Podiatry ancillaries

[Homo sapien]

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What do you folks think of all these podiatric things like PRP, lasers and such. I have next to no experience with it but it seems to pop up a lot. My mind is telling me these sorts of things aren't insurance covered for a reason.

 

[deleted1162946]

A lot seem scammy. But private practice docs gotta feed their families

 

[Adam Smasher]

The problem with all these ancillaries, as you put it, is you have to pay a lot of money down and pay it back slowly by charging people who aren't always willing to pay for the services. (A lot like getting a DPM degree to begin with, lol)

Fungus laser: the bottom has fallen out of this market, you can find groupon deals for a few hundo. Instead of buying the laser just refer the patient to the laser owner who's doing it for the cheapest. Also the evidence is dodgy.

MSK pain laser: hard to see a ROI on this, you have to have the right sub-population of tendonitis/fasciitis patients to see a return. Also the evidence is dodgy.

Wart laser: why buy this when you can get a swift machine?

Swift machine: Once again, there are a number of DPMs in my area who already have one so I would lose money on this thing. Evidence for warts is good. They're saying to use it for IPKs which I think is utter hogwash.

Shockwave: Similar problem to MSK pain lasers. Evidence is better.

PRP: I've got reps making a really hard sell on me for this. There's not any money down, just a commitment to buy a certain number of kits per year. Evidence is pretty good for this in tendonitis/fasciitis. Insurance stopped paying because ortho was wasting it on knee arthritis. Now if only I remembered how to draw blood...

Noninvasive vascular testing: I have one, I lost money on it. It's helped some people.

 

[Homo sapien]

The problem with all these ancillaries, as you put it, is you have to pay a lot of money down and pay it back slowly by charging people who aren't always willing to pay for the services. (A lot like getting a DPM degree to begin with, lol)

Fungus laser: the bottom has fallen out of this market, you can find groupon deals for a few hundo. Instead of buying the laser just refer the patient to the laser owner who's doing it for the cheapest. Also the evidence is dodgy.

MSK pain laser: hard to see a ROI on this, you have to have the right sub-population of tendonitis/fasciitis patients to see a return. Also the evidence is dodgy.

Wart laser: why buy this when you can get a swift machine?

Swift machine: Once again, there are a number of DPMs in my area who already have one so I would lose money on this thing. Evidence for warts is good. They're saying to use it for IPKs which I think is utter hogwash.

Shockwave: Similar problem to MSK pain lasers. Evidence is better.

PRP: I've got reps making a really hard sell on me for this. There's not any money down, just a commitment to buy a certain number of kits per year. Evidence is pretty good for this in tendonitis/fasciitis. Insurance stopped paying because ortho was wasting it on knee arthritis. Now if only I remembered how to draw blood...

Noninvasive vascular testing: I have one, I lost money on it. It's helped some people.

This is pretty much how I feel about these things

I didn't even know there was a wart machine

 

[Sole Badguy]

To add to Smasher's list - diagnostic ultrasound can be another add-on to consider. You can do POCUS to confirm some concerns (e.g. tendon pathologies like itis and ruptures, DVT). It can aid local injections. It can also be used in place of or in conjunction with ABI/PVR non-invasive testing if your practice leans more vascular-friendly. Not 100% necessary to succeed, but handy to have and can be billable with the appropriate CPT code.

 

[deleted1162946]

Podiatrists are diagnosing DVTs in office with ultrasounds?

 

[Homo sapien]

Podiatrists are diagnosing DVTs in office with ultrasounds?

I ain't
I wouldn't even try for that

 

[Sole Badguy]

Podiatrists are diagnosing DVTs in office with ultrasounds?

OK yeah that's a stretch - you'd have to scan at least up to the groin for a proper evaluation (same for arterial ultrasound studies), well beyond the tibial tuberosity even in the most podiatry-friendly states. But then again, ABI/PVR is done at some podiatry offices and that does involve testing the entire lower extremity...so IDK

In any case, POCUS may be less useful than advertised...oops! 🙃

 

[Podstar]

Just say no to these.

 

[Feli]

To add to Smasher's list - diagnostic ultrasound can be another add-on to consider. You can do POCUS to confirm some concerns (e.g. tendon pathologies like itis and ruptures, DVT). It can aid local injections. It can also be used in place of or in conjunction with ABI/PVR non-invasive testing if your practice leans more vascular-friendly. Not 100% necessary to succeed, but handy to have and can be billable with the appropriate CPT code.

