Podiometric Referral Patterns

[CutsWithFury]

Why the hell do PCPs refer podiatrists patients with Chronic gout? It’s called medical management Dr. PCP MD. What am I going to offer the patient?

Why the hell do PCPS refer podiatrists patients with general neuropathic pain? I’m not talking neuroma or tarsal tunnel. I’m talking about chronic neuropathic pain. Why can’t their PCP order an EMG and medically manage the patient? If they can’t do that then why can’t they refer to neurology?

Why does it take a podiatry visit to put that all together to make that happen?

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[GreenHousePub]

I've gotten some good fusions out of them. You can pass on them, I'll take em gladly.

 

[air bud]

Why the hell do PCPs refer podiatrists patients with Chronic gout? It’s called medical management Dr. PCP MD. What am I going to offer the patient?

Why the hell do PCPS refer podiatrists patients with general neuropathic pain? I’m not talking neuroma or tarsal tunnel. I’m talking about chronic neuropathic pain. Why can’t their PCP order an EMG and medically manage the patient? If they can’t do that then why can’t they refer to neurology?

Why does it take a podiatry visit to put that all together to make that happen?

foot pain? go see this guy. i guess chronic is bad, but acute gout sure I will take that level 3 and gladly put them on prednisone (dose pack, I don't bother with indomethacin or colchine.

neuropathy? I know you don't put people on gabapentin, but I think it is pretty easy with minimal risk. bring them back in 3-4 weeks and adjust dose if necessary.

Not everyone is in the position to be turning away patients. If it is a foot/ankle I don't care I want it. I don't want to put any doubt in any referring doctors minda bout what I do or don't do. Send them my way, I will sort out the bodies on my own.

 

[CutsWithFury]

I've gotten some good fusions out of them. You can pass on them, I'll take em gladly.

Why can’t they be medically managed appropriately? You fuse one joint and they are still hurting because they are grossly out of control with their gout.

 

[dtrack22]

Found out a company I’m contracting with pays just shy of 200% Medicare. That means the allowable for a 99203 is $203 and a distal osteotomy bunion pays $1754.

I’m gonna medically manage anything I can, those are level 4 visits. $204 established patient visits with one of my payers. In 2021 those patients can get you a level 4 new patient exam...that’s a $315 for me to order labs and write an Rx

 

[CutsWithFury]

Found out a company I’m contracting with pays just shy of 200% Medicare. That means the allowable for a 99203 is $203 and a distal osteotomy bunion pays $1754.

I’m gonna medically manage anything I can, those are level 4 visits. $204 established patient visits with one of my payers. In 2021 those patients can get you a level 4 new patient exam...that’s a $315 for me to order labs and write an Rx

He's all pumped because his private practice is finally up and running. Enjoy medically managing neuropathy and gout. You can have my referrals. I will send them cross country to you

 

[Scrantonicity]

I honestly don't see this as a bad thing...I mean, they're still seeing their PCP, right? It's not like they dumped the patient on you never to be seen again. Why not have another pair of eyes look at them when they say "my foot hurts?" How many times do PCP's even have patients take off their shoes? I'm gonna go with...almost never... so when the patient can go back and say "well the podiatrist thinks I should go on allopurinol...or a fluid pill...or gabapentin."--that may prompt them to finally say, "OK take off your shoes and lemme look at this."

These are new patient visits--only a hospital employed podiatrist would complain about this lol

 

[heybrother]

Man. Dtrack's associates are going to be pumped to get 30% of these tremendous sums

A few thoughts on gout/experiences
-the PCP was thrown off by the non-diagnostic urate even though they appropriately treated the gout
-they went to an urgent care who said - follow this with someone
-Its essentially impossible to get in with a rheumatologist
-the urgent care/PCP gave an incredibly short course of whatever they prescribed and the patient needed longer duration therapy
-the patient has had recurrent episodes and wants an injection
-the PCP gave them allopurinol and nothing else and the patient is still in misery

And the most common thing of all - the problem is not gout - its something else ie. capsulitis, arthritis, whatever and the patient is complaining about how awful indomethacin is.

