Podiatrists going to jail for cutting nails?

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Mr.Smile12

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I'm just seeking verification.

Medicaid/Medicare isn't reimbursing podiatrists for cutting toenails, and some pods no longer offer this. Some pods are going to jail for not accurately charting doing nail trims.

Can someone clarify my word salad and confirm that podiatrists are going to jail for this? I can't laugh or challenge the podiatrist who said this to me without some understanding of the issue. They are likely right, but I don't understand why.

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Sounds more like fraudulent billing to get paid for nail trimmings that did not qualify for insurance coverage.

That's the only way I can make sense of your experience.
 
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I'm just seeking verification.

Medicaid/Medicare isn't reimbursing podiatrists for cutting toenails, and some pods no longer offer this. Some pods are going to jail for not accurately charting doing nail trims.

Can someone clarify my word salad and confirm that podiatrists are going to jail for this? I can't laugh or challenge the podiatrist who said this to me without some understanding of the issue. They are likely right, but I don't understand why.
There is essentially a bureaucratic process associated with getting Medicare to pay for all forms of nail and callus cutting and trimming and debriding and some of those words have very specific meanings for billing purposes. There are people attempting to "qualify" every patient and there are all sorts of other forms of billing misbehavior, like not using the nail and callus codes and just calling them office visits, which is also a problem. There are a lot of ways to do it wrong and to not get paid. We have a professional organization called the APMA that will report to you each year how much money CMS spent on these codes and my historic experience at these events is that CMS feels like most of the care is unwarranted. If you search online for podiatrist and fraud, you will find stories of people being fined or going to jail for all forms of misbehavior. Fraudulent nail cutting is sometimes one of those issues. How that comes about though is another story ie. what does it actually take for CMS to believe you were committing fraud. One of my attendings used to regularly use the expression - "The tallest blade of grass is the first to be cut". The impression I’m under is that CMS is spending a lot more time looking at people who bill codes at the 99th percentile frequency or engage in behavior that seems outside the norm of the profession. The funniest part about all this though is that the nail codes aren’t worth anything. They are worth some variation of 1/2 to 1/3 of a 99213. There are podiatrist who would love it if all of these codes went away, and there are podiatrist who would go out of business if that happened also. So, yes, you can go to jail for fraudulently cutting nails, but you would have to look at the actual circumstances of how this comes about. Most people are not going to jail for it. I can describe more in detail, but I will say that one of the frustrations of some podiatrists is that PCP’s think we should be cutting every single patient’s nails and a lot of the patients will not meet the billing criteria. Even if they have diabetes.
 
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Good info above.

The 'going to jail' part is unlikely... much more likely to be dropped from MCR and owe a big clawback. (Which would effectively end a podiatrist's career)

You have some pods doing nail care on people who don't qualify by MCR guidelines. Others add a lot of codes (ingrown, nail biopsy, send toenails for histo charges, etc etc) when they are just merely trimming nails (nursing homes, office, wherever). Some of it is just trying to make a living... most is greed. It creates red flags to pound codes (relative to peer docs/groups) obviously.

Right now, there is a CMS scrutiny on cpt 11730 nail avulsion (partial removal of nail, usually for ingrow/injury). It creates audits that are time waste for almost all DPMs, but it happens because some podiatrists have hit CMS for millions on that code where it was barely ever performed or not done at all (just added the code on many/all basic maintenance nail trims). This has happened a number of times over the years.
 
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Good info above.

The 'going to jail' part is unlikely... much more likely to be dropped from MCR and owe a big clawback. (Which would effectively end a podiatrist's career)

You have some pods doing nail care on people who don't qualify by MCR guidelines. Others add a lot of codes (ingrown, nail biopsy, send toenails for histo charges, etc etc) when they are just merely trimming nails (nursing homes, office, wherever). Some of it is just trying to make a living... most is greed. It creates red flags to pound codes (relative to peer docs/groups) obviously.