My ultra probe paid for itself within a year or so. It's a good tool to have. Not too expensive, insurance covered, not shady or too high charge when pts see their EOBs.
I very seldom do injects with it, but it gives you good viewing. I like it for Achilles, PF, peroneals, soft tissue masses, etc. A lot of pods use butterfly, I did Philips Lumify.

If you figure it's roughly a $5k buy for the pocus (and a bit for a basic tablet and stand to go with it), it is paid for in about 120 exams or 40 injects (or combo of such). That is only using it once every clinic day or two for a year... all profit after that. Perhaps replace tablet every few years?

Even for hospital or group employ pods, handheld ultra is a buy you should want the dept/facility to make for you. Good info and easy RVUs.... basically a "quick MRI" option for me (and often still order MRI anyways). It is basically standard equipment for ER, OBs, some cardio, etc these days to have a couple pocus for the dept - or even one for each doc, so it won't be a big deal to most hospitals to get one for podiatry office.

(I don't the handheld ultra for any vasc stuff or DVT, lol.... even if you wanted to, absolutely send for asap duplex dopp)

...I just have that pocus and OTC stuff. You can do fairly well with that, E&Ms and procedures, surgery, and basic DME (boots, ankle braces, NS, etc).
I could see shockwave if a larger group of DPMs or orthos that'll all send pts for it, but it's otherwise pretty hard to get the volume for recouping the cost of the truly high quality units (and doc or MA time of doing all the treatments).
Office DM shoes can be ok if you have the space anyways, but shoes start to take up a LOT of room and need MCR dme paperwork... and will draw audits.

The rest of things mentioned are grifter junk imo (swift, nail lasers, wound "grafts," prp or fancy injects, etc etc). They "solve" problems that don't exist and/or can't be solved with those things either. Shameful for all of us.
Oh, and don't forget the common podiatry supergroup scams of owning the toenail histo and ENFDs lab, over-test nearly everyone for ABI etc, own the vasc lab, own a "custom" dme shop (which strangely gives braces that look a lot like prefab!), maybe own PT place, etc.

 

[MicroPod]

I use ultrasound a lot in my office. The hospital had bought an ultrasound machine for the urogyn doctor but he never used it so I asked if I could have it and they agreed. Not sure how much limited ultrasound exams are reimbursing but I’m sure the hospital is glad someone is using it.

Patients seem to like it cause you can show them in how thick/inflamed their PF or Achilles in real time. Also helps me decide where to inject.

I’m interested in PRP but not sure how to get into doing them in a hospital system.

 

[heybrother]

1. I bought a used Zimmer radial shockwave. It was a steal until it turned out the handpiece was broken. Had to buy a new one. They are quite pricey. Its honestly a really nice tool to have, but its not covered by insurance. I've made some patients very happy, but I haven't broken even yet. One of the problems with ancillaries is - how much do you want to talk about something that most people aren't going to want to do ie. doctors who try to sell every patient custom orthotics. If you spend a minute telling every patient at their first plantar fasciitis visit about shockwave you are probably wasting your breath. I historically have used shockwave for chronic problems that won't go away - people who don't respond to injections, physical therapy, surgery, scar tissue, etc. I've met a large number of patients who've done shockwave elsewhere and many of them are offered shockwave as a take or leave it option with nothing else offered on the first visit. A patient once showed me an lateral with a miniscule detached Achilles spur. The podiatrist told them that the spur was ruptured and they must do Achilles shockwave for $1000 to heal it. Very shady. The shockwave handle I purchased comes with a warranty up to like 2 million pulses or something like that. I initially had an irrational fear that I would reach the pulse count without making my money back. What's kind of funny to me about shockwave is that if you aren't in pain - even in the highest setting doesn't really feel like anything. However, if you are in pain even the lowest slowest setting can be painful - and I'm mostly of the opinion it doesn't work unless the patient perceives the shockwave as unpleasant. A word of caution. Hearing protection. I was having some shoulder pain and used the shockwave on it. Lowest, slowest setting. Didn't seem painful to my ears at the time. It worked, yay, but I experienced 3 days of hyperacusis which is miserable. If you purchase a shockwave you need to have a staffer who is invested in it. Ideally its the same person who consistently does it and they need to like it. I'm not saying they should sell it to people, but their enthusiasm before and during can be helpful.

