Podiatrists complicated cases

[DR.phil99]

I was recently accepted to all podiatry schools I applied to. Podiatry was my first goal during my undergrad and I worked with other medical specialties. However, since I started working with a podiatrist (non-surgical *preceptorship graduate*) I started lacking interested in podiatry as 50-70% of patients leave the clinic with only Motrin prescription and nothing else. Are all non-surgical podiatrists like this? I was wondering what kind of complicated cases podiatrists run into that are non-surgical on daily cases? one example: one patient was referred to wound care clinic for a wound in the foot, I thought all podiatrists can treats wounds in the lower extremity?

ps: I am not including that half of our patients are just for here for cutting mycotic/dystrophic toenails or warts.

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[dtrack22]

Welcome to Podiatry. This will likely be you in 7.5 years

 

[DYK343]

Wounds are not complicated.
1) reduce pressure
2) restore blood flow
3) abscence of infection
4) Sharp debridement/establish healthy wound bed
5) Diabetes control.

Some podiatrists do not want to treat wounds. Some love it. Others do not. Wound care and diabetes complications can really take over your life. The more wounds you do the more late night I&Ds you end up doing. For this reason many podiatrists pass.

Non-surgical will be less complicated than surgical oriented pods.

I follow Medicare guidelines for preventative care 100%. As a result my practice is <10% (more like <5%) nail care. 1-2 patients a day max. Opens up time for more interesting patients/complaints. Granted I am only 2 years out and I am sure my nail care patient percentage will grow but I turn away 95% of them as most dont qualify. I get some negative reviews over it but I dont care.

Shadow another.

 

[Scrantonicity]

Yep, that's the daily grind, man. I mean, Motrin and nothing else--hopefully that's an exaggeration, unless the podiatrist you're working with is super lazy, on autopilot, and/or dumb... but honestly there are only a very few cases per day (if you're lucky---sometimes only per week/month) that are actually INTERESTING once you've been out for a while. It is more likely that the actual patients (their personalities) will be the only interesting thing. I see some wack jobs, and it keeps things interesting and sometimes hilarious...all of this is probably the case for other medical professions, too I'm sure--but if you're turned off by what you're seeing, I'd say stay away.

I will say, seeing a patient feel better after 1 or 2 visits is pretty damn satisfying. Hearing them say, "yeah I told all my co-workers about you, and a few of them have already made appointments". Or, "I was gonna cancel my appointment because I'm not hurting anymore, but I wanted to keep it just to say thank you." Sometimes all I did was give them a cortisone injection, but I'm suddenly a hero. What's better than that?

Surgical podiatry keeps things a little more interesting, of course...it doesn't pay as well as clinic in the long run, and complications can sometimes stress you out, but I do it to keep my sanity.

 

[CutsWithFury]

Surgical podiatry keeps things a little more interesting, of course...it doesn't pay as well as clinic in the long run, and complications can sometimes stress you out, but I do it to keep my sanity.

This is ridiculously false. You can make a ridiculous amount of money having a highly successful surgical podiatry practice compared to the non surgical DPMs. Non surgical DPMs who make "a lot" are one way or another billing fraudulently for the conservative procedures they perform.

 

[Scrantonicity]

This is ridiculously false. You can make a ridiculous amount of money having a highly successful surgical podiatry practice compared to the non surgical DPMs. Non surgical DPMs who make "a lot" are one way or another billing fraudulently for the conservative procedures they perform.

OK, ridiculously false, fine. I'm just looking at my numbers from the year, and the money I have brought in with clinic is a lot higher than my surgical collections. I do about 5-6 surgeries per week.

So doing a bunion or two and getting $600 or less for each, and then seeing those patients for 3 months for free--that makes more money than doing 6 ingrown toenail procedures and a couple tendon releases in a morning? Maybe if I owned a surgery center...or maybe I'm doing it wrong?

I guess if I added more surgery days? Anyways, I don't know what you're getting at.

If you're talking about having a highly successful surgical practice should make more money than a non-surgical practice? Sure, I agree with that--we have a lot more options--a lot more tools at our disposal...but we still have to do clinic--and a lot of it.

 

[CutsWithFury]

OK, ridiculously false, fine. I'm just looking at my numbers from the year, and the money I have brought in with clinic is a lot higher than my surgical collections. I do about 5-6 surgeries per week.

So doing a bunion and getting $600 or less for it, and then seeing that patient for 3 months for free--that makes more money than doing 6 ingrown toenail procedures and a couple tendon releases in a morning? I guess I'm doing it wrong.

I guess if I added more surgery days? Anyways, I don't know what you're getting at.

why does everyone always throw out a bunion as an example of surgery?

How about an insertional achilles tendinosis with spur formation/calcification with large haglunds and recalcitrant plantar fasciitis? What do I bill on those you might ask. I bill gastroc recession, calcaneal ostectomy, FHL tendon transfer, Achilles debridement/repair, plantar fasciotomy. I can do that in 2 hours. We will bill out 5-6K for all of that. Not sure what we end up collecting.

 

[Scrantonicity]

No, I would not ask how much you bill for it. We can bill whatever amount we want. What we collect is the question.