Right now, there is a CMS scrutiny on cpt 11730 nail avulsion (partial removal of nail, usually for ingrow/injury). It creates audits that are time waste for almost all DPMs, but it happens because some podiatrists have hit CMS for millions on that code where it was barely ever performed or not done at all (just added the code on many/all basic maintenance nail trims). This has happened a number of times over the years.
Why the hell would they do 11730 for routine nails

Jfc sometimes this profession is embarrassing
 
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You can read medicare's guidelines on nail debridement here

Medicare does not cover nail or callus care as a general rule.

We have to prove to medicare that there is a medical reason that they must be cut.

In a nutshell this is neuropathy, or class findings A, B, C as discussed in the link.

A grey area is "pain that limits ambulation" which is what a lot of podiatrists use fraudulently to "get the service covered".

If you google podiatrist nail care fraud there are a few in prison for it.

Medicare knows its happening and mostly looks the other way. But every now and then they will pluck one out of the crowd and set an example. Likely the "tallest blade of grass" like HeyBrother said.

My biggest problem with cutting nails is 40-50% of my referrals are fraudulent for me to cut the nails. No risk factors. No class findings. No pain. Thats medicare fraud. But telling a patient they dont qualify and its cash service results in negative reviews and sometimes patients turning verbally abusive towards providers. Especially if a DPM in the area retires who had a whole boat load of the fraudulent "pain" patients getting their nails cut.

A lot of younger DPMs are walking away from nails because of the fraud associated with it. I had a guy retire that flooded my practice with fraud at my last job and I refused to see any nails after that happened. It wasnt fair to my ratings online because I was following the law.

Edit: Infection also covered. Infection meaning bacterial - not fungal. Group 1 and 3 codes at bottom of document state Kidney disease, paraplegia, Rheumatoid, and MS also covered. But most of the rest of the group codes are fairly rare diagnosis.
 
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I will say that one of the frustrations of some podiatrists is that PCP’s think we should be cutting every single patient’s nails and a lot of the patients will not meet the billing criteria. Even if they have diabetes.
This.

I will say I see less referrals from MD/DO for fraudulent nails compared to NP/PA referrals.

Not to dig at the NPs or PAs but I dont think they are educated well in this subject.

Seems to be a lot of blanket podiatry referrals for nail care from them regardless of any qualifying health factors.
 
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...A lot of younger DPMs are walking away from nails because of the fraud associated with it. ...
You Dont Say Stand Up GIF


...A grey area is "pain that limits ambulation" which is what a lot of podiatrists use fraudulently to "get the service covered". ...
Yes and no.

Pain is a subject and dynamic complaint.
There is no pain-o-meter for walking or toenails or bunions or arthritis (or anything).
 
I imagine you could plea it down, but yeah. Inappropriately billing Medicare for nails is bad. Also charging Medicare beneficiaries cash for a covered service is also bad. So it's jail either way
 
I imagine you could plea it down, but yeah. Inappropriately billing Medicare for nails is bad. Also charging Medicare beneficiaries cash for a covered service is also bad. So it's jail either way
You raise an interesting point, but show me a podiatrist who went to jail for charging cash for nail cutting where the government argued the service should have been covered. I don't think it exists because quite simply this podiatrist doesn't show up on a billing report. Additionally, "pain" only pays if the nails are debrided. If the notes could be pulled and the notes say the nails were trimmed then the service couldn't have been covered.

Supposedly, one of the ways to get audited is to bill 11721 and pain repetively because the government only pays for "painful" nails which makes it less likely a person has 6+ painful nails.

Anyway. Like I said in the original post. We are devoting a lot of mental energy to a $32 visit.
 
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You Dont Say Stand Up GIF



Yes and no.

Pain is a subject and dynamic complaint.
There is no pain-o-meter for walking or toenails or bunions or arthritis (or anything).
DPM to patient: "Do they hurt"
Patient: "No"
DPM dication: "painful nails 1-5 both feet debrided back to hygienic length without complication"
11721.

