Only the hard facts

[ExperiencedDPM]

I keep reading ridiculous and repetitive posts regarding how much surgery these young docs are going to perform when they get out, how much money everyone is going to make or supposed to make, etc., etc., etc.

Well it's time for a dose of reality. Surgery 101 class is now in session:

Everyone is tired of hearing about the "good old days" when surgery payed VERY well, documentation was minimal and government intervention was minimal. Now welcome to 2017......things have changed. Reimbursements suck, you are told what to document and how to document, etc., and the government is constantly adding more rules and regulations.

Years ago there were basically three payment models (forgetting about HMO capitation). There was the Medicare fee schedule, Medicaid fee schedule and private insurance. As a general rule, most private insurers paid above Medicare rate. Some were 110% of Medicare, some used the "UCR" formula which was usually and customary fee and some insurers were VERY generous, and paid very well, until doctors took full advantage.

In 2017 and moving forward, the majority, if not all insurers are paying at Medicare level, or some even less. Why? It's simple......because they can!!! If you want to be participating in their plans, you've got to follow their rules and accept their payments. Otherwise the patients will be directed to a participating doctor, and not you. In short, they've got you by the gonads.

So let's continue with reality. You hear those bitter corns, calluses and toenail DPMs telling you that there's no money in surgery, and every day those comments are getting more accurate. There can be money in surgery, but only if there is high volume.

Here's some sobering examples. These are some fees that are the current Medicare reimbursement, and most if not all private insurers:

28805---transmetatarsal amputation pays $757.97
28285---hammertoe surgery/arthroplasty/fusion of a toe pays $390.47 (in a facility)
28296---bunionectomy with distal metatarsal osteotomy pays $532.23
27702---Total ankle arthroplasty with implant pays $995.19
11057---trimming greater than 4 calluses pays $66.39

Remember, an endodontist gets well over $1,000 for an uncomplicated root canal
Remember, your appliance repairman makes a few hundred dollars for walking in your door
Remember, your attorney bills $525.00 an hour, and bills for EVERY email, text and call.

So you are well trained and perform a TAR (total ankle replacement). You travel to the hospital (that's time), your case is bumped an hour (that's time), you spend 2-3 hours in the OR to complete the case (that's time), you stay at the hospital to complete paper work, check the patient in recovery and speak with the family (that's time), you travel to your office to see afternoon patients (that's time) and then you see the patient for weeks to months post operatively. And you can NOT bill for any routine follow up visits for 90 days following the surgery. Post op visits for 90 days are included.

So you made $995 bucks on the case. Spread that over all the time above, including the 90 day post op global time and it 'ain't much bucky.

So you "figured" out how to make more money. You'll charge extra for the screws, plates, etc. when you perform your bunionectomy. Sorry... the hardware is inclusive to the procedure and is not separately payable. Or you figured out a way to "unbundle" the surgery so instead of one procedure, you can fragment it into several procedures. Wrong again bucky, that borders on illegal as per the False Claims Act, and most insurers have a computer based program that "edits" the claims via the CCI---correct coding initiative that won't allow certain codes to be billed with other codes, since unbundling is fraudulent.

So while you're at the hospital making a few bucks, your partner who only does palliative care is trimming some calluses and making over 60 bucks a pop. He sees 20 patients and makes over $1200 bucks doing brainless work, with little to no complications or follow up. And you've got to follow your surgical patient for 90 days for many procedures, at a whopping ZERO additional dollars.

Yes, I perform surgery. Yes, I'm ABFAS board certified. Yes, I enjoy surgery much more than any other aspect of care, but I FULLY understand that it's an added service of the practice, but not necessarily the most economically efficient way to make money.

And please don't make money by selling your patients useless crap. Vitamins for neuropathy, creams for all kinds of crap, laser surgery for nails that doesn't work, topical nail antifungals that work no better than Vicks Vapor rub, or sell every patient a pair of orthotics when they can do fine with OTC products.

Is this all doom and gloom? Not at all, it's reality. My point is that surgery is great and macho, but it's not necessarily a huge money maker when you consider the big picture. You will be told by practice management people how to make money selling, billing too much, etc. DO NOT FOLLOW THEIR ADVICE. Work hard, build a high volume practice and be a professional. Treat patients well, do the right thing and be ready to put in the hours. Nights, weekends, early mornings, etc. Because there IS NO legitimate shortcut. I can name you dozens that took a short cut to make money and they are all paying penalties, lost their licenses and are in jail.

And that's the truth, the whole truth and nothing but the truth.

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[de Ribas]

28805---transmetatarsal amputation pays $757.97
28285---hammertoe surgery/arthroplasty/fusion of a toe pays $390.47 (in a facility)
28296---bunionectomy with distal metatarsal osteotomy pays $532.23
27702---Total ankle arthroplasty with implant pays $995.19
11057---trimming greater than 4 calluses pays $66.39

Are these payments for podiatrists only, or other MDs get the same amount for these same procedures?

So while you're at the hospital making a few bucks, your partner who only does palliative care is trimming some calluses and making over 60 bucks a pop. He sees 20 patients and makes over $1200 bucks doing brainless work, with little to no complications or follow up. And you've got to follow your surgical patient for 90 days for many procedures, at a whopping ZERO additional dollars.

Of course I have not been on the other side of podiatry school and know very little, but when I shadowed my first podiatrist, I was shocked when he said that he stopped doing any surgery and he is not making less. I also thought that surgery cases pay well and the more you do, more you earn. He told me that he used to do it and now he does not do any surgery at all and he does not regret that.

So you are well trained and perform a TAR (total ankle replacement). You travel to the hospital (that's time), your case is bumped an hour (that's time), you spend 2-3 hours in the OR to complete the case (that's time), you stay at the hospital to complete paper work, check the patient in recovery and speak with the family (that's time), you travel to your office to see afternoon patients (that's time) and then you see the patient for weeks to months post operatively. And you can NOT bill for any routine follow up visits for 90 days following the surgery. Post op visits for 90 days are included.