You should probably look at what you end up collecting for that 2 hours. You only get paid for the first procedure really (and only at the "contracted" amount, which is usually much less than you billed for)--then it's 50% off for the 2nd one, then half of that for the 3rd one, and so on. I would guess you collect somewhere around $1200 for the whole thing, depending on the insurance provider of course. In some cases it might even be less than $1000. Not to mention the fact that some insurances will reject 2 or 3 of those procedures, citing "bundling". Believe me, it's sobering when you look at actual collections for this stuff.

Maybe we use bunions as examples because that's about 40% or more of our surgical cases? It's a good litmus test, because it's one simple procedure that we all do.

I forgot to mention--hopefully you are collecting most of that surgical money up front (the patient's portion)--if not, there's a good chance that patient will have a balance for months to come--if so, hopefully they are on a payment plan and sticking to it so you don't have to send them to collections. When looking at my accounts receivable, there is a very large portion of it that I would consider my big surgery cases. Seriously, if you keep really good track of this stuff you will get depressed.

 

[ExperiencedDPM]

why does everyone always throw out a bunion as an example of surgery?

How about an insertional achilles tendinosis with spur formation/calcification with large haglunds and recalcitrant plantar fasciitis? What do I bill on those you might ask. I bill gastroc recession, calcaneal ostectomy, FHL tendon transfer, Achilles debridement/repair, plantar fasciotomy. I can do that in 2 hours. We will bill out 5-6K for all of that. Not sure what we end up collecting.

You need to look at your reimbursement, not your amount billed. You may have to sit down when reality hits you. For years I was the busiest surgically in our practice. I did everything, not just bunions. One of my partners gave up surgery for office only work. He’s honest and did nothing fraudulent and produced more income for the practice than I did.

My friend bills $7500 for a hammertoe repair. So if he does 4 he bills $30,000. He will be lucky if he gets more then 1000 TOTAL. So don’t tell us what you bill, that’s irrelevant. Tell us what you get reimbursed.

 

[CutsWithFury]

You need to look at your reimbursement, not your amount billed. You may have to sit down when reality hits you. For years I was the busiest surgically in our practice. I did everything, not just bunions. One of my partners gave up surgery for office only work. He’s honest and did nothing fraudulent and produced more income for the practice than I did.

My friend bills $7500 for a hammertoe repair. So if he does 4 he bills $30,000. He will be lucky if he gets more then 1000 TOTAL. So don’t tell us what you bill, that’s irrelevant. Tell us what you get reimbursed.

Hey hard ass did I not say that I wasn't sure what I collected? Did you read that? I will be sure to let you know what I collected once its processed.

 

[Scrantonicity]

Back to the OP's question, because as usual we have gone way off track haha. I saw a patient yesterday that has a boneless accessory toe coming off the 2nd digit (distal lateral tip). It even has a tiny nail on it--freakin' weird. I'm seeing them next week, and I'm going to numb the toe and remove the extra one in the office. I'll send it to pathology, but it really just looks like an accessory appendage. So yeah, every once in a while something interesting will walk in--you never know.

 

[dtrack22]

You'll do even better in clinic financially in 2021, assuming the new e/m rules go into effect as scheduled

Surgery can pay, but it needs to be efficient. You can't wipe out a clinic day for 2 surgical cases each week. You also need to have ownership in a facility if you want the big bucks. $100k per year dividend checks make up for a lot of clinic...and you can't be an owner without doing cases. That's also much more legal than the clinic guys who may talk about checks from compounding pharmacies, labs, etc. That stuff can get you put in jail.

Regardless of whether surgery pays well (or can pay well), for most of us it's something we do because we want to help our patients get better, and we've been trained to do so surgically when conservative options fail.

 

[DR.phil99]

Back to the OP's question, because as usual, we have gone way off track haha. I saw a patient yesterday that has a boneless accessory toe coming off the 2nd digit (distal lateral tip). It even has a tiny nail on it--freakin' weird. I'm seeing them next week, and I'm going to numb the toe and remove the extra one in the office. I'll send it to pathology, but it really just looks like an accessory appendage. So yeah, every once in a while something interesting will walk in--you never know.

I think both my title and post were a little off of what I actually meant. I meant interesting cases that make you feel like a physician and using your 7-year education to solve problems. Because prescribing Motrin and Lotrisone all day does not make me feel like a physician or contributing anything to the community health. The case you described is definitely interesting. So do you feel you're a real physician most of the time and contributing to the community?

Since many people brought the money and reimbursements for pods. Well 1st) I know that reimbursements decreased across all medical specialties and not just pods. I know once an ophthalmologist said you just get $12500 for one easy procedure now he only gets $500. 2nd) I would be really happy making $120k a year after paying loans. That's still more than double of what average teacher/engineers/ business graduate makes. Also I would be much happier than the internal med doctor I worked with before who was making $220k/year but did not have any life or that ortho doc who said she her kids grew with their grandparents since day one because she never had time for them.

3rd) most of the people on sdn mostly talk about bunions and hammertoes reimbursements. what about the rearfoot surgery? ankle arthroscopy? flat foot reconstruction? sport injuries surgeries?

 

[air bud]

No, I would not ask how much you bill for it. We can bill whatever amount we want. What we collect is the question.

