines actually posted on the wall in my exam rooms.

 

[ExperiencedDPM]

I get confused by this ... so someone like this and the person you mentioned earlier get to pay back money but other get thrown in jail for nail debridements ?? How does this get determined, paying back money vs jail time? is it a commercial vs federal insurance or not necessarily ?

The government doesn’t take kindly to fraud and when they go after a doc, they make sure there is an ironclad case. They even send in FBI agents to act as patients to collect information. Those agents almost always have some form of camera filming the encounters.

They rarely go after the small time player. When they go after someone they want bang for the buck. They ask for money and jail time.

Private insurers usually just want their money back and will kick the doctor off the panel. They don’t want to waste resources to pursue jail time.

Of course there are exceptions, but when you screw the government, they can be relentless.

 

[ExperiencedDPM]

I'm so afraid of that kind of stuff. I don't cut nails... like almost none. Not because I am better than that but because 99% of them simply do not qualify.

I have a fair amount of patients/PCPs get upset with me.. Honestly most of it is the PCPs fault. They think of podiatry as toenail doctors and if you're diabetic automatic referral for nail debridements/diabetic shoes. They dont know insurance guidelines for it and that is 100% podiatry's fault as most DPMs find ways to get them covered fraudently. They have been sending their diabetic patients to DPMs for years with no problems. Now the new(ish) guy in town turns them away for not qualifying.

I've had some akward messages from PCPs regarding patients they have referred to me after the patients went back and complained. I just copy/paste medicare guidelines and that has solved that... and future referrals from them which sucks because the rules are the rules. Not everyone gets diabetic shoes and their nails cut by a DPM. Sorry.

Like I've said in the past. I am thinking about cutting out 100% diabetic care. I just do not enjoy it. Whenever I see "diabetic foot care" on a new patient I get frustrated because I know 95% chance it's not going to qualify.

OK that was a bit of a rant and slightly off topic. But its a significant frustration of mine as my negative reviews over it are starting to pile up. Maybe I should just join the gravy train and screw over medicare like everyone else is.

- - -

Edit: Any recommendations on how to better handle this would be appreciated. I am nice about it but straight forward about it. I have medicare guidelines actually posted on the wall in my exam rooms.

PCPs are too busy and stressed to worry about you. They couldn’t give a crap about class findings or whether the patient is truly “at risk”. (The only time they DO care is if they have to sign their name on the certifying form for diabetic shoes!).

In their busy world, all they know is the patient is diabetic and needs the nails cut. So they recommend you. They don’t have the time or energy or give a crap whether that patient qualifies.

Even though they may respect your honesty and integrity, they don’t want to hear bitching from the patient about and your “class findings”. They will follow the path of least resistance and refer to the doc who has no issues billing Medicare for a patient with bounding pulses.

It simply makes their lives easier.

I did meet with a few and explained the situation and used the diabetic shoe form as an analogy. I told them that just as they won’t fill it out if it’s fraudulent, that’s the same way I feel about at risk foot care.

Just keep doing the right thing and you’ll sleep better at night.

 

[G0dFather]

Like I've said in the past. I am thinking about cutting out 100% diabetic care. I just do not enjoy it. Whenever I see "diabetic foot care" on a new patient I get frustrated because I know 95% chance it's not going to qualify.

Come on now ... so your telling me the patient with longstanding DMII, HTN, High cholesterol wont be eligible, etc ? .... Even the class findings from Q7 to Q9 ( and i agree that they are all nonsense and not indicative of someone with PVD) encompass all patients on a spectrum ... they could have BOUNDING pulses and they can still qualify for Q9 according to their own rules .... pods provide RFC and we get compensated well for it, people need to get over it it doesn't make you less of a doc to chip and clip lol

 

[DYK343]

Come on now ... so your telling me the patient with longstanding DMII, HTN, High cholesterol wont be eligible, etc ? .... Even the class findings from Q7 to Q9 ( and i agree that they are all nonsense and not indicative of someone with PVD) encompass all patients on a spectrum ... they could have BOUNDING pulses and they can still qualify for Q9 according to their own rules .... pods provide RFC and we get compensated well for it, people need to get over it it doesn't make you less of a doc to chip and clip lol

That's what I'm telling ya...