So, if the surgery is not paid well as it was before and if it involves so much hassle, wouldn't it be smart for many to avoid surgical cases? If yes, less people doing surgeries, wouldn't prices go up?

 

[med2345]

Are these payments for podiatrists only, or other MDs get the same amount for these same procedures?

I was told reimbursement rates are not different between DO, DPM, and MD

 

[GypsyHummus]

Could a podiatrist do a cash based/elective surgery option? Say, do the bread and butter ingrown toenails , corn and calluses and the like and just offer surgery only on a cash base as an option for patients who want it? Obviously, anything trauma prolly would go through insurance, but for elective bunion surgery, why not say “yeah I can do it, but I only accept cash and it’s 700$.” That way you don’t have to go through insurance.

Given, I’m not exactly sure how much is involved in a bunion surgery. I’ve heard of a surgery center in Oklahoma that doesn’t use insurances, instead relies on cash and it’s actually much cheaper for the patient and the doctor gets paid right away. A 360 win

 

[ExperiencedDPM]

As far as I know, there is no reimbursement difference among DPM, MD, DO with Medicare. This can vary with private carriers and state to state with some carriers. When I started practice I was adamant that it would be in a state with parity. I wasn’t going to work for less for providing the same service as someone else.

 

[ExperiencedDPM]

Could a podiatrist do a cash based/elective surgery option? Say, do the bread and butter ingrown toenails , corn and calluses and the like and just offer surgery only on a cash base as an option for patients who want it? Obviously, anything trauma prolly would go through insurance, but for elective bunion surgery, why not say “yeah I can do it, but I only accept cash and it’s 700$.” That way you don’t have to go through insurance.

Given, I’m not exactly sure how much is involved in a bunion surgery. I’ve heard of a surgery center in Oklahoma that doesn’t use insurances, instead relies on cash and it’s actually much cheaper for the patient and the doctor gets paid right away. A 360 win

No. If you are participating with an insurance you can’t pick and choose the procedures you’ll accept. You can simply not participate with insurance. But it’s unlikely a patient is going to pay you when the doc down the street accepts the insurance.

 

[de Ribas]

Could a podiatrist do a cash based/elective surgery option? Say, do the bread and butter ingrown toenails , corn and calluses and the like and just offer surgery only on a cash base as an option for patients who want it? Obviously, anything trauma prolly would go through insurance, but for elective bunion surgery, why not say “yeah I can do it, but I only accept cash and it’s 700$.” That way you don’t have to go through insurance.

Given, I’m not exactly sure how much is involved in a bunion surgery. I’ve heard of a surgery center in Oklahoma that doesn’t use insurances, instead relies on cash and it’s actually much cheaper for the patient and the doctor gets paid right away. A 360 win

If you perform a surgery at the hospital or surgery center, would it mean that everything else (like anesthesia, hospital fees, assistants, etc) would be paid by cash too? I think either the whole surgical procedure is covered by insurance or paid out of pocket. How can you pay cash to a surgeon and everything else be covered under insurance?

 

[GypsyHummus]

dont plastic surgeons do that?

If you perform a surgery at the hospital or surgery center, would it mean that everything else (like anesthesia, hospital fees, assistants, etc) would be paid by cash too? I think either the whole surgical procedure is covered by insurance or paid out of pocket. How can you pay cash to a surgeon and everything else be covered under insurance?

 

[de Ribas]

dont plastic surgeons do that?

I don't say it is not possible, but would you find many who would pay bunion surgery completely out of pocket?

 

[ExperiencedDPM]

I don't say it is not possible, but would you find many who would pay bunion surgery completely out of pocket?

No

 

[air bud]

Great original post. I am fortunate that I live in a small town. I walk to the hospital or the surgery center, they are right next door. I only have a few hours of block time a week, and then do everything else over the lunch hour or 7am start before 8am clinic. I try not to miss any clinic time. There is no reason for an hour lunch. I need 5 minutes before surgery. So far seems to be working well. Hammmertoe, bunion, amps etc non clinic hours, bigger fusions and rearfoot stuff block time.

 

[de Ribas]

No

How much on average is a total cost of a bunion surgery if one would pay out of pocket?

 

[de Ribas]

Great original post. I am fortunate that I live in a small town. I walk to the hospital or the surgery center, they are right next door. I only have a few hours of block time a week, and then do everything else over the lunch hour or 7am start before 8am clinic. I try not to miss any clinic time. There is no reason for an hour lunch. I need 5 minutes before surgery. So far seems to be working well. Hammmertoe, bunion, amps etc non clinic hours, bigger fusions and rearfoot stuff block time.

So, if someone has their own practice, do you just go to your local/nearby hospital and ask if you can perform surgeries and then they provide room, anesthesia and staff? (I guess it is more complicated than than, but in general?)

 

[air bud]

So, if someone has their own practice, do you just go to your local/nearby hospital and ask if you can perform surgeries and then they provide room, anesthesia and staff? (I guess it is more complicated than than, but in general?)

Yes. You apply for privileges. Then you show and so surgery. They do everything else.

 

[de Ribas]

I am fortunate that I live in a small town.

Do you think it is easier to find a job, start a practice and get hospital privileges in a smaller town and rural area or opposite?

This is what I somewhat worry about; I live in rural area and would like to stay in rural area as a podiatrist.

 

[Cranjis McBasketball]

Meanwhile the endodontist I work for does about 7 root canals a day, 4 days a week, working 38-40 hours a week.. and he does one follow up 12 months later... haha

 

[Cranjis McBasketball]

So it seems like your post is saying surgery reimbursement is an issue in medicine in general? Orthopedics included? If thats the case, dont pods still generally make more than primary care docs like Peds and FM physicians?

 

[Weirdy]

So it seems like your post is saying surgery reimbursement is an issue in medicine in general? Orthopedics included? If thats the case, dont pods still generally make more than primary care docs like Peds and FM physicians?

There can be money in surgery, but only if there is high volume.

 

[de Ribas]

plus, the procedures Orthos perform pay better, right?