You should probably look at what you end up collecting for that 2 hours. You only get paid for the first procedure really (and only at the "contracted" amount, which is usually much less than you billed for)--then it's 50% off for the 2nd one, then half of that for the 3rd one, and so on. I would guess you collect somewhere around $1200 for the whole thing, depending on the insurance provider of course. In some cases it might even be less than $1000. Not to mention the fact that some insurances will reject 2 or 3 of those procedures, citing "bundling". Believe me, it's sobering when you look at actual collections for this stuff.

Maybe we use bunions as examples because that's about 40% or more of our surgical cases? It's a good litmus test, because it's one simple procedure that we all do.

I forgot to mention--hopefully you are collecting most of that surgical money up front (the patient's portion)--if not, there's a good chance that patient will have a balance for months to come--if so, hopefully they are on a payment plan and sticking to it so you don't have to send them to collections. When looking at my accounts receivable, there is a very large portion of it that I would consider my big surgery cases. Seriously, if you keep really good track of this stuff you will get depressed.

I get 100 percent of ALL procedures. More and more hospital jobs are like that. Or maybe 50 percent each additional when RVU based. Not the traditional fee schedule for private practice.

 

[air bud]

I think both my title and post were a little off of what I actually meant. I meant interesting cases that make you feel like a physician and using your 7-year education to solve problems. Because prescribing Motrin and Lotrisone all day does not make me feel like a physician or contributing anything to the community health. The case you described is definitely interesting. So do you feel you're a real physician most of the time and contributing to the community?

Since many people brought the money and reimbursements for pods. Well 1st) I know that reimbursements decreased across all medical specialties and not just pods. I know once an ophthalmologist said you just get $12500 for one easy procedure now he only gets $500. 2nd) I would be really happy making $120k a year after paying loans. That's still more than double of what average teacher/engineers/ business graduate makes. Also I would be much happier than the internal med doctor I worked with before who was making $220k/year but did not have any life or that ortho doc who said she her kids grew with their grandparents since day one because she never had time for them.

3rd) most of the people on sdn mostly talk about bunions and hammertoes reimbursements. what about the rearfoot surgery? ankle arthroscopy? flat foot reconstruction? sport injuries surgeries?

No you won't. Talk to us in 7 years and see how you feel. Trust me. Once you see the amount of work you do, and see what others doing similar work make - you won't be happy with 120k. Right now may seem like a lot but its all relative.
I second what some have said earlier. Telling someone to do some stretching, save a few hundred bucks on some powersteps because some PP pod told you custom was needed, maybe a steroid injection. Have them come back in a month, 80 percent better, told all their friends. Do another injection, knock pain out rest of the way and follow up PRN. That is easy and pretty damn satisfying. And most of all NO stress. When I transition to non surgical or forefoot only in the next few years (ok maybe 5 or so) I expect my income to go up and stress to go down.

 

[malleolusman]

So very true. I honestly thought the same way as OP. Once you start making money, and not being paid as an indentured servant, you very quickly become accustomed to getting paid appropriately especially if you are working your tail off. And as they say mo money , mo problems. If you are making good money, it can serve as golden handcuffs too. First world problems, but problems none the less.

With avg debt out of pod school being ~200-250K, 120 K total salary before taxes is piss poor for your training and time invested. Any resident pods out there reading this - take note. You should be paid appropriately for your services.

To OP:
As long as you are well trained and land a job that gives you the patient population you want, you will see the pathology you want to see. Eventually after 2-3 yrs everything becomes routine, even the Charcot recon cases. At that point. . . you gotta start gunning for knee scopes. Jk

No you won't. Talk to us in 7 years and see how you feel. Trust me. Once you see the amount of work you do, and see what others doing similar work make - you won't be happy with 120k. Right now may seem like a lot but its all relative.
I second what some have said earlier. Telling someone to do some stretching, save a few hundred bucks on some powersteps because some PP pod told you custom was needed, maybe a steroid injection. Have them come back in a month, 80 percent better, told all their friends. Do another injection, knock pain out rest of the way and follow up PRN. That is easy and pretty damn satisfying. And most of all NO stress. When I transition to non surgical or forefoot only in the next few years (ok maybe 5 or so) I expect my income to go up and stress to go down.

 

[DYK343]

3rd) most of the people on sdn mostly talk about bunions and hammertoes reimbursements. what about the rearfoot surgery? ankle arthroscopy? flat foot reconstruction? sport injuries surgeries?

I do 3-5 bunion/hammertoe (forefoot) surgeries for every 1 rearfoot surgery.

-Sports injuries a lot of them get better without need for surgery.
-Flat foot recons are not sexy. They can be quite gruesome to manage during post op period.
-Ankle arthroscopy is pretty fun and relatively easy. But honestly a cortisone injection in a lot of cases is just as effective with exception certain pathology.

 

[heybrother]

Surgical reimbursement improves when you add procedures that do not greatly change the course of the recovery/complicate the rehab/recovery/WB etc.