We know its true haha
 
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You raise an interesting point, but show me a podiatrist who went to jail for charging cash for nail cutting where the government argued the service should have been covered. I don't think it exists because quite simply this podiatrist doesn't show up on a billing report. Additionally, "pain" only pays if the nails are debrided. If the notes could be pulled and the notes say the nails were trimmed then the service couldn't have been covered.

Supposedly, one of the ways to get audited is to bill 11721 and pain repetively because the government only pays for "painful" nails which makes it less likely a person has 6+ painful nails.

Anyway. Like I said in the original post. We are devoting a lot of mental energy to a $32 visit.
Biggest red flag you auto schedule them every 3 months (or 61 days if youre a real TFP) for painful nails.
People do it. But they sticking their neck out.
 
This.

I will say I see less referrals from MD/DO for fraudulent nails compared to NP/PA referrals.

Not to dig at the NPs or PAs but I dont think they are educated well in this subject.

Seems to be a lot of blanket podiatry referrals for nail care from them regardless of any qualifying health factors.
It's gross. They think podiatry = nail tech.
 
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This.

I will say I see less referrals from MD/DO for fraudulent nails compared to NP/PA referrals.

Not to dig at the NPs or PAs but I dont think they are educated well in this subject.

Seems to be a lot of blanket podiatry referrals for nail care from them regardless of any qualifying health factors.
For those of us with amenable employers or who own their own practices, why not tell those patients no
 
For those of us with amenable employers or who own their own practices, why not tell those patients no
Oh I do. But the patients dont always take it so well. Which leads to frustration from both parties.

"My doctor told me I have to have my nails cut by a podiatrist and I can not cut them myself!"

Then they leave negative reviews online that you treated them poorly or denied them care.

Its annoying. I hate it.
 
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... I will say that one of the frustrations of some podiatrists is that PCP’s think we should be cutting every single patient’s nails and a lot of the patients will not meet the billing criteria. Even if they have diabetes.
...I will say I see less referrals from MD/DO for fraudulent nails compared to NP/PA referrals.

Not to dig at the NPs or PAs but I dont think they are educated well in this subject.

Seems to be a lot of blanket podiatry referrals for nail care from them regardless of any qualifying health factors.
Correct. The big podiatry demand is, in the vast majority of setups, still for RFC. It creates a patient expectation.
Refers for that routine type nail/DM care outnumber any other pathology in 95% of pod clinics.
PCPs don't know the MCR criteria; they simply know podiatry cuts toenails (not derm or F&A ortho or etc).

It's not PCP's job to know nail care Q-quals... how would they know? I don't know when I send someone with blur vision and recent weight gain if they will definitely receive diabetes Rx or what Rx it might be. If a person asked me for a plastic surgeon in the area, I wouldn't know if they met micromastia criteria (insurance vs cash pay with Plastics). Personally, I'm just happy the MD/DO are sending and involving us in the care overall.

It's a catch-22, thorough and through:

#1) Podiatry basically started because physicians didn't want to cut corns and calluses. Over 100 years after good old NYCPM founded, most of our podiatry refers and "demand" are still for RFC. It's what we do. It's what we're expected to do - by patients and docs alike. And yeah, that's how it is, despite what APMA might try to sell to students or what 21s century DPM picture that ACFAS paints. :)

#2) Now, in the day of 3yr residencies or even more training and "foot and ankle surgery," a lot of podiatrists don't want to do nail care...
The ortho group or MSG or hospital DPMs often try to wiggle out of nail/callus care and say pts don't qualify, try to get a nail care RN or tech or midlevel or whatever. The PP pods will generally do it, qualify the pt some how (Q mods or pain or both)... some dump nail debride mostly to MAs. Basically, we have a lot more skills than nail/callus care 100 years later, and most of us logically want to use those skills instead of what we were founded on: busting crusties.

...So, when in doubt, refer to meme thread (ya, he won for a diff one that year, but I honestly do think this one is the GOAT meme):

1672197893815-png.363914
 
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Why the hell would they do 11730 for routine nails

Jfc sometimes this profession is embarrassing
Yes, it's unfortunately tale as old as time.

