I'm covering to much ground here and trying to hit some things we discussed in other threads recently.
#1 - The majority of nail/callus patients should be seen at 3 months. The only people I see more regularly than that are people who had an ulcer that healed and recurs before they reach 3 months. If you want to see people more regularly than that and you have ever questioned your existence or thought - man, my life sucks, why do people only refer to me for nails? Guess what. You created an additional encounter or two a year in which you agreed to cut someone's toenails. If you are busy enough to fill those spots - fill them with something else. Stimulate yourself.
#2 - That said - I'm in PP and I know exactly what nails and calluses are worth. For all of the ego stroking and the high-paid-hospital people, a 11056+11720 pays better than most commercial insurance in my area. A decent-BCBS 99213 pays like $76. A Medicare nail/callus (earlier) pays over $110 and sometimes you don't even have to talk to the patient. If they complain you tell them treatment will make them feel better. I derive zero joy from it, but with the direction reimbursement is going from many insurance plans I sometimes see a block of diabetics on the schedule and think - let's pound this out. Beats a $50 99213 from a trash commercial insurance.
#3 - Nails by themselves are essentially worthless. Unti lthe audit comes it assuredly a wonderful thing to be paid $90 for these visits rather than $30. Theoretically you can bill 11720 + G0127 if they have a few fungal nails + some dystrophic nails. Something tells me this door will be closed in the future as it pays higher than 11721 and the nursing home people are hammering it. Treating a bunch of people just for nails ie. nail pain is the path to having to see 40+ people to survive.
#4 - Everybody's reimbursement is different. In a recent thread another podiatrist said their BCBS 11750 spread is $180 to 280 (something like that). My spread is $150 to $240. Were I to drop the 1 marketplace plan I cover my matrixectomy spread would be $220-$240. Where I'm going with this is everyone will have different financial motivations/incentives based on their contracts.
#5 - I think we need to stop using terms like "red flags" for legitimate behavior. I am in general for the vast majority of instances paid appropriately when my procedure and E&M(25) are appropriately performed, documented, etc. We should bill for what we do, but some people will have to recalibrate what is reasonable. Everyone is going to have to have a plan for what you do when a patient wants a nail or callus dealt with during an exam for something else. The Medicare/commercial insurance software is going to flag encounters if every single visit is a E&M+procedure ie. injection or whatever. Private insurance will ask for notes. If every plantar fasciitis injection follow-up visit gets an E&M because you reminded them to stretch - that's going to be a problem at some point.If you have a complicated patient you may have to find a way to "control the encounter". I had a bizarre 2nd opinion, already had surgery elsewhere, has an MRI, nerve study, known disk impingement, diabetic, has plantar fasciitis, sinus tarsi syndrome, PTTD, tarsal tunnel patient. I remember thinking - I'd kill for one of these visits to just be an injection both for my sanity, my desire to stop documenting, and my concern about how insurance will perceive it. She shows up intermittently requesting injections, unable to walk, wanting more care. We're changing meds, we're trying new offloading, boots, imaging - whatever. BCBS denies the E&M on one of the visits, but the visit was documented out the wazoo and I got paid afterwards. Its not a perfect system. There are unfair payor practices. Strong documentation is your friend. If you want to be paid for every word you say,every single thing you do - set strong guidelines and be prepared to make people pay cash.
#6 - Whenever I hear someone write as part of a complaint - "I Performed a Comprehensive Examination" etc - I always know I'm on the way to hearing a story about an encounter that will not be paid. There was a recent one on PM News. You did a plantar fascial injection and then the patient complained about a callus so you performed a comprehensive examination and determined you needed to trim the callus. Horror of horrors your 99213 was denied. Bad news, the callus probably isn't covered, using callus as a diagnosis code is always on the path to a denial, your comprehensive examination took 3 seconds, and you skipped the "management" side of the E&M. Also, best case it was a 99212. I don't want to hear patients gripe and complain about extra stupid stuff either but you're not going to get paid for everything and again people need to be conditioned to pay cash for calluses and nails. And can't say it enough - Management.
#7 - Back on track. Use class findings. Treat people with systemic conditions. Get their diabetic doctor. Understand the Q codes. The rules on this are unfortunately tigher than most people realize. Like if they only have findings on one foot theoretically the other foot isn't covered. There's all sorts of rules about if the callus is located on the tip of the toe and you are already charging for debridement of the same nail. Medicare Advantage plans will routinely refuse to pay the 1172x with calluses and claim the services are bundled. Interestingly, they do this every other visit demonstrating their own fraud. Just fired Humana btw. Goodbye!
#8 - My experience with commercial insurance, diabetics with class findings, and nail/callus codes is that private insurance has no idea what to do with it. These cases just get trapped in billing hell with them paying and then not paying etc. I'm open to being wrong but I would only use the 1172x/1105x codes with Medicare. I don't like this situation, but I don't have an answer at the moment.
#9 - I tell commercial insurance with no systemic diagnosis / class findings to pay cash. I charge $70 for nails calluses etc. Its increasing to $75 this year. If you look it up most commercial insurances have a document clearly derived from Medicare describing nails and calluses as routine care and uncovered.
#10 - I have zero interest in using the "nail debridement" + pain codes. You can only use 1172X. If you read the LCD they believe using 11721 for this is very questionable. You can only bill for "painful nails". So even if you cut all the nails only the painful nails are billable. To me this seems like a billing trap waiting to happen. Read the LCD and they want you to explain why every nail needed treatment and what was wrong with it.
My experience with these patients in residency was that they were VA type guys with a big thick nail who showed up at the first visit and were in pain, wanted their nails to be crumbled, and then came back for the rest of forever not in pain. I tell these patients at their first visit that all future nails and calluses will be uncovered.
There is no pathway for calluses to be treated except through a systemic diagnosis.
#11 - To me a 99213+ at a diabetic/PVD nail/callus follow-up visit needs to have a new problem/worsening/something different. Worsening claudication, worsening neuropathy desiring medication, worsening arthritis, new onset wound/cellulitis etc. In general, I aim to have 1 good appointment a year where I reiterate the patient's complications ie. you are diabetic, you have deformity, you need diabetic shoes, etc I talk this out while doing the cutting. That said - this visit doesn't have high level decision making - its basically counselling. If nothing is changing or worsening then I commit the SDN horror of only doing 99212 for this.
#12 - Last final bringing it back together. Document. I've been looking back through time on some claims that got denied. I had fallen behind on notes. I really had truly provided some sort of 25 modifier service ie. procedure + E&M during the visit. I said screw it and wrote a quicky line for my E&M rather than discussing the thought process that went into it ie. patient complications, medication interaction, systemic condition. That was the note they read and that was the note where they said documentation doesn't support E&M. And it didn't - I had cut the note short and thought - eh, its good enough.