Not doing the which is better, but depending upon your practice set-up/insurers some of the in clinic money can be quite good. A new level 3 + 11750 in my area with the 2nd best insurer is almost $400. Most I've done is 7 in one day. Yes, the 2nd is less and Medicare isn't amazing. I've done 102 matrixectomies and 24 avulsions since starting a few months ago. I've had 1 complication - the patient squeezed the pus out on their own and I gave abx. One of the Medicare insurers pays like $120 for a 11042 - a procedure that can often be done more quickly than nails and calluses. A 11720 + 11056 can be $90. Course I've also got a private-Medicare take over payer that would put me out of business if it was my only insurer. Pays ~41% less than classic Medicare. Yeah, its a grind, but these values are higher than I expected. Now I just need more patients.
*We said this above for surgery, but there are plenty of people who don't pay. My clinic collects $150 as a deposit for essentially all 11750s. I still look back at my first 2 weeks of collections - I had 2 patients that my nurse thought we didn't need to collect a deposit on and both have paid $0 3 months later. $150 is better than nothing. Nails and calluses... always pay.

There are complicated cases (ie. multi-level biomechanical deformities or the dreaded "another podiatrist already operated on me"), but more often its just complicated personalities, complicated past histories, complicated co-morbidities (true vascular cases are often the worst). Jokingly, if my nurse writes pain is 1/10 for someone on a 2nd/3rd follow-up I walk in ready to high-five. I've had some very dour long visits where we seriously discuss 1/10 pain. Today a guy came in with a 7 year forefoot ulcer -he's been debrided by every WHC internist and NP in town. A week ago a lady with a recent hospitalization, 2 MRIs potentially showing osteomyelitis, 5 months of therapy with antibiotics, steroids, and colchicine for her ..Charcot. A guy came in today who got run over by a car 4 years ago and never sought therapy. He has a syndesmotic synostosis, rearfoot arthritis ... and severe intellectual disability. I hope he does great with his brace. My goal in all these things is to do what anesthesia does - try and make it look easy. Show good judgement. Solve long term problems. There are a lot of people with aches and pains that have had it a long time. More often then not things resolve with shoes, OTC inserts, stretching, bracing, and a little cortisone. It doesn't feel glamorous, but if other people were solving these problems I wouldn't have referrals.

Flatfoot surgeries that contain an osseous component ie. fusion/osteotomy have long NWB recoveries. The people I've done them on tend to forget at their 1st visit the recovery time and have to be reminded they won't be returning to their heavy lifting job in 2 weeks. I personally like doing Evans, but teenagers can be crappy patients ie. they are teenagers and they are moody bitches at times. Teenagers have a tendency not to appreciate why you/their parent pushed for the procedure.

I work in an area where everyone is employed. There's oilfield work near by. People who are making hay (while the sun is shining) do not want to take time off for surgery. My residency's 70% Medicaid population was much more interested in being cut on.

 

[G0dFather]

This is ridiculously false. You can make a ridiculous amount of money having a highly successful surgical podiatry practice compared to the non surgical DPMs. Non surgical DPMs who make "a lot" are one way or another billing fraudulently for the conservative procedures they perform.

Well where do I even start with this ... I was going to respond and educate on this but then I saw what you wrote afterwards and figured why even waste my energy on someone that has NO idea but came off hot and heavy like they do... adhere to what PADPM had to say and stop slamming the guy regarding this issue ... at the end of the day its completely backwards, what you spent 3+ years in residency training on and what people strive so hard to get BC for, makes you NO money when you compare what can be made with your training at the end of YEAR 3 in pod school .... dont be too upset about it, it is what it is LOL

We will bill out 5-6K for all of that. Not sure what we end up collecting.

 

[G0dFather]

A new level 3 + 11750 in my area with the 2nd best insurer is almost $400. Most I've done is 7 in one day. Yes, the 2nd is less and Medicare isn't amazing. I've done 102 matrixectomies and 24 avulsions since starting a few months ago. I've had 1 complication - the patient squeezed the pus out on their own and I gave abx. One of the Medicare insurers pays like $120 for a 11042 - a procedure that can often be done more quickly than nails and calluses. A 11720 + 11056 can be $90. Course I've also got a private-Medicare take over payer that would put me out of business if it was my only insurer. Pays ~41% less than classic Medicare. Yeah, its a grind, but these values are higher than I expected. Now I just need more patients.

Those are real life examples of money that can be made in minutes in a clinical setting ..... when "heybrother" is seeing 100 patients a week on the regular he will be happy camper , but not so much when that post op global patient comes in that you cant even do a xray or even strapping on ... at that point he will be factoring in the money that could have been made from the time slot that patient is taking up and he'll subtract that from the total he COLLECTED from the sx which will depress him even further ... there will be many occasions where he'll note that number going into the negative territory and when he factors in the cost of his SURGICAL malpractice and the risk vs reward further into it, one will wonder WTH is going on !! You want to go be happy with the blade and feel like a surgeon for those few hours that is one thing but dont be so naive and think your actually making money doing it in this profession, in many instances if you are a busy doc clinically you are actually PAYING to operate, this of-course all has to do with IN NETWORK surgery ... OUT of NET is a totally different ball game

 

[DYK343]

RVU/hospital employed provider surgeries can pay better than private practice surgeries. A hospital employed provider makes more money for the hospital in the OR and they would rather have a provider be in the OR. Where I trained my attendings got 100% RVU for all procedures and were not scaled down/bundled as Airbud said.

Private practice (in absence of owning surgery center as someone stated above) really does not get paid that well for a surgery.

Nothing worse than an I&D/amp. They pay me nothing and I have to keep going back to the hospital every or every other day for bandage changes. I&Ds/amps should really pay more considering how much time we spend caring for them afterwards.