 

[dtrack22]

So while you're at the hospital making a few bucks, your partner who only does palliative care is trimming some calluses and making over 60 bucks a pop. He sees 20 patients and makes over $1200 bucks doing brainless work, with little to no complications or follow up. And you've got to follow your surgical patient for 90 days for many procedures, at a whopping ZERO additional dollars.

I'm going to play Devil's advocate for a couple of reasons...I hate it when the AAPPM guys come in and say surgery doesn't pay, you need to sit in an office and rip people off like we do in order to get rich, and more importantly get the thread back on track after students yet again tried to take it off the rails. I don't disagree with your overall point at all, falling reimbursements make surgery less profitable, but nobody is going bankrupt from having an average to heavy surgical volume practice...they have from getting stuck doing almost nothing but routine foot care.

The only problem with the above quote is also the thing that drives me nuts about podiatry. Routine foot care. Commercial plans will not pay you to trim calluses. Put an L84 on your claim and watch the entire thing get rejected. Medicare will only pay (depending on the administrator's/state's LCD) for callus debridement if they are deemed to be at risk. You cannot see 20 patients every morning doing nothing but trimming calluses (and billing for callus trimming) without committing fraud. Not to mention that $60 per patient visit isn't going to keep the lights on. Again, I agree with your overall premise, the example would just be better if you would have said heel pain and neuromas and ankle sprains. Routine foot care needs to die until reimbursement levels are in line with the time and staff it takes to perform. Those patients are a total drain on any private office.

Inefficient surgery does not pay. Of course if you are losing a morning clinic to go do a single case at the hospital, you are losing money. Your cases should be done in one morning or one day consistently to maximize your time at the surgery center or hospital. You also shouldn't spend more than 2 hours in an OR for anything other than disaster revision cases and a nail with a frame over it. You don't have to be high volume in order to have 4-5 cases a week. Here was my Friday last week...all medicare reimbursement $, nothing took over an hour of tourniquet time:

Case 1
I&D - 28002= $323.88
delayed closure of surgical wound - 13160= $809.43
$1,133.31

Case 2
1st MPJ arthrodesis - 28750 = $598.27
flexor tenotomy x3 - 28232 (59 and digit code modifiers) = $496.72
capsulotomy lesser PIPJ x3 - 28272 = $520.10
$1,615.09

Case 3
wart excision - 11422 = $137.18
adjacent tissue transfer - 14040 = $641.95
$779.13

Case 4
Calc saucerization - 28120 = $504.90
FHL transfer - 27691 = $755.53
$1,260.43

I was done early afternoon and totaled $4874.96. If you spent that time in clinic and were doing well at $120 per patient visit, you would have had to see 40 patients from 8am to 2pm and you'd end up with significantly more documentation (4 dictions and orders vs 40 notes). You would also have to pay the staff required to see all of those folks. It varies from practice to practice but you have some amount of decreased overhead on your OR day that should be accounted for. Do surgery wisely and efficiently and it adds value to your practice. Or be the guy that sends everything that needs to go to the OR out of your office and watch those referrals start skipping over you completely.

 

[de Ribas]

Case 1
I&D - 28002= $323.88
delayed closure of surgical wound - 13160= $809.43
$1,133.31

Case 2
1st MPJ arthrodesis - 28750 = $598.27
flexor tenotomy x3 - 28232 (59 and digit code modifiers) = $496.72
capsulotomy lesser PIPJ x3 - 28272 = $520.10
$1,615.09

Case 3
wart excision - 11422 = $137.18
adjacent tissue transfer - 14040 = $641.95
$779.13

Case 4
Calc saucerization - 28120 = $504.90
FHL transfer - 27691 = $755.53
$1,260.43

Are these the amounts that you are directly getting or these are total for these procedures in general?

Commercial plans will not pay you to trim calluses. Put an L84 on your claim and watch the entire thing get rejected.

So, if these procedures are not covered, can you bill the patient directly because insurance does not cover?

 

[ExperiencedDPM]

I'm going to play Devil's advocate for a couple of reasons...I hate it when the AAPPM guys come in and say surgery doesn't pay, you need to sit in an office and rip people off like we do in order to get rich, and more importantly get the thread back on track after students yet again tried to take it off the rails. I don't disagree with your overall point at all, falling reimbursements make surgery less profitable, but nobody is going bankrupt from having an average to heavy surgical volume practice...they have from getting stuck doing almost nothing but routine foot care.

The only problem with the above quote is also the thing that drives me nuts about podiatry. Routine foot care. Commercial plans will not pay you to trim calluses. Put an L84 on your claim and watch the entire thing get rejected. Medicare will only pay (depending on the administrator's/state's LCD) for callus debridement if they are deemed to be at risk. You cannot see 20 patients every morning doing nothing but trimming calluses (and billing for callus trimming) without committing fraud. Not to mention that $60 per patient visit isn't going to keep the lights on. Again, I agree with your overall premise, the example would just be better if you would have said heel pain and neuromas and ankle sprains. Routine foot care needs to die until reimbursement levels are in line with the time and staff it takes to perform. Those patients are a total drain on any private office.

Inefficient surgery does not pay. Of course if you are losing a morning clinic to go do a single case at the hospital, you are losing money. Your cases should be done in one morning or one day consistently to maximize your time at the surgery center or hospital. You also shouldn't spend more than 2 hours in an OR for anything other than disaster revision cases and a nail with a frame over it. You don't have to be high volume in order to have 4-5 cases a week. Here was my Friday last week...all medicare reimbursement $, nothing took over an hour of tourniquet time:

Case 1
I&D - 28002= $323.88
delayed closure of surgical wound - 13160= $809.43
$1,133.31

Case 2
1st MPJ arthrodesis - 28750 = $598.27
flexor tenotomy x3 - 28232 (59 and digit code modifiers) = $496.72
capsulotomy lesser PIPJ x3 - 28272 = $520.10
$1,615.09

Case 3
wart excision - 11422 = $137.18
adjacent tissue transfer - 14040 = $641.95
$779.13

Case 4
Calc saucerization - 28120 = $504.90
FHL transfer - 27691 = $755.53
$1,260.43

I was done early afternoon and totaled $4874.96. If you spent that time in clinic and were doing well at $120 per patient visit, you would have had to see 40 patients from 8am to 2pm and you'd end up with significantly more documentation (4 dictions and orders vs 40 notes). You would also have to pay the staff required to see all of those folks. It varies from practice to practice but you have some amount of decreased overhead on your OR day that should be accounted for. Do surgery wisely and efficiently and it adds value to your practice. Or be the guy that sends everything that needs to go to the OR out of your office and watch those referrals start skipping over you completely.