To be clear (for any students/resident/inexp ppl reading this):
  • Podiatrists are NOT "going to jail" for 11721.
It is super easy to qualify most people for that RFC via either legit pain or legit Q9 (or find other legit path to do e/m if non-MCR or whatever). Maybe not for ongoing visits, but you can easily qualify the initial refer visit (DM, arthropathy, amp, deformity, pain, skin condition, old injury... 1000 other things). Even if the documentation was sloppy, it'd probably be a fairly smallish clawback and/or having to document better going forward. Unless a bunch of patients or a former biller or someone called MCR saying the doc never cut their nails - yet 11721 was billed and charged, it's very unlikely to be an issue. Podiatrists are toenail cutters... through and through. Most of the people calling "fraud" simply don't want to do the nail care and/or documentation. I don't blame them. It pays little and is tedious work. I try to minimize it (and do more other stuff we're trained for), but I do it... there are a ton of refers for foot exam/nails and a definite need for it. Most PP docs I know do same: see and do RFC (possibly limit appts for it a bit) and just look for other path also for those pts. Either way, podiatry was founded on RFC, people want RFC, PCPs think of podiatry when they think of RFC, and it's not going away.

  • Podiatrists HAVE (and will) get kicked off MCR or owe monies back if busted for putting a lot of 11730, 11755, and other codes onto basic nail care + foot exam visits.
This happens mainly at nursing homes: why make 20 x 11721 when you could add 11730 for half of them and 97597 for five of them for little abrasion scabs they may have on digits/malleoli/etc? They are geriatric and/or dementia pts, so who will know, right? Well, after weeks and months and years, you will have waaay more of those codes than peers and possibly get audited and owe MCR for a thousand 11730 you never did the work. Ditto for the office greed of billing 99213/4 + 11721 + 11755 + 11730 (and a big path lab bill, maybe ABI charge also) for just clipping nails and sending them for "histology" at the lab the group owns (which the result of changes nothing with the pt's tx... simply running up the bill in a major way). That stuff done daily makes for a 10 foot tall blade of grass pretty quick. That's the stuff that typically ends careers with huge clawbacks and/or kicked off MediCare (unlikely bona fide "jail"... but technically not impossible).

...It goes beyond nails to anything (wound "grafts," charging for custom and giving prefab DME, wound debrides week after week after week, u/s injects, DME never even given, whatever). If you didn't do it and/or you did do it but just slam on the codes a ton more than area peers, you will likely be asked for explanation and/or money back. It's that simple. If a patient or colleague or associate or resident or employee or basically whoever reports or complains of you to MCR or other payers about fraud or abuse, you are also likely going to get grilled.
 
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I simply refuse all of it. Qualify or not. The staff know if patients call or walk in to inquire, it is a hard no matter what.

One patient threatened to sue me because I was not providing standard of care even after wasting time in the room explaining Medicare guidelines. Why put yourself through this

This has significantly decreased angry patients and negative reviews. Some still sneak in no matter what but rare.
 
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I simply refuse all of it. Qualify or not. The staff know if patients call or walk in to inquire, it is a hard no matter what.

One patient threatened to sue me because I was not providing standard of care even after wasting time in the room explaining Medicare guidelines. Why put yourself through this

This has significantly decreased angry patients and negative reviews. Some still sneak in no matter what but rare.
Yep, this is the way to go if you want to structure the practice/office that way.^^

We should really be able to garner and treat whatever we like.
There are Neuros who only see movement disorders (no basic stuff), Endos who only see growth hormone pts (no common DM/thyroid), etc... list goes on infinitely for MD/DO subspecialists. It is really hard to pull off in podiatry due to saturation and expectations (a ton easier for ortho F&As obviously).

95% of DPMs can't do this aggressive filtering because they are not owner and/or they need the RFC income/goodwill from PCPs.
 