Neuropathy - most patients don't want a NC/EMG in my experience. Does anyone regularly order labs?
ie. B12, A1C, ESR, ANA, serum protein electrophoresis

Most patients who come to me for neuropathy in general have already exhausted most medication therapy.

 

[msuDPM]

Why the hell do PCPs refer podiatrists patients with Chronic gout? It’s called medical management Dr. PCP MD. What am I going to offer the patient?

Why the hell do PCPS refer podiatrists patients with general neuropathic pain? I’m not talking neuroma or tarsal tunnel. I’m talking about chronic neuropathic pain. Why can’t their PCP order an EMG and medically manage the patient? If they can’t do that then why can’t they refer to neurology?

Why does it take a podiatry visit to put that all together to make that happen?

I can get behind this movement. I have less of an issue with Gout, most gout I see is acute and I'm injecting/tapping (which isn't a lot).

Neuropathy referrals kill me. Especially when it is a known entity and the pt is already on Gaba/Lyrica/cymbalta. I have told my staff to stop putting it on my schedule. They still occasionally slip through the cracks. Just yesterday I had a new patient "feet get hot and cold, go numb", pcp previously got ABIs, checked a1c, thyroid panel, vit b12 etc...what do you want me to do with that?!

Just plain old onychmycosis is the other one that gets me. Patient wanders in off the street with nail fungus that they want treated, no problem. Patient goes to their pcp to see about their nail fungus and pcp refers them to me...why?! Can you not write for 12 weeks of Lamisil?

 

[CutsWithFury]

I can get behind this movement. I have less of an issue with Gout, most gout I see is acute and I'm injecting/tapping (which isn't a lot).

Neuropathy referrals kill me. Especially when it is a known entity and the pt is already on Gaba/Lyrica/cymbalta. I have told my staff to stop putting it on my schedule. They still occasionally slip through the cracks. Just yesterday I had a new patient "feet get hot and cold, go numb", pcp previously got ABIs, checked a1c, thyroid panel, vit b12 etc...what do you want me to do with that?!

Just plain old onychmycosis is the other one that gets me. Patient wanders in off the street with nail fungus that they want treated, no problem. Patient goes to their pcp to see about their nail fungus and pcp refers them to me...why?! Can you not write for 12 weeks of Lamisil?

This. This is my twin. Let’s have beers some time

 

[dtrack22]

Dtrack's associates are going to be pumped to get 30% of these tremendous sums

25%...actually no associates. No new grads. Equity or managerial partnership only. Probably not even that. You aren’t going to sit back and make money purely off of associates without working a ton yourself until you have 7-8 of em and I’m not in an area that would support that. Revenue from 1 associate isn’t worth the headache. At all. I’ll probably end up selling my practice to the hospital in a few years unless I can get two orthos to partner with me and purchase the current owners building and assets (MRI, ASC, rent from Path lab).

 

[G0dFather]

foot pain? go see this guy. i guess chronic is bad, but acute gout sure I will take that level 3 and gladly put them on prednisone (dose pack, I don't bother with indomethacin or colchine.

neuropathy? I know you don't put people on gabapentin, but I think it is pretty easy with minimal risk. bring them back in 3-4 weeks and adjust dose if necessary.

Nice man thats why i do for gout also along with injections xrays etc... i put people on 300 BID neurontin and go up from there .... is that how you start them off? as for minimal risk ... i guess but it can make people really drowsy tho

 

[G0dFather]

Neuropathy - most patients don't want a NC/EMG in my experience. Does anyone regularly order labs?
ie. B12, A1C, ESR, ANA, serum protein electrophoresis

what do you look for when ordering these ?

 

[G0dFather]

Found out a company I’m contracting with pays just shy of 200% Medicare. That means the allowable for a 99203 is $203 and a distal osteotomy bunion pays $1754.

I’m gonna medically manage anything I can, those are level 4 visits. $204 established patient visits with one of my payers. In 2021 those patients can get you a level 4 new patient exam...that’s a $315 for me to order labs and write an Rx

This is how i felt when i found out that medicare allows 130+ for debriding one callus and one mycotic nail LOL

 

[heybrother]

what do you look for when ordering these ?