In my post I clearly stated that in order for surgery to be profitable it must be high volume.

My example of callus trimming was simply a sarcastic example of how ridiculous the payment system functions. You can substitute any simple Office procedure you’d like.

And please don’t forget my point about global fees post op.

On quick note. As I stated, I’m often consulted by insurance companies for review. And 14040 is one of the most abused and misrepresented codes. I can elaborate on that in another thread.

 

[air bud]

Can we all agree to stop responding to these questions that miss the point of a post and distract the conversation?

 

[ExperiencedDPM]

Can we all agree to stop responding to these questions that miss the point of a post and distract the conversation?

Agreed 100%. Some of the barrage of questions from one person who isn’t even in training yet, prove that he or she hasn’t done his/her homework and I’m not here to hold someone’s hand in lieu of that person making contacts, shadowing and learning hands on.

I have ignored those posts.

 

[med2345]

Are these payments for podiatrists only, or other MDs get the same amount for these same procedures??

If you do some research just googling podiatric procedures you can find the total cost and the money that will be reimbursed to you for several procedures especially common ones. It's relatively easy to find.

Edit: Just wanted to comment I don't want to get off course just helping someone

 

[podoloco]

I own a fairly busy practice with one associate and cover 2 major hospital systems in our region. We are the preferred providers for wound care and inpatient call. No ER call thankfully. Between my associate and I, we cover 3 wound care clinic days. Average of 1 outpatient elective a week (usually bunions), and often several inpatient amps or I&Ds a week.

I review all EOBs and have a regular review of what is being covered and what is being denied, as well as monitor the revenues from each facility.

Wound care brings in about 15% of the revenue, outpatient surgery less than 10%, and inpatient call/surgeries about 10-15%, and the rest is from clinic time. We don't do anything particularly out of the ordinary in clinic. Fair amount of at risk and diabetic care. I send all medicare patients to a prosthetic supplier to get shoes (Saves on paperwork and headaches calling PCPs for notes). Diabetic shoes for private and medicaid are done in clinic. Orthotics if OTCs don't work, usually at least 1 pair a week. A few products that I tend to send patients looking for otherwise (toe spacers and compression stockings).

Surgery is a necessary part of the equation for patient care, but not the primary one. The clinic is hands down the most profitable part of the business, and of that it is mostly the diabetic / at risk foot care (nails & calluses), then office visits, then injections, then procedures, such as tenotomies, warts....

*Also, I use a multi-specialty billing service. For private insurances, I am paid about 15% less than my MD/DO Dermatology and Orthopedic colleagues, for certain procedures, not all. I think office visits are paid the same. Medicare and Medicaid rates are the same.

 

[dtrack22]

In my post I clearly stated that in order for surgery to be profitable it must be high volume.

...

On quick note. As I stated, I’m often consulted by insurance companies for review. And 14040 is one of the most abused and misrepresented codes. I can elaborate on that in another thread.

But I disagree with the high volume part. It only has to be efficient. Efficient in terms of time you take to do cases and efficient in terms of scheduling. I don't think volume matters at all. If your volume is really low, maybe 1 case per week, then you close your clinic one day and operate once a month. If its a couple cases a week, then you operate every other Friday. If its inpatient pus, you figure out a way to add them on to a regular surgery schedule, or fit them in during lunch, or see a couple less patients at the end of the day, or you just don't do it. You know what each clinic patient is worth in terms of avg collections, you know what surgery will pay, you can make 1 case a month or 20 cases a month work.

You can make any volume of surgery you want "profitable" and you can replace clinic visits with surgical patients if you are efficient and schedule appropriately based on your volume IMO. Of course, if you are missing a morning clinic to run to the hospital for a toe amp, you are losing money...and you are an idiot for doing that.

I hope you find some time to post about the adjacent tissue transfer code. I don't get worried too much about billing stuff that is abused by others...especially when its a code I may use a couple of times per year. Use the code correctly and you'll be fine.

 

[dtrack22]

The clinic is hands down the most profitable part of the business, and of that it is mostly the diabetic / at risk foot care (nails & calluses), then office visits, then injections, then procedures, such as tenotomies, warts....

I don't think we should confuse "profit" or "profitable" with % of collections...

 

[ExperiencedDPM]

If you do some research just googling podiatric procedures you can find the total cost and the money that will be reimbursed to you for several procedures especially common ones. It's relatively easy to find.

Edit: Just wanted to comment I don't want to get off course just helping someone

It’s not quite that simple. When additional procedures are performed during the same encounter, those fees are reduced. You do not get 100% of the allowable fee on all procedures that day.

Additionally, some procedures are inclusive to other procedures and are not separately payable. Those on this site with little to no actual experience tend to over simplify matters.

 

[med2345]

It’s not quite that simple. When additional procedures are performed during the same encounter, those fees are reduced. You do not get 100% of the allowable fee on all procedures that day.

Additionally, some procedures are inclusive to other procedures and are not separately payable. Those on this site with little to no actual experience tend to over simplify matters.

Understood but I assume it can give an average ballpark estimate. I doubt any pod student or pre-pod would be that focused on payment as of now. And to ask a pod/someone you shadow that in depth would probably come off as a little ridiculous but it's better than nothing.

 

[podoloco]

I don't think we should confuse "profit" or "profitable" with % of collections...