2. I had a great convo with Feli about ultrasound - got a Lumify for like $3600 on Ebay. Hilariously, brand new in the box. Cheapest Android pad at Costco was $200 and Feli told me what stand to buy. I had no prior ultrasound experience so I've been watching videos. Its honestly different and I'm really enjoying learning and exploring something new. If you are comparing ancillaries then ultrasound really is going to shine because - you can bill for it. There's two tricky things to it - the first is that you have to engage in the effort of using it. So - you have to go get it, type in the patient information, wheel it in etc. There's no doubt - its easier to just walk in and stick the patient. It definitely takes some getting use to reading the ultrasound and there's a game of hands related to how you hold a syringe and a ultrasound probe and have someone spray cold spray. There's also something to be said for the idea of - does the ultrasound change your management or treatment plan and I think the answer is also going to be partially shaped by how well you read the images and what you can intuit from them. It is nice if there is other relevant pathology coming into your office that would benefit from being looked at. I concur though that patients really seem to enjoy seeing ultrasound. The classic pro ultrasound line is "I normally tell patients I can't see soft tissues, but with ultrasound you can". The reimbursement is surprisingly good. If x-ray paid like ultrasound and all injections paid like ultrasound guided then our finances would be greatly improved.

*I'm strongly under the impression that ultrasound guided joint injections are paid absurdly by Medicare to hospitals under OPPS. I swear I saw a table in a prior post I made showing a $600 reimbursement for like a large ultrasound guided injection.

3. I carry 3 functional orthotic prefabs ie. custom knock-offs for $65 that I believe I buy for $15. I almost never have to make custom orthotics. I think I made 2-3 pairs last year. People buy these and then come back and buy multiples and different kinds. I've griped in the past about how much money hospital pods make on E&M compared to private practice, but if you have a solid no effort product like an orthotic that people actually want to buy from you the the math starts to look at alot more favorable.

4. A lot of ancillaries involve trying to make money on a problem that is otherwise not enjoyable to treat. ie. nail laser, vascular tests.

5. I have no idea how much the in office vascular tests cost to implement or what you recoup, but people I've met who were "Happy" about them were often essentially testing every diabetic/smoker with Medicare every year. People in IPED were literally putting treadmills in their office so they could justify higher level studies on vascular testing because exercise induced testing counted as multiple levels or something like that. Offering some sort of vascular testing in a podiatrist's office seems like good value for patients, but my suspicion is the cost to implement it for the practice is too high unless you actively seek patients to perform it on. Capturing revenue and offering services is great, but building relationships with cardiologists is very important.

6. I remain a die hard cantharone fan so wart microwaves can suck it. Had a 15 year old girl actually ask for a second cantharone application today for a wart on her heel. She wants it gone. Her insurance paid $181 2 weeks ago, and I guess her mom will be paying $181 today. Why would I pay tens of thousands of dollars when a $100 bottle mints dinero. I can't even tell you how many 17110s I've gotten out of 1 bottle.

7. My office owns an MLS laser. I don't think I've ever used it. There's a sign in the lobby and every patient who asks about it wants it for a non-foot body part. My receptionist told me once that she thought it was 50% effective. LoL. My staffer who did shockwave for me also did people's laser sessions for my partner and she thought it was absolute garbage and never worked. "If it works, why do the patient's have to keep coming back so much".

 

[Adam Smasher]

I can't even tell you how many 17110s I've gotten out of 1 bottle.

I did an experiment where I put a piece of tape on a couple of bottles (N=2) and marked a tick mark each time I used it.

The answer is 16.

 

[HardRoadPaved]

"If it works, why do the patient's have to keep coming back so much".

 

[Bluecollarmed]

6. I remain a die hard cantharone fan so wart microwaves can suck it. Had a 15 year old girl actually ask for a second cantharone application today for a wart on her heel. She wants it gone. Her insurance paid $181 2 weeks ago, and I guess her mom will be paying $181 today. Why would I pay tens of thousands of dollars when a $100 bottle mints dinero. I can't even tell you how many 17110s I've gotten out of 1 bottle.