 

[G0dFather]

That's what I'm telling ya...

We will agree to to disagree then ... as long as reimbursements continue to hold, RFC is and will forever be podiatry's golden goose ... i have actually completely stopped preforming INNETWORK SX at this point ... less than 1k for a surgery to only have that patient replace someone in my schedule for at least the next 2-3 months that can generate money... no thank you, makes no sense in a private practice setting, OUT of NET SX on the other hand is a diff animal ... but i guess when your being paid by the hospital you dont have to think about it that much

 

[ExperiencedDPM]

We will agree to to disagree then ... as long as reimbursements continue to hold, RFC is and will forever be podiatry's golden goose ... i have actually completely stopped preforming INNETWORK SX at this point ... less than 1k for a surgery to only have that patient replace someone in my schedule for at least the next 2-3 months that can generate money... no thank you, makes no sense in a private practice setting, OUT of NET SX on the other hand is a diff animal ... but i guess when your being paid by the hospital you dont have to think about it that much

Out of network benefits may soon be a thing of the past. Insurers are evaluating why they should be spending extra money for OON benefits rather than pay their in network providers. Insurers are also doing this with hospitals. Out of network....out of luck.

So get it while you can because out of network benefits will end or they will make the patient out of pocket responsibility off the radar.

 

[air bud]

Out of network benefits may soon be a thing of the past. Insurers are evaluating why they should be spending extra money for OON benefits rather than pay their in network providers. Insurers are also doing this with hospitals. Out of network....out of luck.

So get it while you can because out of network benefits will end or they will make the patient out of pocket responsibility off the radar.

yeah there has been a lot of stuff lately on "surprise billing" and thats not even the stuff i see podiatrists do with OON and they just so happen to be owners of the OON surgery center....its crazy.

 

[G0dFather]

Out of network benefits may soon be a thing of the past. Insurers are evaluating why they should be spending extra money for OON benefits rather than pay their in network providers. Insurers are also doing this with hospitals. Out of network....out of luck.

So get it while you can because out of network benefits will end or they will make the patient out of pocket responsibility off the radar.

I would hope that would be case and increase the innetwork providers fee schedule ( but THAT will actually never happen, in the short time ive dealt with these animals they will just keep it and keep cutting, "why increase the fees when they are doing it anyway for what we give them") .. but they have been saying this very thing since i started looking into podiatry in 2007 and they still haven't shut it down... weren't they also saying that Private practice will go extinct in X amount of years??

 

[Creflo]

I'm so afraid of that kind of stuff. I don't cut nails... like almost none. Not because I am better than that but because 99% of them simply do not qualify.

I have a fair amount of patients/PCPs get upset with me.. Honestly most of it is the PCPs fault. They think of podiatry as toenail doctors and if you're diabetic automatic referral for nail debridements/diabetic shoes. They dont know insurance guidelines for it and that is 100% podiatry's fault as most DPMs find ways to get them covered fraudently. They have been sending their diabetic patients to DPMs for years with no problems. Now the new(ish) guy in town turns them away for not qualifying.

I've had some akward messages from PCPs regarding patients they have referred to me after the patients went back and complained. I just copy/paste medicare guidelines and that has solved that... and future referrals from them which sucks because the rules are the rules. Not everyone gets diabetic shoes and their nails cut by a DPM. Sorry.

Like I've said in the past. I am thinking about cutting out 100% diabetic care. I just do not enjoy it. Whenever I see "diabetic foot care" on a new patient I get frustrated because I know 95% chance it's not going to qualify.

OK that was a bit of a rant and slightly off topic. But its a significant frustration of mine as my negative reviews over it are starting to pile up. Maybe I should just join the gravy train and screw over medicare like everyone else is.

- - -

Edit: Any recommendations on how to better handle this would be appreciated. I am nice about it but straight forward about it. I have medicare guidelines actually posted on the wall in my exam rooms.

I esssentially do the same thing, but the way I handle it is have the pcp sign a referral form listing the icd 10 code, and if they don't sign off on the code, patient pays out of pocket. I think it actually gets my name out there to the pcp's when the patient gives them the form to sign. What's frustrating is when I require self pay and the patient says that John Smith DPM down the street has always billed Medicare.