The percentages I mentioned are a % of the total of the revenue collected from each aspect of the practice. I consider each half day in regards to the revenue generated, not meaning gross billings. Things that we have found that are not as productive as others, such as nursing homes for us, I have let go. The hospital for me is the biggest time suck for the least return, but it is necessary due to my network contract

 

[bunNfxr]

As I understand it, this post it is to dispense information to young and aspiring podiatrists. As such my opinion on the above billings are below. I hope Dtrack is right, in his state, maybe coding rules don't apply the same as other places I have worked, but I believe his state may be denial.

Case 1
I&D - 28002= $323.88
delayed closure of surgical wound - 13160= $809.43
$1,133.31

Case 2
1st MPJ arthrodesis - 28750 = $598.27
flexor tenotomy x3 - 28232 (59 and digit code modifiers) = $496.72
capsulotomy lesser PIPJ x3 - 28272 = $520.10
$1,615.09

Case 3
wart excision - 11422 = $137.18
adjacent tissue transfer - 14040 = $641.95
$779.13

Case 4
Calc saucerization - 28120 = $504.90
FHL transfer - 27691 = $755.53
$1,260.43


1. Is that your EOB? or are you looking up the Medicare Fee schedule? I'm guessing its the latter, because it does not look like Medicare rates on 2nd procedures, which pay 50% of reimbursable amount; 25% on 3rd and 4th and $0 on 5th procedures.
2. Pretty sure Medicare does not allow 28232 and 28272 together. You'll probably get paid for just one or the other, may be asked for an op report, So some clerk with no medical education can review your chart for buzz words on a list and deny your claim altogether or pay for the lesser procedure and make you waste time appealing the decision so you can make an extra $30
3. Adjacent tissue transfer for a wart. I would be very surprised if you were not asked for the op report on this and the claim gets denied for not meeting criteria for medical necessity. Medicare generally just denies the claim and makes you appeal it. Blue cross would ask for the op report
4. FHL transfer with a calc sucerization? again, why transfer a tendon with a calc sauceraization? Is the foot collapsing and needs to be fused? Is the foot infected and you are doing tendon work with an active infection? Medical necessity? Op report submit, deny claim, appeal.

I am guessing you work for a hospital or MSG/ortho group and don't see how this actually works. You may get away with this for a while, but I don't believe you billing looks sustainable. At the very least, I don't think you understand the reimbursements on multiple procedures. You are not collecting what you think you are. And if you are, I don't think you will keep it. I wish you well. But if you are paid on RVUs billed out. You are doing fine. But if you are paid on cash collected, I think your calculations are way off

 

[dtrack22]

1. Is that your EOB? or are you looking up the Medicare Fee schedule? I'm guessing its the latter, because it does not look like Medicare rates on 2nd procedures, which pay 50% of reimbursable amount; 25% on 3rd and 4th and $0 on 5th procedures.
2. Pretty sure Medicare does not allow 28232 and 28272 together. You'll probably get paid for just one or the other, may be asked for an op report, So some clerk with no medical education can review your chart for buzz words on a list and deny your claim altogether or pay for the lesser procedure and make you waste time appealing the decision so you can make an extra $30
3. Adjacent tissue transfer for a wart. I would be very surprised if you were not asked for the op report on this and the claim gets denied for not meeting criteria for medical necessity. Medicare generally just denies the claim and makes you appeal it. Blue cross would ask for the op report
4. FHL transfer with a calc sucerization? again, why transfer a tendon with a calc sauceraization? Is the foot collapsing and needs to be fused? Is the foot infected and you are doing tendon work with an active infection? Medical necessity? Op report submit, deny claim, appeal.

We do not accept medicare without a supplement. We dot not accept Medicaid. Our lowest paying commercial contract is 110% of medicare, the others are 120%. I haven't had any plan reject 28232 and 28272 with a 59 modifier on 28232 (the column 2 code), including medicare. Adjacent tissue transfer has paid without problems, if I remember right one payor did not want to pay the $100 for the excision, so go ahead and subtract that from my total. With the saucerization (or ostectomy until those redundant codes are fixed) it is easy to justify tendon transfer and/or code for repair of Achilles tendon. There are no CCI edits and both have been paid without issue where I practice.

The percentages I mentioned are a % of the total of the revenue collected from each aspect of the practice.

Exactly. That doesn't determine how "profitable" a certain visit type or pathology is. Of course if 60% of your practice is RFC, those patients may make up the highest % of your collections. But if you replaced every RFC patient with a heel pain patient, your revenue would increase. Those are more "profitable" visits. Collections per visit would be a more accurate way to determine how profitable a given visit type or pathology is. I haven't run across a practice yet where they are bringing in more money per visit on routine foot care compared to heel pain, neuroma or FF pain, sprains/injuries, wound care, etc.

 

[bunNfxr]

As far as Routine care not being done without fraud. It often is. But I have worked with many docs that can bang out 60-80 patients a day, 5 days a week and passed Medicare Audits. It is a different style of practice that is probably not sustainable with EMRs and current regulations, but for now it still flies.
The ability to charge cash on non-covered patients depends on your colleagues honesty. If they "find a way to make it covered" then you will loose patients or have to break your ethics and risk your license. If most or all the docs within 30-40 miles of you charge patients for non covered care than patients will line up outside your door, if you treat them well and make them feel like someone cares about them and their inability to care for their own personal needs.

High Volume surgery is also currently sustainable. But will it be in 5-10 years. I don't know. Because, after 2008 we saw people with high deductibles shift their habits for elective surgery. As the economy is coming around and people have sat on some of these issues for a while and still need certain things done, people are coming back in to offices now. However, economic trends in podiatry are not immune from economic shifts and insurance companies now know full well how they have the power to shift the dynamics of the medical economy. Moreover, I have seen some shifts in practice trends out of private practice. However, there are not enough hospital jobs, ortho and multi spec jobs to go around. This can create a downward pressure on podiatry salaries. Particularly, if corporate bean counters think a DPM is bringing in revenue such as that presented above only to find out that actual reimbursement is much lower and much of the billings superfluous to insurance companies paying the bills. Mind you the hospitals make the real money on OR time and hospitalized patients, so the DPM salary can be absorbed right along with the ID doc, Endocrinologist and the Rheumatologist. The difference could be that 10 or maybe 50 DPMs that want that job while they require a national search to fill a Rheumatologist or Endocrine position.