That particular list is part of a what I believe is a templated note my local neurologist sends out along with NC/EMG tests. Vitamin deficiency/pernicious anemia, vasculitic neuropathy/autoimmune, multiple myeloma. Obviously it would be nice to gather more history to shape your testing.

"He is an individual who would benefit from serologic evaluation of common causes of neuropathy including checking vitamin B12 level, hemoglobin A1C, ESR, ANA, and serum protein electrophoresis."

 

[G0dFather]

That particular list is part of a what I believe is a templated note my local neurologist sends out along with NC/EMG tests. Vitamin deficiency/pernicious anemia, vasculitic neuropathy/autoimmune, multiple myeloma. Obviously it would be nice to gather more history to shape your testing.

"He is an individual who would benefit from serologic evaluation of common causes of neuropathy including checking vitamin B12 level, hemoglobin A1C, ESR, ANA, and serum protein electrophoresis."

very nice though i like this .. could do great service to pt if you catch something like this ... great topic guys !

 

[air bud]

Nice man thats why i do for gout also along with injections xrays etc... i put people on 300 BID neurontin and go up from there .... is that how you start them off? as for minimal risk ... i guess but it can make people really drowsy tho

you are getting xrays on a gout patient? and injecting acute gout? Man, I need to get in the PP mindset I have never ordered an xray for acute gout. I already know what it is.

I mean, am I doing this wrong? I will soon be in PP (along with hospital gig). Am I supposed to get an xray on every patient? I rarely get xrays at my hospital because its a pain in the ass. Even when someone comes in for a bunion or something, I tell them what to (wider shoes, OTC orthotics that won't solve the bunion but might make the foot feel better) and then if still bothering them come back, we will take xrays and talk about next step. I just have a hard time ordering xrays when they won't change the course of treatement for that visit. Of course some of this disdain for the xray process is that the patient often gets charged a co-pay for the hospital registration (I am employed by the medical group technically) and then has to pay for a radiologist to read the xray even though they read it after I have already seen the patient.

 

[air bud]

That particular list is part of a what I believe is a templated note my local neurologist sends out along with NC/EMG tests. Vitamin deficiency/pernicious anemia, vasculitic neuropathy/autoimmune, multiple myeloma. Obviously it would be nice to gather more history to shape your testing.

"He is an individual who would benefit from serologic evaluation of common causes of neuropathy including checking vitamin B12 level, hemoglobin A1C, ESR, ANA, and serum protein electrophoresis."

Yeah, I see zero reason for a podiatrist to order these. But I get mad at my referring neurologist when I see he orders every lab in the book when I refer him these idiopathic neuropathy patients...but I guess you are tyring to find the reason why they have it.

Also, these are expensive tests (ana, anti-smith etc). Let a specialist order them.

 

[CutsWithFury]

you are getting xrays on a gout patient? and injecting acute gout? Man, I need to get in the PP mindset I have never ordered an xray for acute gout. I already know what it is.

I mean, am I doing this wrong? I will soon be in PP (along with hospital gig). Am I supposed to get an xray on every patient? I rarely get xrays at my hospital because its a pain in the ass. Even when someone comes in for a bunion or something, I tell them what to (wider shoes, OTC orthotics that won't solve the bunion but might make the foot feel better) and then if still bothering them come back, we will take xrays and talk about next step. I just have a hard time ordering xrays when they won't change the course of treatement for that visit. Of course some of this disdain for the xray process is that the patient often gets charged a co-pay for the hospital registration (I am employed by the medical group technically) and then has to pay for a radiologist to read the xray even though they read it after I have already seen the patient.

If you aren’t ordering x-rays on every foot pain patient then you are dumb.

 

[shadesofgrey]

you are getting xrays on a gout patient? and injecting acute gout? Man, I need to get in the PP mindset I have never ordered an xray for acute gout. I already know what it is.