 

[Scrantonicity]

RVU/hospital employed provider surgeries can pay better than private practice surgeries. A hospital employed provider makes more money for the hospital in the OR and they would rather have a provider be in the OR. Where I trained my attendings got 100% RVU for all procedures and were not scaled down/bundled as Airbud said.

Private practice (in absence of owning surgery center as someone stated above) really does not get paid that well for a surgery.

Nothing worse than an I&D/amp. They pay me nothing and I have to keep going back to the hospital every or every other day for bandage changes. I&Ds/amps should really pay more considering how much time we spend caring for them afterwards.

This I did not know (all procedures paid in full for hospital employed surgeons)--that's pretty interesting. Definitely a good case for approaching hospitals for employment. Also a pretty stupid double standard when it comes to how insurances reimburse private surgeons...like, why? It's the same work either way--I guess hospitals just have a lot more pull... You still have to worry about the patient paying their part though, right?

I always thought RVU's were just a way for the hospital to see how busy you were, and pay you accordingly--didn't realize the hospital actually collects the full amount for each code. Is this something you're absolutely sure of? Or did these surgeons say they got 100% "credit" for each RVU--if so, I bet they don't care to call the billing department to see how much was actually "collected", because it would not impact them either way. I could be wrong, I just don't wanna believe it.

 

[air bud]

I get paid 100 percent of every procedure regardless if they have insurance or not. No idea what hospital collects. Also remember I am critical access, so that is very different vs non critical access.
In the end I love it, I get paid for what I do, and most importantly I can treat each person how they deserve to be treated because I don't care what insurance they have. ( A sad reality).

Also to all you prepods and current students. When it's your patient and you ass on the line, nobody like complicated cases. At least not my generation. These older dudes with something to prove about how they are a real doctor may feel differently. But all my friends that are new grads that understand who and what they are want layups. Sleep at night. Good outcomes. Help people, do good work. I am not risking my job or status in the community for a Trainwreck. It's going to be a bad outcome regardless of me or someone else. So that person is going to someone else.

It's just different during residency. You scrub in and it's just a leg on a table. When you are an attending there is a person attached to it. When you are in a small town, that is your neighbor, you see them at grocery store. Kids play together. Real world is different. Complicated cases are not fun cases.

 

[air bud]

Another thing with these cool complicated cases -. Are you the best person to be doing them? I am not. My reality is I am very low surgical volume now. Low patient volume actually...not only is this complicated case not worth it to me for many reasons, it is most importantly not in the best interest of the patient. Send them to someone who truly specializes in that type of case ie charcot, true angular deformity etc. Making 2k on a case that you never die, has high risk of poor outcome with possible litigation is not worth it.

I am actually coming to this reality very soon. I'm going to have to make some decisions about my future. My surgical volume is pretty low, and if I stay in my current position it will stay low. At some point I'm going to have to stop doing certain procedures. I'm not necessarily opposed to this, but I want to be compensated for it. basically I could leave go to a larger City keep doing these procedures and use all of my training Or I could stay in my current very small town not do these procedures and then give them up going forward. I'm not against either option, but again I want to be compensated for this. Ultimately I think it will be successful as some may argue that my employer will just replace me with somebody else for less money however I'm not talking about that much more of a increase in salary and the following person is going to have the same issues and who knows if they will even want to stay here long-term like I am willing to do. We shall see...

 

[air bud]

I studied my butt off during school graduated near the top of my class did a very good residency with very high volume. Did I plan on my practice turning out like it currently is? When I was in school, I thought I was going to be big some big-time hot shot. big difference between your late 20s like I was during school or early twenties like most people and where you are at once you hit you are mid to late thirties. Things change, priorities change, life happens.
So I will leave you with these words of wisdom: write out your life, specifically these next five to ten years, in pencil not pen

 

[Scrantonicity]

I get paid 100 percent of every procedure regardless if they have insurance or not. No idea what hospital collects. Also remember I am critical access, so that is very different vs non critical access.
In the end I love it, I get paid for what I do, and most importantly I can treat each person how they deserve to be treated because I don't care what insurance they have. ( A sad reality).

So you are not salary based--you get paid per code?

No idea what the hospital collects? Does anyone? It seems like we are talking about 2 different things (what you are paid by the hospital vs what the hospital actually collects for the CPT codes).

The hospital gets paid so much just for the Operating Room time, anesthesia, etc. that it's probably insignificant what they get paid for your CPT codes, so of course they can afford to pay you the full amount.

I know there's tons of benefits of being hospital employed, but we were talking about ACTUAL collections for surgeon's fees--like from the patient's pocket and/or insurance into your hands--so it really is irrelevant to this particular discussion if the hospital is paying you for those RVU's...I mean, it's great for you that they are, but this wasn't really the point, ya know? Or maybe it just makes the distinction--for hospital employed surgeons, I guess surgery does pay more than the clinic (when you take into account all those other fees)?

I guess that's the biggest difference between hospital employed vs private practice---only private practice podiatrists actually have to care about this crap 🙂

 

[air bud]

I am not straight salary. I have a base threshold and then earn a certain amount per RVU over that threshold. My base is 3800 RVU which won't come close to hitting anytime soon, but might one day when add another large outreach clinic. So yes hospital employed care about RVUs. Straight salary might not as much, but you still want to generate them as means more profit for the case you did.