Maybe that is just fear mongering. But I think it is worthy of consideration if you are entering this profession.

 

[bunNfxr]

Pretty sure in most areas of the country, private insurance is less than Medicare. Larger practices and hospital practices can and often do negotiate better rates with some payers. This is another luxury that is mostly inaccessible to private practices. They just are not big enough to commit a negotiator every time a new contract comes out for each plan. Opting out does not phase them, they wont even know you are gone.

 

[dtrack22]

Why don't we use Dr. DeHeer's numbers that include operating on Medicaid patients? $678 average per case. 5 cases is just over $3300 and would be higher without accepting Medicaid. That's a 30 patient clinic day. More if you do a significant amount of RFC. Yes, he would make more money seeing 30 patients with plantar fasciitis, or doing 30 ingrowns. But he's not working for free. I know ExperiencedDPM isn't saying don't do surgery, and everyone that tells you the golden days of high surgical reimbursements are long gone are telling the truth. I just can't stand the AAPPM type folks that use surgical reimbursements as a reason to promote shady clinical billing practices, ruthless hiring practices, and this fight to keep routine foot care alive in our practices all while totally taking it on the chin in terms of RFC reimbursement. Like I mentioned in my first post, I'm playing devil's advocate more than anything else...gotta keep things interesting around here

 

[ExperiencedDPM]

Why don't we use Dr. DeHeer's numbers that include operating on Medicaid patients? $678 average per case. 5 cases is just over $3300 and would be higher without accepting Medicaid. That's a 30 patient clinic day. More if you do a significant amount of RFC. Yes, he would make more money seeing 30 patients with plantar fasciitis, or doing 30 ingrowns. But he's not working for free. I know ExperiencedDPM isn't saying don't do surgery, and everyone that tells you the golden days of high surgical reimbursements are long gone are telling the truth. I just can't stand the AAPPM type folks that use surgical reimbursements as a reason to promote shady clinical billing practices, ruthless hiring practices, and this fight to keep routine foot care alive in our practices all while totally taking it on the chin in terms of RFC reimbursement. Like I mentioned in my first post, I'm playing devil's advocate more than anything else...gotta keep things interesting around here

Please note that in my original post I also slammed the practice management thieves.

I am very involved with the insurance industry and can tell you the days of privates paying 110%, 120% of Medicare are coming to a hault. As per my original post.......why......because they can.

Additionally, the majority of the surgery we do is elective. And they are scrutinizing these cases more than ever.

 

[Trollest]

I keep reading ridiculous and repetitive posts regarding how much surgery these young docs are going to perform when they get out, how much money everyone is going to make or supposed to make, etc., etc., etc.

Well it's time for a dose of reality. Surgery 101 class is now in session:

Everyone is tired of hearing about the "good old days" when surgery payed VERY well, documentation was minimal and government intervention was minimal. Now welcome to 2017......things have changed. Reimbursements suck, you are told what to document and how to document, etc., and the government is constantly adding more rules and regulations.

Years ago there were basically three payment models (forgetting about HMO capitation). There was the Medicare fee schedule, Medicaid fee schedule and private insurance. As a general rule, most private insurers paid above Medicare rate. Some were 110% of Medicare, some used the "UCR" formula which was usually and customary fee and some insurers were VERY generous, and paid very well, until doctors took full advantage.

In 2017 and moving forward, the majority, if not all insurers are paying at Medicare level, or some even less. Why? It's simple......because they can!!! If you want to be participating in their plans, you've got to follow their rules and accept their payments. Otherwise the patients will be directed to a participating doctor, and not you. In short, they've got you by the gonads.

So let's continue with reality. You hear those bitter corns, calluses and toenail DPMs telling you that there's no money in surgery, and every day those comments are getting more accurate. There can be money in surgery, but only if there is high volume.

Here's some sobering examples. These are some fees that are the current Medicare reimbursement, and most if not all private insurers:

28805---transmetatarsal amputation pays $757.97
28285---hammertoe surgery/arthroplasty/fusion of a toe pays $390.47 (in a facility)
28296---bunionectomy with distal metatarsal osteotomy pays $532.23
27702---Total ankle arthroplasty with implant pays $995.19
11057---trimming greater than 4 calluses pays $66.39

Remember, an endodontist gets well over $1,000 for an uncomplicated root canal
Remember, your appliance repairman makes a few hundred dollars for walking in your door
Remember, your attorney bills $525.00 an hour, and bills for EVERY email, text and call.

So you are well trained and perform a TAR (total ankle replacement). You travel to the hospital (that's time), your case is bumped an hour (that's time), you spend 2-3 hours in the OR to complete the case (that's time), you stay at the hospital to complete paper work, check the patient in recovery and speak with the family (that's time), you travel to your office to see afternoon patients (that's time) and then you see the patient for weeks to months post operatively. And you can NOT bill for any routine follow up visits for 90 days following the surgery. Post op visits for 90 days are included.

So you made $995 bucks on the case. Spread that over all the time above, including the 90 day post op global time and it 'ain't much bucky.

So you "figured" out how to make more money. You'll charge extra for the screws, plates, etc. when you perform your bunionectomy. Sorry... the hardware is inclusive to the procedure and is not separately payable. Or you figured out a way to "unbundle" the surgery so instead of one procedure, you can fragment it into several procedures. Wrong again bucky, that borders on illegal as per the False Claims Act, and most insurers have a computer based program that "edits" the claims via the CCI---correct coding initiative that won't allow certain codes to be billed with other codes, since unbundling is fraudulent.

So while you're at the hospital making a few bucks, your partner who only does palliative care is trimming some calluses and making over 60 bucks a pop. He sees 20 patients and makes over $1200 bucks doing brainless work, with little to no complications or follow up. And you've got to follow your surgical patient for 90 days for many procedures, at a whopping ZERO additional dollars.

Yes, I perform surgery. Yes, I'm ABFAS board certified. Yes, I enjoy surgery much more than any other aspect of care, but I FULLY understand that it's an added service of the practice, but not necessarily the most economically efficient way to make money.