As for the local anesthesia topic, I once had a superficial foreign body removed from my elbow. The CRNA came in and started talking about putting me to sleep. I said, "cant you just give me some local?" He was like "oh, let me ask the MD." They agrred, gave me some marcaine, and I walked out of the OR and went about my day after the procedure. Then the surgeon gave me about 30 percocet tablets (this was a few years ago before the new laws came into effect), I guess that's for another thread.

I'm all for doing procedures on the foot under local if the patient is a good candidate. I think PICA doesn't like procedures done in the office, don't quote me on this. I called my carrier who is fine with it.

 

[air bud]

I esssentially do the same thing, but the way I handle it is have the pcp sign a referral form listing the icd 10 code, and if they don't sign off on the code, patient pays out of pocket. I think it actually gets my name out there to the pcp's when the patient gives them the form to sign. What's frustrating is when I require self pay and the patient says that John Smith DPM down the street has always billed Medicare.

As for the local anesthesia topic, I once had a superficial foreign body removed from my elbow. The CRNA came in and started talking about putting me to sleep. I said, "cant you just give me some local?" He was like "oh, let me ask the MD." They agrred, gave me some marcaine, and I walked out of the OR and went about my day after the procedure. Then the surgeon gave me about 30 percocet tablets (this was a few years ago before the new laws came into effect), I guess that's for another thread.

I'm all for doing procedures on the foot under local if the patient is a good candidate. I think PICA doesn't like procedures done in the office, don't quote me on this. I called my carrier who is fine with it.

Interesting, didn't think about checking with carrier to see what they think. I guess you should seeing as how they are the one paying the bill (then passing on to you)

 

[ExperiencedDPM]

One point that has been omitted is the anesthesiologists. We can literally perform almost any procedure under straight local if we had to, etc.

Many facilities get pushback from the anesthesia department if they aren’t involved in a case and making money.

The anesthesia crew isn’t happy if there are rooms running cases if they aren’t involved with the case. No involvement means no money for them.

In most facilities, anesthesia “runs” the ORs and makes sure things are running smoothly, on time (that’s a joke), etc.

In facilities where I’ve worked, if there is a straight local case, anesthesia wouldn’t even start an IV snd would tell us that if there was an “event” it’s our issue as the surgeon since they aren’t involved.

I don’t believe anesthesia can bill for “monitoring” a case if there is only local injected by the surgeon. So the bottom line is that most facilities frown on straight local cases since they get pushback from anesthesia.

Anesthesia uses scare tactics and warns that events can and do happen and having an IV and monitoring is safer for the patient, etc.

This is not a knock on anesthesiologists. It’s simply a matter of economics. Everyone wants their piece of the pie.

 

[G0dFather]

Everyone wants their piece of the pie

Who is the one handing out the pie ?

 

[DYK343]

One point that has been omitted is the anesthesiologists. We can literally perform almost any procedure under straight local if we had to, etc.

Many facilities get pushback from the anesthesia department if they aren’t involved in a case and making money.

The anesthesia crew isn’t happy if there are rooms running cases if they aren’t involved with the case. No involvement means no money for them.

In most facilities, anesthesia “runs” the ORs and makes sure things are running smoothly, on time (that’s a joke), etc.

In facilities where I’ve worked, if there is a straight local case, anesthesia wouldn’t even start an IV snd would tell us that if there was an “event” it’s our issue as the surgeon since they aren’t involved.

I don’t believe anesthesia can bill for “monitoring” a case if there is only local injected by the surgeon. So the bottom line is that most facilities frown on straight local cases since they get pushback from anesthesia.

Anesthesia uses scare tactics and warns that events can and do happen and having an IV and monitoring is safer for the patient, etc.

This is not a knock on anesthesiologists. It’s simply a matter of economics. Everyone wants their piece of the pie.

Youre 100% right on this. I was doing 5th toe arthroplasties local only when I first started. Suddenly one day the hospital said no more that's not a hospital case take it to surgery center. Now they all get put to sleep for a 5 min case and the hospital says nothing.