How are you guys going about getting cantharidin? My hospital just did a deep dive to get some and since we can't buy the Canadian version (Cantharone), they paid for one pack of Ycanth....at $3600. That includes 6 single use vials. I guess they looked into the insurances we cover and were okay with that price but I can't imagine that makes sense from a dollars and cents standpoint. My hospital is very anti multiuse anything so a bottle, like we used in every clinic in residency, is a flat no-go even if we could find it.

 

[heybrother]

How are you guys going about getting cantharidin? My hospital just did a deep dive to get some and since we can't buy the Canadian version (Cantharone), they paid for one pack of Ycanth....at $3600. That includes 6 single use vials. I guess they looked into the insurances we cover and were okay with that price but I can't imagine that makes sense from a dollars and cents standpoint. My hospital is very anti multiuse anything so a bottle, like we used in every clinic in residency, is a flat no-go even if we could find it.

There's no good answer on this right now.

1. YCANTH isn't going to work for plantar foot warts. I know this because during the pandemic I was able to acquire a bottle of "regular strength cantharone" from Canada and it worked zero times. The podophyllin is clearly essential for the reaction.
2. Interestingly - you can buy podophyllin (it was listed places when I looked online previously). General surgeons may use it for things.. I personally wonder if it is actually the wart big hitter. The problem is that it comes in a concentration that is higher than we use for warts. If you worked for a hospital you might be able to get your pharmacist to dilute/compound something with it for you, but the instructions on podophyllin to my memory recommend against use on bleeding lesions. Small aside - when I used cantharone regular strength - I never saw the chalky white build-up appearance that you get when you roll a wooden stick on the skin after you've applied Cantharone plus. I don't know if that's the salicylic acid or the podo.
3. It goes without saying that YCANTH are exploitative douchebags destroying the healthcare system.
4. Affordable cantharone is always going to be multi-use so that's going to work against you.
5. I've got a compounding pharmacy in the works - they tell me my shipment is coming very soon / being manufactured but it hasn't been delivered yet. If you read YCANTH's website they are clearly going out of their way to deny other pharmacies access to cantharidin source materials to prevent people from competing.
6. And I'm tweaking too cause I'm on my last bottle. I accidentally spilled a bottle months ago. Refrained from screaming the F-word in front of the patient.

 

[shadesofgrey]

How are you guys going about getting cantharidin? My hospital just did a deep dive to get some and since we can't buy the Canadian version (Cantharone), they paid for one pack of Ycanth....at $3600. That includes 6 single use vials. I guess they looked into the insurances we cover and were okay with that price but I can't imagine that makes sense from a dollars and cents standpoint. My hospital is very anti multiuse anything so a bottle, like we used in every clinic in residency, is a flat no-go even if we could find it.

Called a bunch of compounding pharmacies. The trick is finding one that will send it to the office rather than to the patient.

 

[heybrother]

Called a bunch of compounding pharmacies. The trick is finding one that will send it to the office rather than to the patient.

I've heard this before and its beyond dumb. Part of cantharidin's safety profile was that it was only safe for application by a physician.

 

[Feli]

Called a bunch of compounding pharmacies. The trick is finding one that will send it to the office rather than to the patient.

Yes, you will do fine, particularly if you're buying other stuff from the pharma.

For me, cantharidin is used in <5% of warts... it causes pain often, hematoma freaks them out, loses patients +/- bad reviews, even gets bacteria infected wound sometimes, just not necessary. I use cantharidin less and less the longer I've been out in practice.

Salicylic crm + proper debride of callus/epidermis works for 95% of verruca (surgery excis for <1%).

 

[shadesofgrey]

Yes, you will do fine, particularly if you're buying other stuff from the pharma.

For me, cantharidin is used in <5% of warts... it causes pain often, hematoma freaks them out, loses patients +/- bad reviews, even gets bacteria infected wound sometimes, just not necessary. I use cantharidin less and less the longer I've been out in practice.

Salicylic crm + proper debride of callus/epidermis works for 95% of verruca (surgery excis for <1%).

How often do you treat them in the office? We have 50% sal cream but I just don't seem to get enough improvement with Sal alone.

The longer I've been practicing, the more cavalier I've become with cantharidin. I avoid on PVD and with caution on diabetics. I typically will apply cantharidin every 2-4 weeks in office (left in place up to 24 hours) and then have them apply sal acid in between office debridements. If that doesn't work, will excise or offer fancy Swift. Only had one really bad reaction, but the patient left the cantharidin on for like 4 days.