"According to court filings, Dr. Michael Thomas, age 55, pleaded guilty to eight counts of health care fraud arising from a scheme to bill Medicare for toenail trimming, which is not covered by Medicare, as if it were nail debridement, which is a more serious procedure that may be covered if certain clinical criteria are met. As part of the scheme, Thomas created medical records that falsely reported clinical evidence which would justify Medicare coverage for nail debridement even though Thomas did not properly examine the beneficiary and did not find the reported clinical evidence. Thomas also fraudulently submitted nail debridement claims to Medicare when he only trimmed the beneficiary’s toenails, and when he did not provide any service at all to the beneficiary. Thomas employed this scheme to defraud Medicare for at least five years from December 2011 through November 2016."

Toenail trimming is covered though - G0127 - if the patient meets criteria and has a systemic complication. Makes me think these were "nail pain" nails.

The guy in question has a linkedin in page. Amusing, there is a much younger fellowship trained podiatrist albeit in a different area with the exact same name.


1727566596864.png


2017 is essentially when the federal case went through. It appears the guy in question is still practicing, but is cash pay + home visits only. The assisted living facilities stands out to me as probably part of the problem. I don't understand how most nursing home care takes place from a billing perspective. I wondered how they would argue with your notes ie. if your notes say pulses not palpable, but my guess is that he was billing for visits that weren't happening or using the same template on everyone allowing the notes to be discarded.
 
I still don't know what a g code is not have I used in 8 years of practice
 
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G0246+G0247 is a nice little bonus when you tick off all the right boxes.

First it's Medicare only. I guess check other payers' fee schedule, but pretty sure Medicare beneficiaries only. Secondly they have to have LOPS. Thirdly they can't have seen you or any other podiatrist in the past 6 months. This means it will probably never be a typical elderly beneficiary who's often standing outside your office counting down the seconds to day 61 for their nail trim.

Most often it's someone with a psych dx collecting disability making them eligible for Medicare who lets their nails get overgrown. You need to document that you checked their shoes and their webspaces, which you probably should do anyway as part of your diabetic foot exam, and then you trim/debride nails.

But as always make sure your documentation is on point, otherwise it's 🚔
 
MD/DO know exactly what they are doing when they refer these patients to your practice. Here is a tip.

If the patient is 55 years or older and the reason for visit is "ingrown toenail" trust me it is NOT. It's a fungal toenail that the patient can't manage on their own. Typically they want you to cut all their toenails.

Every time I see this on my schedule we call the patient to clarify. It's usually the case and we tell them we are not seeing this. Problem solved.

I agree to not treating them at all and this will alleviate a lot of issues.

I am hospital based. I task my nurse with screening the routine foot care patients on the schedule and making sure they have class findings. If they do not we make them sign an ABN before I see the patient just in case insurance does not cover the foot care.

I loath nail and callus care. Nobody is every satisfied. The patient is upset if its not covered. The patients are needy. Admin gets frustrate if you try and refuse this. You the provider hate it. These are low RVU/reimbursement visits.

The only reason private practice podiatrists want to keep doing it is because all of them are doing some kind of mischievous billing practices to make it profitable for them. If they are not I really don't know how they could continue to survive making this the majority of their practice. Something does not add up.
 
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The only reason private practice podiatrists want to keep doing it is because all of them are doing some kind of mischievous billing practices to make it profitable for them. If they are not I really don't know how they could continue to survive making this the majority of their practice. Something does not add up.
Part of it is that some payers (Medicare advantage plans) cover 6 nail/callus visits per year no matter what. Also, and I've been derided for saying this before, but most patients age 75 and up have a Q modifier. So nailcare can generate modest revenue. [Insert farmer meme: It's not much but it's honest work]
 
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Part of it is that some payers (Medicare advantage plans) cover 6 nail/callus visits per year no matter what. Also, and I've been derided for saying this before, but most patients age 75 and up have a Q modifier. So nailcare can generate modest revenue. [Insert farmer meme: It's not much but it's honest work]
Define modest revenue for that visit please
 
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Part of it is that some payers (Medicare advantage plans) cover 6 nail/callus visits per year no matter what. Also, and I've been derided for saying this before, but most patients age 75 and up have a Q modifier. So nailcare can generate modest revenue. [Insert farmer meme: It's not much but it's honest work]
Wait what? 6 visits?
 
