Relevancy of PM News

[Boba Foot]

I think there will be a shift with younger podiatrists being more ethical and treating associates better particularly if they had bad experiences with mustasche pods in the past. I would work for someone who knows how bad that can be.

There are a lot of current gen pods who joke about hiring associates for peanuts but I haven’t seen anyone under 40 actually hire an associate and treat them like crap in reality

Boomers seem to think the entire world revolves around them and their hedonistic tendencies. Of course boomer pods are the same way.

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[HeySister]

She was in the acfas podcast on associate contracts. The terms she discussed were abysmal. "Bonus" structures worse than most associate contracts I have seen.

 

[GreenHousePub]

She was in the acfas podcast on associate contracts. The terms she discussed were abysmal. "Bonus" structures worse than most associate contracts I have seen.

Just listened to it. There are definitely some new fresh mustaches in town

My interpreted highlights of the discussion:

-Calling 175-200k bases extremely high
-Laughing about sign on bonuses
-Mandatory "you need to go market yourself to bring in patients to my practice" in the contract. (Why don't they just open their own place then?)
-Saying that getting a percentage of 30% of collections extremely high.
-Lots of discussion on non-competes
-Make sure that associates ask for a percentage of the DME dispensed and billed for (People aren't doing that?)

Once again reminded why I don't listen to those podcasts.

 

[Boba Foot]

-Lots of discussion on non-competes

FWIW Lina Khan, Biden’s FTC chair, is looking to eliminate non-competes entirely even in medicine. I saw it mentioned in an APMA brief, so you know it’s going mustache pods sweating bullets.

 

[Feli]

I think there will be a shift with younger podiatrists being more ethical and treating associates better particularly if they had bad experiences with mustasche pods in the past. I would work for someone who knows how bad that can be.

There are a lot of current gen pods who joke about hiring associates for peanuts but I haven’t seen anyone under 40 actually hire an associate and treat them like crap in reality

This is a good sentiment, but it gives younger PP owners a bit too much credit...

They're just smarter. They know the game in its present form. They understand the debt and the org jobs.

The main moustache PP owner mistakes are:

1. They don't understand current DPM loan burden and hospital job options.
2. They think they can pay associates ultra-low (they are actually right on this... podiatry was saturated and is now getting super-saturated).
3. They think their practice is highly valuable and starting a competing practice is very costly (it's cheaper and easier than ever to start up).

...the younger DPMs know that associates are a big flight risk in many ways. Associates will often suck their base salary, look for hospital jobs every break and lunch, and leave in a couple years to some VA or simply another PP job in a place they like better. Many of them take a PP job since they were lazy or late in starting the job search. That is a waste of interviewing, hiring, training, etc for the owner. That losing a doc they just introduced a year before also hurts the rep of solo or small pod groups who depends on community and PCP rep. Mainly, they know that if the associate does like the area, in most places, the associate can go solo down the street with advantage of being on payers, hospitals, PCP and community intros. Not ideal.

Nearly all of the under-40 and 45yo owner DPMs that I know who were considering hiring an associate ultimately decided against it. Associates aren't really necessary unless you're playing the takeover-the-world game. They create liability, and they bring many staffing and logistical issues. It is often better for owners to just get more exam rooms and MAs... and/or cut out bad payers.
And sure, a few of them do hire associates, and it fairly often works... typically works best to hire the passive types who do want to be in that area, don't want the work or responsibility of ownership (read: family-oriented types, usually associate also has a financially competent partner). That can be a win-win if the associate is treated fairly well hours/pay in a city they like... and the owner still makes six figures off doing the staffing/supplies/accounting/etc for them and supplying patients. Not everyone is a go-getter.

The supergroups, moustache associate mills, etc will eat the turnover. They will each hire the passive, the gunners, the desperate... whoever will answer their job posting and work for cheap. Moustaches will underpay and offer overpriced "partnership," but supergroups will appear to pay fair - until associates realize it's an endless hamster wheel. The supergroups can pay because they can funnel the podiatry patients into their big ticket vasc center, PT place, custom DME shop, "path lab," maybe MRI machine, and other services that make large profit for their owners/shareholders. That churn and burn of docs/staff and heavy billing on patients damages their practice rep, but they don't care. They can just buy more marketing with the profits. They just keep ads up and hire associates (and office staff) perpetually... constant supply of new DPM grads gets bigger and bigger. Get ready for this flood of people who couldn't get DPM hospital jobs and are stuck commuting to three offices and working weekends in the 35% pay supergroups griping on SDN in years to come.