So....yes I get paid per code. It just so happens that I don't produce enough to actually get paid per code , so instead defaults to my fully guaranteed base which is based on producing 3800 RVUS.

 

[NatCh]

It's just different during residency. You scrub in and it's just a leg on a table. When you are an attending there is a person attached to it. When you are in a small town, that is your neighbor, you see them at grocery store. Kids play together. Real world is different. Complicated cases are not fun cases.

Man, that is so true. Although my city has a population of over 90,000, my social circle feels more like 5000 and everyone knows everyone else. I run into patients pretty much any time I set foot out of the house. At last count I have six patients in my immediate neighborhood: one next door, two of them three doors down, one across the park, and two just up the hill. At my supermarket I run into a patient pretty much every time I go. One of the pharmacists and one of the cashiers is a patient. I ride mountain bikes and go skiing with people who were friends first then became patients. They all refer their friends and family. The last thing I want is a crappy surgical outcome.

 

[dtrack22]

There's oilfield work near by. People who are making hay (while the sun is shining) do not want to take time off for surgery.

That King Ranch and those truck nuts ain't gonna pay for themselves, baw

Although my city has a population of over 90,000, my social circle feels more like 5000

Well, when 70,000 of those homes belong to people who spend most of their time in Seattle and Portland... 😉

Trust me. Once you see the amount of work you do, and see what others doing similar work make - you won't be happy with 120k. Right now may seem like a lot but its all relative.

Once you start making money, and not being paid as an indentured servant, you very quickly become accustomed to getting paid appropriately especially if you are working your tail off.

Yup. It's not about being content with $120k, or even being able to live off of it. You will be very dissatisfied with that income because you will quickly realize that you are WORTH a lot more than that. Hell, NatCh works a day and a half per week and makes more than that. That's because you are a doctor, who provides a service that other people can't, and many are willing to pay for. Not to mention you are going to have Podiatry colleagues signing for $250-300k right out of residency, and then you start seeing how MD/DOs are treated by employers (Hint: its way better than any podiatrist will treat you)...$120k and being an associate in a Podiatry group becomes insulting

Flat foot recons are not sexy. They can be quite gruesome to manage during post op period.

That's why you just throw Hyprocures in everyone. Don't forget to do a gastroc. 30 minutes later you have a grand in your pocket!

A new level 3 + 11750 in my area

What are you billing for the e/m code if the patient comes in for a chief complaint of ingrown toenail, and that's really all they have? I have a sneaking suspicion that Podiatrists aren't going to get away with this for much longer. BCBS has laid the groundwork for everyone else on blanket denials of every 25 modifier...not to mention if you bill most of those the way I imagine you do, any review of records would show it to be a bundled service. Medicare would ask you for that money back. But I guess you could be squeezing a legitimate second complaint out of all those folks 😉

My clinic collects $150 as a deposit for essentially all 11750s

If this doesn't already violate the terms of your commercial contracts, it may soon. Though this the dumbest thing insurance companies will do. Every doctor should fight that language in contracts.

when that post op global patient comes in that you cant even do a xray or even strapping on

But you can

I always thought RVU's were just a way for the hospital to see how busy you were, and pay you accordingly--didn't realize the hospital actually collects the full amount for each code. Is this something you're absolutely sure of? Or did these surgeons say they got 100% "credit" for each RVU--if so, I bet they don't care to call the billing department to see how much was actually "collected", because it would not impact them either way. I could be wrong, I just don't wanna believe it.

I'm not sure you understand how hospital contracts work and how those MSG/Hospital group MD/DO/DPMs are paid... The hospital is not getting 100% of each CPT code billed, they get paid just like a private practice doctor does, other than the fact that they get a bunch of money in facility fees and may have higher reimbursements. But the rules still apply. They are talking about the Podiatrist getting wRVU credit for each procedure he/she does. It's a pretty mixed bag. Many hospitals will give you full wRVU credit for every procedure and others will cut your wRVU in half after the first procedure. What insurance pays the hospital and what the hospital pays the Dr. are mutually exclusive as the hospital makes up $$$ with facility fees (OR and clinic), internal referrals, ordering labs/imaging/arterial or neurologic testing, etc.

The hospital gets paid so much just for the Operating Room time, anesthesia, etc. that it's probably insignificant what they get paid for your CPT codes, so of course they can afford to pay you the full amount.

Now you're getting it!

Or maybe it just makes the distinction--for hospital employed surgeons, I guess surgery does pay more than the clinic (when you take into account all those other fees)?

DING, DING, DING! And don't forget that many hospital clinics can charge the patient a facility fee for a post op visit. While you got 0$ for the e/m and maybe $45 for the xray. The hospital got to charge a $75 facility fee even though the patient is in the global, and they might get $75 for the xray...

 

[heybrother]

Appreciate the feedback. My "billing teacher" (...ha) in residency was intent that we find a 2nd diagnosis, always. "Yes, your 2nd toe is a little curly, but we don't need to do anything about that." From a stickler point of view ... a problem that doesn't require treatment isn't going to require much MDM...(edit: probably better to say - its problem point value is "minor, self limited")

The ability to bill for a new visit + a procedure when essentially they are both the same problem is something I've been trying to wrap my head around for awhile. Our billing/office manager says some of the insurers will reduce the E&M since there's a component of E&M built into the procedure. I write my notes with both a procedure description ie. the procedure, the rehab and instructions, the follow-up and then with a unique/non-templated description concerning the specific patient and how we came to what we're doing / whether they need abx etc. Losing all 25 modifiers will suck. I try to be reasonable about follow-up visits and minimally do both, but those people at 1st visits want everything, today.