I mean, am I doing this wrong? I will soon be in PP (along with hospital gig). Am I supposed to get an xray on every patient? I rarely get xrays at my hospital because its a pain in the ass. Even when someone comes in for a bunion or something, I tell them what to (wider shoes, OTC orthotics that won't solve the bunion but might make the foot feel better) and then if still bothering them come back, we will take xrays and talk about next step. I just have a hard time ordering xrays when they won't change the course of treatement for that visit. Of course some of this disdain for the xray process is that the patient often gets charged a co-pay for the hospital registration (I am employed by the medical group technically) and then has to pay for a radiologist to read the xray even though they read it after I have already seen the patient.

During residency I would moonlight at a attending's medicaid clinic and he required every new patient got b/l xrays. I mean every single patient, you are a diabetic here for nail care? Great, got to make sure you dont have charcot. Sketchy...

 

[CutsWithFury]

During residency I would moonlight at a attending's medicaid clinic and he required every new patient got b/l xrays. I mean every single patient, you are a diabetic here for nail care? Great, got to make sure you dont have charcot. Sketchy...

diabetic foot care patients. yes def sketchy. But if the patient makes an appointment for "foot or ankle pain" they are getting x-rays prior to me seeing them to keep clinic smooth and fast.

 

[heybrother]

Yeah, I see zero reason for a podiatrist to order these. But I get mad at my referring neurologist when I see he orders every lab in the book when I refer him these idiopathic neuropathy patients...but I guess you are tyring to find the reason why they have it.

Also, these are expensive tests (ana, anti-smith etc). Let a specialist order them.

A lot of me agrees with you. I seldom order labs at all. I don't like the idea of blind tests - if you go online and start looking for potential lab tests to perform the sky is the limit. HIV causes neuropathy, but it obviously isn't right to just order that. The same could be said for a lot of the rheum tests - if you are ordering very specific tests ie. anti-DS or centromeres or whatever you are probably wasting the patient's time and money. Also, a lot of those conditions may have a neuropathy component, but it could easily be the "least" part of the condition. You could be testing for something associated with a condition where the patient should be sick as hell - not complaining about their toes being numb in bed at night.

I seldom order labs at all and there's a part of me that feels sometimes its too easy in this profession to just run away from things. I don't want to manage a lot of these things, but we're also potentially smarter than we give ourselves credit for. Awhile back I had a patient who needed a triple who told me his mom died at like 28 from an unprovoked blood clot/PE. My attending sent them to their PCP to be tested for coagulation issues and their PA ordered all the wrong tests. Like didn't order a single test for coagulation. I have zero interest in managing warfarin, but we were perfectly capable of ordering the right tests (would we be able to interpret them is another question!).

Ridiculous side note - the washingtonpost runs a "medical mystery" series and I swear every patient with a weird problem has seen a podiatrist at some point where they ultimately have a weirdo condition, but the podiatrist tells them they have flatfeet. I don't think I would have diagnosed this person, but I'd like to improve on trying to be just a hammer-nail doctor. If I could find a reasonable set of labs that aren't overly expensive but capture something we didn't see coming, I'd be interested in broadening my horizon. That said, yeah, I have zero interest in managing neuropathy and my community is well served with neurologists and pain specialists. My residency hospital on the other hand had -zero- neurologists. They put in their visa time and moved to greener pastures.

https://www.washingtonpost.com/health/medical-mysteries/his-anemia-was-followed-by-searing-foot-pain-seventeen-years-later-in-precarious-shape-a-stellar-athlete-learned-what-was-wrong/2020/06/26/1acfdebe-95ec-11ea-82b4-c8db161ff6e5_story.html

I'd like to work on trying to do the right thing for people. However, I also get when people refer because they recognize the 1% of complications from mostly benign things are going to ruin their day. I prescribe terbinafine and its definitely going to screw my clinic up if someone walks in with liver failure. A few weeks ago I did surgery on someone and they got hydrocodone. They got stuffed up and instead of calling me - they called their PCP. He told the patient that since he didn't write the pain medication he wasn't going to do anything to help them. If other physicians in your community will help you, it obviously makes practicing easier.

 

[NatCh]

you are getting xrays on a gout patient? and injecting acute gout? Man, I need to get in the PP mindset I have never ordered an xray for acute gout. I already know what it is.