 

[Adam Smasher]

Nearly all of the under-40 and 45yo owner DPMs that I know who were considering hiring an associate ultimately decided against it. Associates aren't really necessary unless you're playing the takeover-the-world game.

This is the problem with the podiatry private practice business model in its current incarnation. It doesn't really pay to scale your operation. If you bring on another doc, double your revenue, double your operating costs, the only way your personal take-home increases is if you underpay the new guy. Maybe if you have some expensive panacea (Shockwave, swift, laser, office PCR, etc) that the 2 of you can overutilize, profits can be made that way.

A better alternative would be to have someone like a dental hygienist but for feet whos does all the low level things in podiatry (nails, calluses, foot screenings) and can bill insurance while the doctor does things requiring actual medical decision making, then it pays to scale up.

 

[HardRoadPaved]

They also have this thing called electronic mail aka (e-mail now)

 

[PlainsPod]

Dr. Brucato's website has a link entitled "Skip the Wound Care Center". If I'd had a drink in my mouth when I read that I'd have spit it out laughing. Good for her.

Tell me where she’s wrong

 

[heybrother]

Tell me where she’s wrong

She ain't. A wound healing center is where a toe tip ulcer goes to get hyperbaric oxygen.

 

[PlainsPod]

She ain't. A wound healing center is where a toe tip ulcer goes to get hyperbaric oxygen.

Time as old as tale. Seen it a million times.

 

[HardRoadPaved]

28490 = fracture of the great toe

Also S92.411D? Should be an A if you're seeing an acute fracture and are doing management of the injury
Ugh and I'd hate to be this DPMs patient being told to wear a hallux valgus splint for a sagittal plane injury. Give them an L3260 surgical shoe and call it a day until the pain subsides.

 

[Shiyuan]

I absolutely love the oxymoron title of this thread. It cracks me up every time!

 

[heybrother]

I did not expect to see podiatry in the WSJ this morning.

 

[Adam Smasher]

Words fail me

 

[HardRoadPaved]

I hate when fungal and bacterial conditions dont cause athlete's foot and cellulitis too.

 

[Adam Smasher]

I for one could not be prouder of this resident. This is the kind of outside-the-box thinking we as a profession need.

 

[NatCh]

View attachment 379334

I for one could not be prouder of this resident. This is the kind of outside-the-box thinking we as a profession need.

Paging ExperiencedDPM…

 

[Hybrocure]

The newest issue has a pod calling himself dr pickleball, when I google that all I see is a doctor of physical therapy and an ortho surgeon of 37 years with the name.

Very bunion king-esque

 

[Retrograde_Nail]

View attachment 379334

I for one could not be prouder of this resident. This is the kind of outside-the-box thinking we as a profession need.

This is def a VA program

 

[HardRoadPaved]

I hear stage 6 is only reserved for podiatrists trying to make diagnoses.

 

[Hybrocure]

View attachment 380421


I hear stage 6 is only reserved for podiatrists trying to make diagnoses.

And the first candidate for best meme of 2024 begins

 

[icebreaker32]

Second candidate for best meme of 2024.

Podiatry expands scope to include the spine in 2024 and 80K associate jobs become a thing of the past!

Ivar claims he is going to start placing spinal cord stimulators to treat neuropathy. As many of you know this man does not even accept insurance.

I doubt it ever actually happens, but we know this man does not joke around because this is the same man that mails carbon rib-back 15 blades to his son in podiatry school.

 

[Shiyuan]

Second candidate for best meme of 2024.

Podiatry expands scope to include the spine in 2024 and 80K associate jobs become a thing of the past!

Ivar claims he is going to start placing spinal cord stimulators to treat neuropathy. As many of you know this man does not even accept insurance.

I doubt it ever actually happens, but we know this man does not joke around because this is the same man that mails carbon rib-back 15 blades to his son in podiatry school.

View attachment 380673

I saw this. Big LOL

 

[Homo sapien]

View attachment 379334

I for one could not be prouder of this resident. This is the kind of outside-the-box thinking we as a profession need.

This resident is ****ing stupid

 

[GreenHousePub]

Second candidate for best meme of 2024.

Podiatry expands scope to include the spine in 2024 and 80K associate jobs become a thing of the past!