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Define modest revenue for that visit please
200ish and little note to do for a 15min (or less) f/u visit is fine in PP if owner/partner keeping 50 or 60%.

If hospital pod 2.34 wRvu or associate getting 35% of 200ish, it's pretty bad.
 
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Define modest revenue for that visit please
I wish it was 200ish.

In my area, nails are $25-45 depending on payer and which codes are appropriate. Calluses add $60-90 to the encounter. G0246+G0247 is ~$120. Which is nothing to boast over, but it's significantly less time and effort than a typical 11042 or 99213 visit.

In one of my more out-of-the-box moments, I wondered what would happen if I hired a pedicurist and offered FREE nail trims to all patients who came to see me once/year for a "foot screening." The rationale for this is I could keep pts and PCPs satisfied while freeing up my schedule to render actual medical care. I was sure the proceeds from this would offset the lost revs from not billing nails myself.

Well, I took a deep dive into my numbers, looking at how many nailcare followups did I get in a typical week, how many of them needed callus care, how many of them had additional complaints beyond toenails, and how much money it all generated, in comparison to how much demand am I facing from real patients. Bottom line, it wouldn't work. For me, it's too big a chunk of the business to give up.

The question is not "is it a good profit to get 35 or 50 or 60% profit on a nailcare visit?" But rather "do you want the money or not?" I've said before I'd love to tell these patients to F off, every last one of them, but the only thing I would gain for myself is empty space on my schedule. So I grind my way through patients, accepting my modest pittance.
 
I wish it was 200ish.

In my area, nails are $25-45 depending on payer and which codes are appropriate. Calluses add $60-90 to the encounter. G0246+G0247 is ~$120. Which is nothing to boast over, but it's significantly less time and effort than a typical 11042 or 99213 visit.

In one of my more out-of-the-box moments, I wondered what would happen if I hired a pedicurist and offered FREE nail trims to all patients who came to see me once/year for a "foot screening." The rationale for this is I could keep pts and PCPs satisfied while freeing up my schedule to render actual medical care. I was sure the proceeds from this would offset the lost revs from not billing nails myself.

Well, I took a deep dive into my numbers, looking at how many nailcare followups did I get in a typical week, how many of them needed callus care, how many of them had additional complaints beyond toenails, and how much money it all generated, in comparison to how much demand am I facing from real patients. Bottom line, it wouldn't work. For me, it's too big a chunk of the business to give up.

The question is not "is it a good profit to get 35 or 50 or 60% profit on a nailcare visit?" But rather "do you want the money or not?" I've said before I'd love to tell these patients to F off, every last one of them, but the only thing I would gain for myself is empty space on my schedule. So I grind my way through patients, accepting my modest pittance.

A few shekels is better than no shekels. What a sad existence for the private practice podiatry associate.

The biggest diss a patient ever said to me was when their unemployed daughter came with him to get his nails cut. The daughter asked how long was my training and education. She then said “you spent 7 years just to cut nails” this was followed by her and her dad the patient laughing out loud.

I fired the patient after that visit but they were right.
 
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I wish it was 200ish.

In my area, nails are $25-45 depending on payer and which codes are appropriate. Calluses add $60-90 to the encounter. G0246+G0247 is ~$120. Which is nothing to boast over, but it's significantly less time and effort than a typical 11042 or 99213 visit.

In one of my more out-of-the-box moments, I wondered what would happen if I hired a pedicurist and offered FREE nail trims to all patients who came to see me once/year for a "foot screening." The rationale for this is I could keep pts and PCPs satisfied while freeing up my schedule to render actual medical care. I was sure the proceeds from this would offset the lost revs from not billing nails myself.

Well, I took a deep dive into my numbers, looking at how many nailcare followups did I get in a typical week, how many of them needed callus care, how many of them had additional complaints beyond toenails, and how much money it all generated, in comparison to how much demand am I facing from real patients. Bottom line, it wouldn't work. For me, it's too big a chunk of the business to give up.