And please don't make money by selling your patients useless crap. Vitamins for neuropathy, creams for all kinds of crap, laser surgery for nails that doesn't work, topical nail antifungals that work no better than Vicks Vapor rub, or sell every patient a pair of orthotics when they can do fine with OTC products.

Is this all doom and gloom? Not at all, it's reality. My point is that surgery is great and macho, but it's not necessarily a huge money maker when you consider the big picture. You will be told by practice management people how to make money selling, billing too much, etc. DO NOT FOLLOW THEIR ADVICE. Work hard, build a high volume practice and be a professional. Treat patients well, do the right thing and be ready to put in the hours. Nights, weekends, early mornings, etc. Because there IS NO legitimate shortcut. I can name you dozens that took a short cut to make money and they are all paying penalties, lost their licenses and are in jail.

And that's the truth, the whole truth and nothing but the truth.

Forever the GOAT!

 

[podoloco]

Exactly. That doesn't determine how "profitable" a certain visit type or pathology is. Of course if 60% of your practice is RFC, those patients may make up the highest % of your collections. But if you replaced every RFC patient with a heel pain patient, your revenue would increase. Those are more "profitable" visits. Collections per visit would be a more accurate way to determine how profitable a given visit type or pathology is. I haven't run across a practice yet where they are bringing in more money per visit on routine foot care compared to heel pain, neuroma or FF pain, sprains/injuries, wound care, etc.

I see what you are saying. I definitely have more at risk foot care than any other one population. I do have a rather steady flow of new patients weekly, many heel pains and sprains from the many local manufacturing plants. Initial visits are great, although some established visit reimbursements make me depressed. I definitely am looking at realigning my patient base to more office and procedure type visits and having my associate do more of the DM foot care.

Wound care is tricky. I get sent alot of level 3 and 4 wounds that require I take them to a wound center and/or OR. While the superficial and subQ wounds would pay better in the office, the time lost in my clinic doing all the management, debridement and dressings, makes it more efficient to me to take the majority to the wound center. My wound clinic is very efficient, and they maxed out at 15 visits per half day. That many in my clinic would take the entire day due to most of them being train wrecks. I am busier than the other providers there and it still doesn't produce the level of revenue that I initially was expecting, but like the hospital, it is necessary for my practice.

Efficiency makes all the difference. Structuring the schedule properly was the hardest thing to figure out initially. There has to be a balance between efficient use of surgical bloc time and clinic time, and hospital call, and administration work, and everything else.

 

[that1guyfromFL]

I hardly ever get on here these days, but I felt compelled tonight. Is it a full moon?

I've seen these types of threads come up so many times and it's the same arguments over and over and over again.

One thing that is nearly always left out of the equation when the topic of whether "surgery pays" or not is the ancillary investment opportunity that exits for providers caring for a steady volume of MSK patients.

Imaging, surgery center (in and out of network) and other opportunities to invest and recoup more of the down stream revenue YOU generate with your evaluation and treatment of these patients are real.

Question: Why aren't there more voices on SDN talking about how to run an efficient, high volume surgical practice profitably?

Answer: they have zero time to waste posting about it on a message board.


1) SDN does not have real world proportional representation when it comes to types of attending staff willing to participate.

2) When browsing SDN, always consider the source of the information you come across.

3) Everyone speaks from their own experience, complete with bias (including me).

4) Do your own research. SDN doesn't count.

5) Find a mentor with the practice profile you want to have. Learn from them.

6) Get the new Call of Duty game and challenge dtrack22, he is mediocre at best.

 

[dtrack22]

6) Get the new Call of Duty game and challenge dtrack22, he is mediocre at best.

add me on xbone...he speaks the truth

 

[Creflo]

Regarding routine foot care in clinic and surviving audits, I'm curious what percentage of some of your clinics is painful mycotic nails vs. diabetes vs. peripheral arterial disease? These are probably the 3 most common qualifiers for trimming nails/calluses. And when you diagnose PAD, are you getting the primary care provider to sign off on this diagnosis? The reason for this is I've heard medicare has targeted podiatrists for diagnosing PAD when they aren't "physicians." I know I will get pushback on this on sdn, but I met with a medical compliance professional that PICA uses for podiatry administrative defense coverage and he suggested that this (sign off by MD for PAD diagnosis) be done.

 

[NatCh]

It’s probably a good idea but an awful lot of time spent to make $35.

 

[dtrack22]

It’s probably a good idea but an awful lot of time spent to make $35.

But Elliot Udell told me that we should be fighting to keep routine foot care

 

[NatCh]

But Elliot Udell told me that we should be fighting to keep routine foot care

I guess I'd better find where I put my nippers.

 

[AttackNME]

Regarding routine foot care in clinic and surviving audits, I'm curious what percentage of some of your clinics is painful mycotic nails vs. diabetes vs. peripheral arterial disease? These are probably the 3 most common qualifiers for trimming nails/calluses. And when you diagnose PAD, are you getting the primary care provider to sign off on this diagnosis? The reason for this is I've heard medicare has targeted podiatrists for diagnosing PAD when they aren't "physicians." I know I will get pushback on this on sdn, but I met with a medical compliance professional that PICA uses for podiatry administrative defense coverage and he suggested that this (sign off by MD for PAD diagnosis) be done.

Does signing off mean making sure the MD also documents the presence of PAD in his/her soap note? Are you saying you've heard of medicare not compensating podiatrists for their routine foot care because they cannot make the PAD diagnoses?

 

[podoloco]

I would imagine the trouble people get into with billing for at risk foot care with PVD diagnosis is the use of the Q9 modifier, which is to signify presence of significant vascular disease symptoms. Use of the Q9 should only be used if there is documentation of recent vascular specialist evaluation or intervention, or documentation of a referral to one. This only applies to Medicare, and Podiatrists are physicians under Medicare, so I am confused where there would be an argument against us diagnosing vascular disease of the lower extremities.
I am 1 year in, so maybe I have not been audited enough to have any problems. I have pretty much monthly chart requests for different medicare advantage plans and have not had any issues with at risk foot care for patients with PVD issues. I order alot of vascular testing, as well and refer patients out, so that may be part of it.
As noted above, all of this is anecdotal to each of our experiences.