I mean, am I doing this wrong? I will soon be in PP (along with hospital gig). Am I supposed to get an xray on every patient? I rarely get xrays at my hospital because its a pain in the ass. Even when someone comes in for a bunion or something, I tell them what to (wider shoes, OTC orthotics that won't solve the bunion but might make the foot feel better) and then if still bothering them come back, we will take xrays and talk about next step. I just have a hard time ordering xrays when they won't change the course of treatement for that visit. Of course some of this disdain for the xray process is that the patient often gets charged a co-pay for the hospital registration (I am employed by the medical group technically) and then has to pay for a radiologist to read the xray even though they read it after I have already seen the patient.

You'll have your own in-office x-ray setup, I assume? There's no Radiology fee with those so you won't have to worry about that aspect any longer. Any patient whose chief complaint includes pain, joint pain, generalized musculoskeletal pain, will expect an x-ray. Even if you're convinced that you know what the problem is (e.g. neuroma, PF) if you don't resolve the problem within one visit they will criticize you for not having gotten an x-ray even if it wouldn't have affected the treatment course. Getting an x-ray simply to placate the patient isn't necessarily good medicine but it could keep them in your practice long enough for you to fix their problem rather than driving them to another provider to finish what you started, which is just reality of private practice in the USA where people feel entitled to Presidential level care. If they have MSK pain then I think that x-ray is justifiable though.

Regarding referrals for gout, I've found on numerous occasion that even though someone in the past told the patient that they have gout, their actual problem was a bunion or hallux rigidus. Someone simply thought "big toe joint pain -- probably gout" when the problem was something else. With chronic gout even if the patient is medically managed by the PCP you might be able to treat specific joint pain. Maybe Cuts With Fury is getting referrals for medical management of chronic gout (I'm not doubting him) but I can't recall ever being sent a patient for medical management of chronic gout. The PCP or Rheumatologist already got that covered and they sent the patient to me to address focal foot pain.

I'll estimate that less than 5% of the referrals I've seen with a gout diagnosis have ever had a joint aspiration. An urgent care doc or PCP in the past saw a red, painful big toe joint and diagnosed gout either by appearances alone or by high uric acid. If it's acute then anesthetize the joint (patient gets immediate pain relief and will love you for it), collect fluid for a crystal exam, then inject steroid for rapid relief. Prescribe colchicine or NSAIDS too if they haven't gotten it already.

I suspect that referrals for neuropathy are expecting you to prescribe protective shoes and/or orthotics. PCPs know that diabetic neuropathy can lead to limb loss so they're trying to do everything possible for the patient (or maybe to share liability, who knows). Just for the hell of it I googled "diabetes neuropathy" and WebMD states, "Ask your doctor if you should go to a podiatrist." If a patient were to ask their doctor if they should go to a podiatrist how many doctors would say no?

I've always appreciated the difference in viewpoint between salaried providers ("What a bulls*** referral -- they could've done this themselves.") to a private practice provider who does piece work ("Send them my way -- easy money.").

 

[619]

I've always appreciated the difference in viewpoint between salaried providers ("What a bulls*** referral -- they could've done this themselves.") to a private practice provider who does piece work ("Send them my way -- easy money.").

I like your last sentence. I have said it before, those who work for a Hospital group don't have to worry about referrals/marketing. They can pick and choose. However in PP, you want your PCP to send you "all and any foot and ankle problem". You the podiatrist will be the one to examine the patient and make the appropriate referral when necessary.

An example, had a patient sent to me for a painful ulcer. I diagnosed it immediately as an Ischemic pain. Made Vascular referral, they found popliteal occlusion, did re-vascularization and ulcer healed and pain went away without me doing much. The PCP will not know to refer patient to Vascular. The patient thanked me endlessly even though I did not do much.

How many times have we seen a patient for gangrenous toe sent to our clinic and we know to make a vascular referral. Or a patient comes in with restless leg syndrome, I don't treat that, will probably send to neuro or something. The point is, you want your PCP to send you everything. I want to be the primary care for the foot. Take the load off the PCP. Above all you get to bill a new patient visit.

 

[G0dFather]

you are getting xrays on a gout patient? and injecting acute gout? Man, I need to get in the PP mindset I have never ordered an xray for acute gout. I already know what it is.