The question is not "is it a good profit to get 35 or 50 or 60% profit on a nailcare visit?" But rather "do you want the money or not?" I've said before I'd love to tell these patients to F off, every last one of them, but the only thing I would gain for myself is empty space on my schedule. So I grind my way through patients, accepting my modest pittance.
I still need you to explain these g codes to me please. Also, nail care as an associate.....woof
 
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G0246+G0247
I dont do a lot of nails but I will be accepting more - true need patients - to beef up my schedule a bit.
I suppose I should learn more.

I was under impression every 6 months you can bill a diabetic foot exam plus nails/calluses. 99203/99213 + 11721. Thats actually not a bad visit income wise when on RVU for 10 minutes time (about 2 RVU).

But after researching these G codes thats not correct? Every 6 months bill G0246 (eval code) and bill G0247 (routine foot care code) with each visit? That knocks it back down to not worth it territory at 1 RVU total.

Edit: Looks like you answered before I hit save. Thanks.
 
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With G codes when do you use a 11721? Never? Obsolete? Or just used for non diabetics?

Teach me the ways of lobsterism.
 
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So new patient G0245 (New eval) + G0247 (Nails + Callus + wound?).
See back in 3 months. No acute complaints. 11721 + 11055 only. No separate E&M.
See back in 3 months G0246 (F/U 6 month exam) plus G0247 (nails + Callus + wound).

Rinse repeat? If so this G0247 code sucks and is a major reduction in reimbursement.

Also, I refuse to stick my hand in anyones shoes. Gloved or not. Not happening. Nope. Too many crusties in there.
 
I don't use the codes but this may explain part of why they exist.

Imagine a patient comes to you who is diabetic and says they want a diabetic foot exam. I give the coding people credit when they are right - for example - knowing your LCD - but according to the coding people there is no such thing as a diabetic foot exam. So a patient comes to you and says I'm diabetic and I want my feet checked out - they would tell you there is no applicable code for a visit like this.

There is literally no one else in medicine who thinks this way or is freaking out about this, but apparently a visit has to be made for it rather than charging an office visit like everyone else in medicine.

So there you go - we get something like G0246 that is worth - not kidding - $37.
For perspective - A 99212 is worth like $53. A 11720 is $32. A 11721 - $42.

You can then use the G0247 to do nails or calluses if they have any, but you can only do it once every 6 months and you can't bill it if the patient saw you anytime in the prior 6 months. Its worth essentially the same as 11720+11056 when billed in combination with g0246. It doesn't appear to require class qualifiers - just diabetic neuropathy. So they can have palpable pulses etc. They can also have a wound ... so why would you bill a G code when you can bill a wound debridement code.
 
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So new patient G0245 (New eval) + G0247 (Nails + Callus + wound?).
See back in 3 months. No acute complaints. 11721 + 11055 only. No separate E&M.
See back in 3 months G0246 (F/U 6 month exam) plus G0247 (nails + Callus + wound).

Rinse repeat? If so this G0247 code sucks and is a major reduction in reimbursement.

Also, I refuse to stick my hand in anyones shoes. Gloved or not. Not happening. Nope. Too many crusties in there.

No - you can't do any 3 month type care. So the 11721+11055 visit is off the table because you can only see this patient every 6 months. This patient doesn't have to have class findings ie. they just have diabetic neuropathy but they can have palpable pulses

Essentially what this code allows is a person who is diabetic but doesn't have class findings to have some form of nail/callus cutting every 6 months when they wouldn't normally qualify under the class findings system. Historically I suppose this patient would come to you and say "I'm diabetic and have a callus". You would say "you are diabetic, but you aren't truly a Q9 so I can't cut your callus". Now this patient can get their callus cut twice a year if they don't come to you for any other reason.
 