 

[NatCh]

Well, when 70,000 of those homes belong to people who spend most of their time in Seattle and Portland... 😉

Ha! yeah, that sounds about right. Don't forget the Bay Area too.

Hell, NatCh works a day and a half per week and makes more than that.

Excuse me... TWO and a half.

 

[Scrantonicity]

I'm not sure you understand how hospital contracts work and how those MSG/Hospital group MD/DO/DPMs are paid... The hospital is not getting 100% of each CPT code billed, they get paid just like a private practice doctor does, other than the fact that they get a bunch of money in facility fees and may have higher reimbursements. But the rules still apply. They are talking about the Podiatrist getting wRVU credit for each procedure he/she does. It's a pretty mixed bag. Many hospitals will give you full wRVU credit for every procedure and others will cut your wRVU in half after the first procedure. What insurance pays the hospital and what the hospital pays the Dr. are mutually exclusive as the hospital makes up $$$ with facility fees (OR and clinic), internal referrals, ordering labs/imaging/arterial or neurologic testing, etc.

Yeah--that's how I always thought it worked...but people were chiming in here saying "I get paid the full amount for every procedure I perform", so I was trying to understand the logic by asking those hypothetical questions. I think I get it now.

I am not straight salary. I have a base threshold and then earn a certain amount per RVU over that threshold. My base is 3800 RVU which won't come close to hitting anytime soon, but might one day when add another large outreach clinic. So yes hospital employed care about RVUs. Straight salary might not as much, but you still want to generate them as means more profit for the case you did.

Of course you care about RVU's--I was only saying you don't care about the actual money that is collected by the hospital from the patient and their insurance...it just doesn't impact you in any way. This is where you hospital employees really luck out! I have patients that I performed triple arthrodesis on that STILL have a $400 balance a year later...never gonna see that. Pretty depressing.

Anyways, as usual, good to get the perspectives of my colleagues.

 

[dtrack22]

My "billing teacher" (...ha) in residency was intent that we find a 2nd diagnosis, always. "Yes, your 2nd toe is a little curly, but we don't need to do anything about that." From a stickler point of view ... a problem that doesn't require treatment isn't going to require much MDM...

So a level 2 new patient...

The ability to bill for a new visit + a procedure when essentially they are both the same problem is something I've been trying to wrap my head around for awhile. Our billing/office manager says some of the insurers will reduce the E&M since there's a component of E&M built into the procedure.

Has anyone else had a payer just magically pay less than the contracted rate? I've never heard of this. Sounds like some shady crap you're being told so that they can lower your collections and you won't notice or think anything of it. All I've ever seen is the e/m being denied as bundled in the procedure, or it gets paid at the contracted rate. If denied you appeal, then it gets denied again. Even when you have a legitimate "unrelated e/m" to the procedure. Then you send a 2nd level appeal where someone who MIGHT have an idea of what you are actually treating sees it. Then, if legit, it finally maybe gets paid. But if you're e/m is cellulitis that you deem necessary to treat with PO abx, and your procedure is an ingrown...on the same toe...it gets denied. Because it should get denied. Because as dumb as it is, that is a bundled service as the cellulitis is directly related to the 11730/50.

I try to be reasonable about follow-up visits and minimally do both, but those people at 1st visits want everything, today.

The only time when someone with a handful of complaints doesn't make me want to hang myself in a closet...because that $75 injection DOES NOT actually cover the cost of the office visit and time it took to decide they needed it, even though CMS and private payers are claiming it does.

 

[DR.phil99]

Not to mention you are going to have Podiatry colleagues signing for $250-300k right out of residency, and then you start seeing how MD/DOs are treated by employers (Hint: its way better than any podiatrist will treat you)...$120k and being an associate in a Podiatry group becomes insulting

Is this common for new pods (PMSR/RRA graduates) ??? what about the $100-120k jobs on indeed and podiatryexchange.org

 

[G0dFather]

What are you billing for the e/m code if the patient comes in for a chief complaint of ingrown toenail, and that's really all they have? I have a sneaking suspicion that Podiatrists aren't going to get away with this for much longer. BCBS has laid the groundwork for everyone else on blanket denials of every 25 modifier...not to mention if you bill most of those the way I imagine you do, any review of records would show it to be a bundled service. Medicare would ask you for that money back. But I guess you could be squeezing a legitimate second complaint out of all those folks

This will differ depending on the demo you are treating ... in certain demos they come in with many problems and want rx for all issues .. also there is nothing wrong with a new EVALUATION ETC. for the pain in the toe/foot and then DX it as ingrown with/o cellulitis then MANAGING it by doing a procedure... if it makes you feel better or that your documentation is not enough down code to the next level ... it a new patient/new problem ... ive had no issues with BCBS they pay decent so far ... a 11730 vs 50 tho has no global for when you want to see them next week in case anyone didnt know

 

[G0dFather]

Has anyone else had a payer just magically pay less than the contracted rate? I've never heard of this. Sounds like some shady crap you're being told so that they can lower your collections and you won't notice or think anything of it. All I've ever seen is the e/m being denied as bundled in the procedure, or it gets paid at the contracted rate. If denied you appeal, then it gets denied again. Even when you have a legitimate "unrelated e/m" to the procedure. Then you send a 2nd level appeal where someone who MIGHT have an idea of what you are actually treating sees it. Then, if legit, it finally maybe gets paid. But if you're e/m is cellulitis that you deem necessary to treat with PO abx, and your procedure is an ingrown...on the same toe...it gets denied. Because it should get denied. Because as dumb as it is, that is a bundled service as the cellulitis is directly related to the 11730/50.