 

[Flip-flop-flerpity]

Yes, you will do fine, particularly if you're buying other stuff from the pharma.

For me, cantharidin is used in <5% of warts... it causes pain often, hematoma freaks them out, loses patients +/- bad reviews, even gets bacteria infected wound sometimes, just not necessary. I use cantharidin less and less the longer I've been out in practice.

Salicylic crm + proper debride of callus/epidermis works for 95% of verruca (surgery excis for <1%).

Respectfully disagree here. 2-3 cantharone plus applications gets nearly every wart. Blisters maybe 10% of the time, never had a patient complain of pain with it. It's a shame we can't get it anymore.

 

[Feli]

How often do you treat them in the office? We have 50% sal cream but I just don't seem to get enough improvement with Sal alone.

The longer I've been practicing, the more cavalier I've become with cantharidin. I avoid on PVD and with caution on diabetics. I typically will apply cantharidin every 2-4 weeks in office (left in place up to 24 hours) and then have them apply sal acid in between office debridements. If that doesn't work, will excise or offer fancy Swift. Only had one really bad reaction, but the patient left the cantharidin on for like 4 days.

I do q2-3wks usually... but I'm super busy. We sell little jars of sal 30% with instructions for them to use at home (clean area, pumice/emery aggressive, apply under band aids +/- wrap q1-2wks for 1-2d per app). So if they start doing that, then I see them just maybe q6wks or so. Warts are good visits, but I just have too many NPs.

No matter what you use, the debridement then occlusion of the sal is really the main thing (and get them to leave sal on for about 24hr-72hrs max). Pharmacists will tell you this also: 20% vs 30% vs 40% vs 50% etc sal acid crm doesn't really matter... prep well and occlude well, keep treating.

 

[Feli]

Respectfully disagree here. 2-3 cantharone plus applications gets nearly every wart. Blisters maybe 10% of the time, never had a patient complain of pain with it. It's a shame we can't get it anymore.

You can get it (if you're an owner). We just said that above.... talk to compound pharmas.

Patients with pain won't complain... they just cancel or no-show their follow up. 🙂
A lot of the patients who "got better" really went to your competitors (for almost any pathology). Source: a few associates in/near my area use canth on warts first visit, and I see them. (I use it infrequently - and pretty much never first visit... just not needed).

 

[Homo sapien]

Respectfully disagree here. 2-3 cantharone plus applications gets nearly every wart. Blisters maybe 10% of the time, never had a patient complain of pain with it. It's a shame we can't get it anymore.

I've used adapalene on mine post debridement and it seems to work. No patient side effects

 

[DYK343]

Fluorouracil for nearly 100% of my warts.
Debride wart aggressively.
Apply twice a day under duct tape.
100% have resolved (or if they didnt they went elsewhere but seriously this stuff works).

If not covered insurance GoodRx is usually <$50.

Hospital wont let me use cantharone since its not FDA approved.

 

[MicroPod]

Fluorouracil for nearly 100% of my warts.
Debride wart aggressively.
Apply twice a day under duct tape.
100% have resolved (or if they didnt they went elsewhere but seriously this stuff works).

If not covered insurance GoodRx is usually <$50.

Hospital wont let me use cantharone since its not FDA approved.

I have been doing this as well with good results so far. Was wondering what procedure code you bill for this type of encounter?

 

[HardRoadPaved]

Fluorouracil for nearly 100% of my warts.
Debride wart aggressively.
Apply twice a day under duct tape.

I do this. Bleomycin for failures aka non compliance

 

[DYK343]

I have been doing this as well with good results so far. Was wondering what procedure code you bill for this type of encounter?

99203/99213
Its not a procedure.

 

[DYK343]

Bleomycin for failures aka non compliance

Derm referral and bye for me.
I hate warts.

 

[heybrother]

Hospital and PP docs will have differing financial incentives.

17110 is 0.7 work RVUs while 99213 is 1.3 work RVUs.
The most common commercial insurance where I am pays $180 for a 17110 and $76 for a 99213.

 

[air bud]

I have been doing this as well with good results so far. Was wondering what procedure code you bill for this type of encounter?

I used to work for a hospital that had similar approach since it was an FDA approved.... Good news you can't buy it in the United States anymore so we don't have to worry about it. Although if the dread pirate Roberts gets out maybe we can still find a way to get it.