I mean, am I doing this wrong? I will soon be in PP (along with hospital gig). Am I supposed to get an xray on every patient? I rarely get xrays at my hospital because its a pain in the ass. Even when someone comes in for a bunion or something, I tell them what to (wider shoes, OTC orthotics that won't solve the bunion but might make the foot feel better) and then if still bothering them come back, we will take xrays and talk about next step. I just have a hard time ordering xrays when they won't change the course of treatement for that visit. Of course some of this disdain for the xray process is that the patient often gets charged a co-pay for the hospital registration (I am employed by the medical group technically) and then has to pay for a radiologist to read the xray even though they read it after I have already seen the patient.

Alot of gout i see also has tophi ... so i do simultaneous sx work up also etc ... Im on board with much of what you posted in a different thread of how you practice podiatry but yeah MSK pains in general pts come in PP come in expecting an xray and injection ... patients run the show in PP .... its a business and the customer is always right ... you need to bite the bullet in PP when it comes to certain things but at the same time your also not a door mat, took me a bit to get that fine balance but once you do i believe it is a huge success factor and growth attributor

 

[heybrother]

What does a hospital charge a patient for an x-ray? In my clinic the highest x-ray reimbursement is $40 (but the plan reimburses poorly for E&M). The vast majority of other plans allow a charge of $25-31 a foot.

 

[G0dFather]

plans allow a charge of $25-31 a foot

Make that money!

 

[heybrother]

Make that money!

I half expected you to reply that you get $50 an x-ray. I think I get $85 from Medicare for the nail/callus you get $130. That said - in my town there's literally a podiatry office building with 10 exam room/3 offices for sale that I think is going to go for like $150K so I'm guessing real estate is cheaper here.

We had a thread elsewhere about whether x-ray is a luxury. My experience has been patients expect it. I want to go into the room 1 time and have a confident, definitive, short, helpful encounter.

 

[NatCh]

I want to go into the room 1 time and have a confident, definitive, short, helpful encounter.

Me too. And looking at it from the viewpoint of a patient, I have to take time out from the rest of my life to go to see a doctor. Having to schedule three visits (initial office visit, x-ray at a different facility, return to office for treatment) would be a huge inconvenience.

 

[NatCh]

patients run the show in PP .... its a business and the customer is always right

Eeesh. I wouldn't take it to that extent. Sometimes it's our job to tell them when they're wrong.

 

[619]

We had a thread elsewhere about whether x-ray is a luxury.

In Europe or even next door Canada, I don't think they take x-ray liberally like we do here. The Canadians even came up with the Ottawa rules regarding requirement for foot x-ray, to justify getting a (simple) x-ray. X-ray is like handing out candy here in the USA so patients expect it and we deliver and most important, we get paid for it. So I have no complain.

I am in PP, so anyone with ankle/foot pain gets an x-ray in the office. Except for purely skin conditions. We have good MAs so they are pretty good at screening who gets x-ray or not before I walk into the room. Makes things move smoothly.

 

[heybrother]

I wonder though - how many things in medicine were done/justified/etc a certain way because rendering this care was so much more expensive/difficult back in the day.

Consider - my residency clinic used FILM albeit processed in a machine. We became digital right as I was leaving. An old attending described for me films being taken intra-op in which they basically had someone run off and leave and process.

Now the patient walks down the hallway - has their views taken, the views instantly are available on the network, and my clinic gets paid $25. How much do you think x-rays cost back in the day with films and chemicals and development and care being rendered in ED/hospital.

I'm saying this not to be argumentative - I just wonder how does the calculus on cost that can drive decisions change through time. If you could deliver ankle x-rays for a dollar would anyone ever have come up with a classification system to save $1. I should also point out that in some of my favorite articles of all time - the English place basically ALL 5th metatarsal base fractures into a boot and tell the patient to start walking.

Perhaps a similar thought - part of the reason patients used to undergo fungal testing before being prescribed terbinafine is that the medication was so expensive that you couldn't justify using it on a patient who didn't actually have fungus. And now fungal testing exists simply as a blood sucking mechanism to drain podiatry patients and terbinafine costs next to nothing.