Thankfully havent had this issue yet... there are always ways to "navigate" however

 

[G0dFather]

Is this common for new pods (PMSR/RRA graduates) ??? what about the $100-120k jobs on indeed and podiatryexchange.org

No its not common at all sadly, even though they should seeing the reimbursements coming in to my practices now .... the overwhelming majority of the money in podiatry is in private practice and therefore most associates will get 50-60 per hour (20-30% of what they earn grossly) with limited benefits which can be presented in a variety of different ways .... the salaries that are posted on here north of 250k and 300k belong only to an ELITE group of pods and they also happen to be active on these forums also ..LMAO!

 

[DR.phil99]

No its not common at all sadly, even though they should seeing the reimbursements coming in to my practices now .... the overwhelming majority of the money in podiatry is in private practice and therefore most associates will get 50-60 per hour (20-30% of what they earn grossly) with limited benefits which can be presented in a variety of different ways .... the salaries that are posted on here north of 250k and 300k belong only to an ELITE group of pods and they also happen to be active on these forums also ..LMAO!

What about the MGMA data listed below?

Median midwestern pod surgeon $287k.

I know the picture is little blurry but I think you still read it. 1st column (Eastern) 2nd (midwest) 3rd (southern) 4th (western)

I have the remaining data if you are interested

 

[dtrack22]

It’s not uncommon compensation at all for those who work for multi-specialty groups and hospital networks. Those jobs are becoming more common thankfully, but they are still A minority. I will say that I could pretty easily rattle off 30-40 folks that finished residency the same year I did, who I know have positions like that. And you know there are a lot more than that. But even if it’s 100 jobs (and that’s probably the high end any given year) only 20% of graduates are getting salaries like that. There are probably 10-20% of podiatry jobs where you will be treated fairly and truly be invested in. The rest are associate mills. So it is, at best, a coin flip wether or not you get bent over right out of residency.

 

[G0dFather]

What about the MGMA data listed below?

Median midwestern pod surgeon $287k.

I know the picture is little blurry but I think you still read it. 1st column (Eastern) 2nd (midwest) 3rd (southern) 4th (western)

I have the remaining data if you are interested

Thanks man I have seen this data and i have no doubt that it would be true .. but isnt it a small sample size and what good is it if one cant go and bargain with it when the majority of jobs are take it or leave it .. but its a good step in right direction, if the salary situation in this feild is corrected it applications to pod school will sky rocket..feet or not

It’s not uncommon compensation at all for those who work for multi-specialty groups and hospital networks. Those jobs are becoming more common thankfully, but they are still A minority. I will say that I could pretty easily rattle off 30-40 folks that finished residency the same year I did, who I know have positions like that. And you know there are a lot more than that. But even if it’s 100 jobs (and that’s probably the high end any given year) only 20% of graduates are getting salaries like that. There are probably 10-20% of podiatry jobs where you will be treated fairly and truly be invested in. The rest are associate mills. So it is, at best, a coin flip wether or not you get bent over right out of residency.

Thanks for acknowledging what i was really getting at, and i agree with you on the above ... but at least with a coin flip its fifty fifty if i use your math in this comment it WAY less lol

 

[dtrack22]

Thanks for acknowledging what i was really getting at, and i agree with you on the above ... but at least with a coin flip its fifty fifty if i use your math in this comment it WAY less lol

I mean if you took the high end of my meaningless, anecdotal math then it’s 60/40. That’s not too far from a coin flip. I actually think That if you are willing to work anywhere in the country, your odds are even better than 50/50 of getting a job that pays good money from day 1. But that means anywhere...

 

[theconzumer]

I guess I'm about to start looking for jobs next year. I'm graduating from a pretty unknown program but feel very confident in my clinical and surgical skills. Graduating with my loans paid off. I'm pretty limited to major cities as my wife works in finance and her salary is going to be double mine as an attending. I don't mind working for a hospital but would like to have my own practice. I don't mind starting off making ~100k a year if it pays off later on and I make around 200k vs starting at 200k like a lot of people here seem to be who sign on with hospitals. I guess I am pretty limited in job opportunities and salaries if I'm working in a bigger city (say SF, LA, Chicago, NYC), do people tend to make more in private practice in these areas vs hospital podiatrist, or multi-speciality groups or podiatry groups.

 

[G0dFather]

do people tend to make more in private practice in these areas

Which ever area you are in, big city or small city, if you have a busy practice >200 pts a week you should be grossing or close to grossing 1 million ( billing conservative too) ... from that point its all about how good you control your expenses that will determine how much you can squeeze out of that gross