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No - you can't do any 3 month type care. So the 11721+11055 visit is off the table because you can only see this patient every 6 months. This patient doesn't have to have class findings ie. they just have diabetic neuropathy but they can have palpable pulses

Essentially what this code allows is a person who is diabetic but doesn't have class findings to have some form of nail/callus cutting every 6 months when they wouldn't normally qualify under the class findings system. Historically I suppose this patient would come to you and say "I'm diabetic and have a callus". You would say "you are diabetic, but you aren't truly a Q9 so I can't cut your callus". Now this patient can get their callus cut twice a year if they don't come to you for any other reason.
Thank you. Great explanation. I was so confused.

So scrap the G codes and go back to using "pain that limits ambulation" :rofl:
 
Thank you. Great explanation. I was so confused.

So scrap the G codes and go back to using "pain that limits ambulation" :rofl:
There really is no free lunch with any of these podiatry codes.

I was looking into some facility work at theoretically a place that would pay a positive multiplier. The facility rates for podiatry codes are so low that even if you ask for an enormous multiplier the values still aren't really worth anything.
 
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My partner called them the "LOPS codes" so they have to have loss of protective sensation. And they can't have seen you--or any other podiatrist--in the past 6 months. So these codes are almost never billable and even when they are, there might be a better code.

So basically it's typically a shut-in or other mental illness that leads the patient to neglect their basic nailcare for half a year.

Also snowbirds who live half the year in AZ/SC/FL etc and during that time just grow their nails out instead of seeing a dpm there, ugh
 
As long as I'm griping, "shoe evaluation" is another load of 💩. My patients wear crocs/sandals/slip-ons to their appts with me specifically because they're easy to kick on and off for their doctor appt. These are obviously not their every day shoes but I'm supposed to infer a pattern of behavior from this? And what is the incidence of sandal-related ulcers anyway?
 
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I’m fortunate that basically all of my RFC patients in PP meet a Q8 or Q9. I enjoy doing that type of work. It’s easy, the patients are happy, and it’s a nice moment where I can shut my brain off between my other patient visits that deal with more involved pathology.

Granted a majority of my nail patients are over 70. So by then they likely have absent pedal hair, cold feet in an exam room, poor pulses, and with a lot of the DM patients at that age, neuropathy.

If I have a younger patient come in expecting nail care who is generally healthy I give them the “you don’t meet criteria” talk. Don’t think I’ve ever billed nails off of pain other than billing a nail debridement code for a slant back. Never billed a nail avulsion for a slant back.

Regarding the G codes I only use them in patients with normal nails who meet Q code criteria. But most who meet that criteria have awful nails.

The simple way of explaining this to PCPs is that this type of care is only covered if the patient has PAD, neuropathy, or history of amputation. And by neuropathy I don’t mean they tell you they have tingling feet, it’s if it can be proven in an exam and hardly any PCP is taking a patients shoes off these days. I think the days of podiatrists thinking just because a patient is a diabetic they need frequent appointments for this stuff has sailed.
 
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I’m fortunate that basically all of my RFC patients in PP meet a Q8 or Q9. I enjoy doing that type of work. It’s easy, the patients are happy, and it’s a nice moment where I can shut my brain off between my other patient visits that deal with more involved pathology.

Granted a majority of my nail patients are over 70. So by then they likely have absent pedal hair, cold feet in an exam room, poor pulses, and with a lot of the DM patients at that age, neuropathy.

If I have a younger patient come in expecting nail care who is generally healthy I give them the “you don’t meet criteria” talk. Don’t think I’ve ever billed nails off of pain other than billing a nail debridement code for a slant back. Never billed a nail avulsion for a slant back.

The simple way of explaining this to PCPs is that this type of care is only covered if the patient has PAD, neuropathy, or history of amputation. I think the days of podiatrists thinking just because a patient is a diabetic they need frequent appointments for this stuff has sailed.
@BubbaWub you logged in to the wrong account
 
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As long as I'm griping, "shoe evaluation" is another load of 💩. My patients wear crocs/sandals/slip-ons to their appts with me specifically because they're easy to kick on and off for their doctor appt. These are obviously not their every day shoes but I'm supposed to infer a pattern of behavior from this? And what is the incidence of sandal-related ulcers anyway?
They are.
 
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