 

[NatCh]

my residency clinic used FILM albeit processed in a machine. We became digital right as I was leaving. An old attending described for me films being taken intra-op in which they basically had someone run off and leave and process.

Good lord, I'd forgotten all about that. In my Residency that's how they did it. A tech would roll the portable machine in, grab the views, then run off to process the films before everyone left. The image quality was super ****ty too.

Perhaps a similar thought - part of the reason patients used to undergo fungal testing before being prescribed terbinafine is that the medication was so expensive that you couldn't justify using it on a patient who didn't actually have fungus. And now fungal testing exists simply as a blood sucking mechanism to drain podiatry patients and terbinafine costs next to nothing.

I think that might also apply to the adage that Lamisil will destroy your liver. Doctors probably started telling patients that because they wanted to avoid jumping through all of the prior authorization hoops.

 

[PeaJay]

Jees, my MSG owns the insurance company and hospital. The goal is to provide high quality care at a lower cost. There is No way irradiating people indiscriminately would go on for any length of time in my area. You would be flagged as an outlier.

 

[air bud]

What does a hospital charge a patient for an x-ray? In my clinic the highest x-ray reimbursement is $40 (but the plan reimburses poorly for E&M). The vast majority of other plans allow a charge of $25-31 a foot.

It's the 200 dollar fee for the radiologist to read it

 

[Redsting]

What does a hospital charge a patient for an x-ray? In my clinic the highest x-ray reimbursement is $40 (but the plan reimburses poorly for E&M). The vast majority of other plans allow a charge of $25-31 a foot.

I believe my hospital collects $180 for 3 view plus a mandatory radiologist over read for another $30. Its not a high income area so while I do try to make the hospital money I am not trying to send everyone to radiology. If I do send them, I try and get it before I see them cause otherwise the patient flow is horrific if I have to send them from clinic. Any history of trauma goes for an xray first.
When I had the xray in office it was much easier for me, cheaper for them so I got them more frequently. That and the turnover at the front desk has been insane and they are so hit an miss with following "foot pain= xray", that I honestly just gave up.

 

[air bud]

Also, I agree what people are saying about an efficient clinic. It's hard to take up even half a day with 8 patients and being inefficient. I agree I will do many more x-rays when in PP strictly for a more efficient clinic.

 

[Utvolsdpm]

I think that might also apply to the adage that Lamisil will destroy your liver. Doctors probably started telling patients that because they wanted to avoid jumping through all of the prior authorization hoops.

From a recent experience, this may have started with fluconazole? This is my anecdote at least: I recently had a patient that was prescribed fluconazole in the past (years ago) and wanted it again. When I ordered it, it was flagged by the pharmacist as they were on a statin. Through discussion the pharmacist related that they wouldn’t recommend fluconazole and a statin concurrently, but if the combo was lamisil and a statin they couldn’t care less. ‍♂
As many of you have probably heard in school etc - statins and lamisil are a huge no no, however later in practice I have seen many people take these together. With it without checking LFTs half way through.

 

[air bud]

Also, I understand what you guys are talking about with people want some instant results. Again, since I have a ton of time and can be inefficient, I have almost all injections wait for the lidocaine to kick in, walk around and say that feels good. I say see there you that tells us the pain is coming from there.
But again, x-rays are so unnecessary. Patient comes in complaining of "ankle" pain. Talking to them it hurts more outside on uneven ground. Pain on palpation over sinus tarsi, not the ankle. No crepitus or pain with ROM of ankle or STJ. Sinus tarsi injection for "sinus tarsi syndrome.". No x-ray needed. Wait 10 mins, have patient walk around in grass outside back door. Boom pain is gone. They are happy. See them in 3 weeks if they are less than 90 % improved.