 

[ExperiencedDPM]

If a patient does NOT have class findings with DM or PVD I would HIGHLY discourage billing for "painful mycotic nails which limit ambulation". Have those patients pay you cash or let them go to your competitor.

I've been in practice greater than 25 years and I can't say I've truly seen any patient that had toenails that were so painful that they limited ambulation. Don't get involved with that crap.

And someone quoted Dr. Udell. I'll take the high road and will say "no comment". This is the same doc who posted a question on another site asking what type of car he should drive based on what patients will think.

Unless my patients are paying my car payment, I never once thought about what they will think about my "ride".

 

[heybrother]

If a patient does NOT have class findings with DM or PVD I would HIGHLY discourage billing for "painful mycotic nails which limit ambulation". Have those patients pay you cash or let them go to your competitor.

I've been in practice greater than 25 years and I can't say I've truly seen any patient that had toenails that were so painful that they limited ambulation. Don't get involved with that crap.

And someone quoted Dr. Udell. I'll take the high road and will say "no comment". This is the same doc who posted a question on another site asking what type of car he should drive based on what patients will think.

Unless my patients are paying my car payment, I never once thought about what they will think about my "ride".

They ..might be in that situation when they show up the first time (as the accompanying family member makes shocked faces and says "I didn't know *gasp*".) When they inevitably are back again in ...63 days they are probably not.

 

[I post PRN]

I keep reading ridiculous and repetitive posts regarding how much surgery these young docs are going to perform when they get out, how much money everyone is going to make or supposed to make, etc., etc., etc.

Well it's time for a dose of reality. Surgery 101 class is now in session:

Everyone is tired of hearing about the "good old days" when surgery payed VERY well, documentation was minimal and government intervention was minimal. Now welcome to 2017......things have changed. Reimbursements suck, you are told what to document and how to document, etc., and the government is constantly adding more rules and regulations.

Years ago there were basically three payment models (forgetting about HMO capitation). There was the Medicare fee schedule, Medicaid fee schedule and private insurance. As a general rule, most private insurers paid above Medicare rate. Some were 110% of Medicare, some used the "UCR" formula which was usually and customary fee and some insurers were VERY generous, and paid very well, until doctors took full advantage.

In 2017 and moving forward, the majority, if not all insurers are paying at Medicare level, or some even less. Why? It's simple......because they can!!! If you want to be participating in their plans, you've got to follow their rules and accept their payments. Otherwise the patients will be directed to a participating doctor, and not you. In short, they've got you by the gonads.

So let's continue with reality. You hear those bitter corns, calluses and toenail DPMs telling you that there's no money in surgery, and every day those comments are getting more accurate. There can be money in surgery, but only if there is high volume.

Here's some sobering examples. These are some fees that are the current Medicare reimbursement, and most if not all private insurers:

28805---transmetatarsal amputation pays $757.97
28285---hammertoe surgery/arthroplasty/fusion of a toe pays $390.47 (in a facility)
28296---bunionectomy with distal metatarsal osteotomy pays $532.23
27702---Total ankle arthroplasty with implant pays $995.19
11057---trimming greater than 4 calluses pays $66.39

Remember, an endodontist gets well over $1,000 for an uncomplicated root canal
Remember, your appliance repairman makes a few hundred dollars for walking in your door
Remember, your attorney bills $525.00 an hour, and bills for EVERY email, text and call.

So you are well trained and perform a TAR (total ankle replacement). You travel to the hospital (that's time), your case is bumped an hour (that's time), you spend 2-3 hours in the OR to complete the case (that's time), you stay at the hospital to complete paper work, check the patient in recovery and speak with the family (that's time), you travel to your office to see afternoon patients (that's time) and then you see the patient for weeks to months post operatively. And you can NOT bill for any routine follow up visits for 90 days following the surgery. Post op visits for 90 days are included.

So you made $995 bucks on the case. Spread that over all the time above, including the 90 day post op global time and it 'ain't much bucky.

So you "figured" out how to make more money. You'll charge extra for the screws, plates, etc. when you perform your bunionectomy. Sorry... the hardware is inclusive to the procedure and is not separately payable. Or you figured out a way to "unbundle" the surgery so instead of one procedure, you can fragment it into several procedures. Wrong again bucky, that borders on illegal as per the False Claims Act, and most insurers have a computer based program that "edits" the claims via the CCI---correct coding initiative that won't allow certain codes to be billed with other codes, since unbundling is fraudulent.

So while you're at the hospital making a few bucks, your partner who only does palliative care is trimming some calluses and making over 60 bucks a pop. He sees 20 patients and makes over $1200 bucks doing brainless work, with little to no complications or follow up. And you've got to follow your surgical patient for 90 days for many procedures, at a whopping ZERO additional dollars.

Yes, I perform surgery. Yes, I'm ABFAS board certified. Yes, I enjoy surgery much more than any other aspect of care, but I FULLY understand that it's an added service of the practice, but not necessarily the most economically efficient way to make money.

And please don't make money by selling your patients useless crap. Vitamins for neuropathy, creams for all kinds of crap, laser surgery for nails that doesn't work, topical nail antifungals that work no better than Vicks Vapor rub, or sell every patient a pair of orthotics when they can do fine with OTC products.

Is this all doom and gloom? Not at all, it's reality. My point is that surgery is great and macho, but it's not necessarily a huge money maker when you consider the big picture. You will be told by practice management people how to make money selling, billing too much, etc. DO NOT FOLLOW THEIR ADVICE. Work hard, build a high volume practice and be a professional. Treat patients well, do the right thing and be ready to put in the hours. Nights, weekends, early mornings, etc. Because there IS NO legitimate shortcut. I can name you dozens that took a short cut to make money and they are all paying penalties, lost their licenses and are in jail.

And that's the truth, the whole truth and nothing but the truth.

Nailed it