 

[dtrack22]

It's the 200 dollar fee for the radiologist to read it

the radiologist doesn’t get $200 for reading an X-ray. The interpretation component of 73630 (using Dallas area Medicare fee schedule) is $8.69

 

[NatCh]

Also, I understand what you guys are talking about with people want some instant results. Again, since I have a ton of time and can be inefficient, I have almost all injections wait for the lidocaine to kick in, walk around and say that feels good. I say see there you that tells us the pain is coming from there.
But again, x-rays are so unnecessary. Patient comes in complaining of "ankle" pain. Talking to them it hurts more outside on uneven ground. Pain on palpation over sinus tarsi, not the ankle. No crepitus or pain with ROM of ankle or STJ. Sinus tarsi injection for "sinus tarsi syndrome.". No x-ray needed. Wait 10 mins, have patient walk around in grass outside back door. Boom pain is gone. They are happy. See them in 3 weeks if they are less than 90 % improved.

As long as the pain is gone then they're happy. It's when the pain doesn't go away quickly that they'll start to question your work. If you're the only DPM for 200 miles then they have little choice but to come back to you. If you have ten other DPMs within five miles of you then it changes the scenario a bit.

 

[NatCh]

Jees, my MSG owns the insurance company and hospital. The goal is to provide high quality care at a lower cost. There is No way irradiating people indiscriminately would go on for any length of time in my area. You would be flagged as an outlier.

How does that even work??? The hospital bills a ludicrous amount then the insurance company pays themselves a cut rate? Lol. I bet someone is making a ton of money there. I'd be looking at the C-level administrators, haha.

 

[PeaJay]

How does that even work??? The hospital bills a ludicrous amount then the insurance company pays themselves a cut rate? Lol. I bet someone is making a ton of money there. I'd be looking at the C-level administrators, haha.

Think of it as Kaiser but smaller. It is very common in my region. There is the hospital system that is associated with the physician group that also has ownership in an insurance company. Multiple competing systems in the area and essentially no private practice of any specialty.

 

[GreenHousePub]

In Europe or even next door Canada, I don't think they take x-ray liberally like we do here. The Canadians even came up with the Ottawa rules regarding requirement for foot x-ray, to justify getting a (simple) x-ray.

Ottawa rules aren't followed here because (the biggest one to me) 1) malpractice and malpractice lawyers, as well as 2) insurance reimbursement.

 

[CutsWithFury]

It's the 200 dollar fee for the radiologist to read it

You should be reading it and billing for it

 

[air bud]

You should be reading it and billing for it

Not allowed to period trust me I have tried. Plus the X-ray machine is owned by the hospital. At my last job which was a multi-specialty group, Ortho was able to power their way through and be able to read and open their own pictures and radiologists don't repeat it but no other specialists or primary care could.

 

[air bud]

the radiologist doesn’t get $200 for reading an X-ray. The interpretation component of 73630 (using Dallas area Medicare fee schedule) is $8.69

Correct. I meant the hospital charge. Here is a throacic spine x-ray. Not sure if paid a co pay to the hospital that day on top of it.
Radiology got 11.73. Hospital 195.

 

[dtrack22]

Correct. I meant the hospital charge. Here is a throacic spine x-ray. Not sure if paid a co pay to the hospital that day on top of it.
Radiology got 11.73. Hospital 195.

correct. Some of the PP docs in a Facebook group really struggled to grasp how MGMA median compensation crosses $300k. They just had no understanding of “facility fees.” Ownership of real estate and facilities is where the real money is at in medicine, not e/m and CPT codes.

Well that and cash pay cosmetic stuff...but even things like Botox are getting increasingly more affordable. It’s crazy how prices become more competitive and really affordable when you take 3rd party payers out of the mix and let a market function the way it should...

 

[G0dFather]

I think I get $85 from Medicare for the nail/callus

Not bad .. isnt that great... just pump up the volume

podiatry office building with 10 exam room/3 offices for sale that I think is going to go for like $150K so I'm guessing real estate is cheaper here.

Wow... this looks like a POWERHOUSE! Does the surrounding area's volume support this kid of infrastructure?

My experience has been patients expect it.

i agree

I am in PP, so anyone with ankle/foot pain gets an x-ray in the office.

At the end of the day this is America and god bless it !

 

[G0dFather]

Ottawa rules aren't followed here because (the biggest one to me) 1) malpractice and malpractice lawyers, as well as 2) insurance reimbursement.

This is so key ! its a about CYA and being defensive ... so its good to get paid for doing so at least