Ivar claims he is going to start placing spinal cord stimulators to treat neuropathy. As many of you know this man does not even accept insurance.

I doubt it ever actually happens, but we know this man does not joke around because this is the same man that mails carbon rib-back 15 blades to his son in podiatry school.

View attachment 380673

Based Allen Jacobs.

Also this is the guy who on one website claims he is working on a cure for neuropathy.

 

[Utvolsdpm]

Another creative billing highlight today:

Query: Removal of Screws I have a patient who developed an infection over a non-union (1st MPJ fusion). Two of the screws backed out of their original location; therefore, they would be considered foreign bodies and should be coded as removal of deep foreign bodies. However, there remained a plate and 3 other screws that were all stable. They needed to be removed as well as to prevent future issues of their failure. Of course, since there was an overlying infection, all hardware should be removed. Can I bill for removal of foreign body AND internal hardware? Codes I am considering are 20680 and 28192. PM News Subscriber

 

[Shiyuan]

Another creative billing highlight today:

​

Query: Removal of Screws I have a patient who developed an infection over a non-union (1st MPJ fusion). Two of the screws backed out of their original location; therefore, they would be considered foreign bodies and should be coded as removal of deep foreign bodies. However, there remained a plate and 3 other screws that were all stable. They needed to be removed as well as to prevent future issues of their failure. Of course, since there was an overlying infection, all hardware should be removed. Can I bill for removal of foreign body AND internal hardware? Codes I am considering are 20680 and 28192. PM News Subscriber

Wow. Shameful.

 

[Bored Snorlax]

Another creative billing highlight today:

​

Query: Removal of Screws I have a patient who developed an infection over a non-union (1st MPJ fusion). Two of the screws backed out of their original location; therefore, they would be considered foreign bodies and should be coded as removal of deep foreign bodies. However, there remained a plate and 3 other screws that were all stable. They needed to be removed as well as to prevent future issues of their failure. Of course, since there was an overlying infection, all hardware should be removed. Can I bill for removal of foreign body AND internal hardware? Codes I am considering are 20680 and 28192. PM News Subscriber

This is just sad.

 

[Adam Smasher]

Actually, preposterous as it may seem, it might be on point. Michael Warshaw has talked about this. When a screw backs out, it ceases to be defined as an "implant" and becomes a "foreign body." "Implant" denotes screws/plates that remain implanted. Because podiatry.

Edit: no, I can't find a source on this but I swear he said it at a conference. Dunno if you get to double-dip like the pm news writer is trying to do

 

[HardRoadPaved]

He forgot he could bill 28005 if he debrided the infected bone and the RVU are handsomer on that.

 

[HardRoadPaved]

Call in the paddywagon for this unbundling mess....

 

[air bud]

View attachment 380787

Call in the paddywagon for this unbundling mess....

Well he is just needs to unbundle it properly. He has already done a ray amputation. That is one ray. So now he can bill 28810 x4. I am going to assume 28810 is 2hat meant to say, not excision of bunion 28110....but can't assume. Also love the deep bone biopsy performed open at the time of amputation lol. It's called just removing a little more bone than necessary and sending to a lab. Definitely a billable procedure...

 

[Adam Smasher]

Also love the deep bone biopsy performed open at the time of amputation lol. It's called just removing a little more bone than necessary and sending to a lab. Definitely a billable procedure...

That's legit, they talk about this at the ACFAS billing seminar. Clear margin biopsy. "It won't pay much, but it will pay for your lunch"

 

[air bud]

That's legit, they talk about this at the ACFAS billing seminar. Clear margin biopsy. "It won't pay much, but it will pay for your lunch"

Yeah I know. From gods mouth to your ears.

Narrator: it's not

Don't make me bring in EXDpm...not going to tag him and mess up his chi

 

[heybrother]

https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-1.pdf

Providers/suppliers shall only report a biopsy separately when pathologic examination results in a decision to immediately proceed with a more extensive procedure (e.g.,excision, destruction, removal) on the same lesion; or when performed on a separate lesion.

Providers/suppliers shall not report a biopsy separately when it is to assess resection margins or to verify resectability; or when performed and submitted for pathologicevaluation completed after performing the more extensive procedure.

They've changed the wording on this a few times, but I don't think any of this is new. This is from 2024 and I found a 2017 CMS biopsy document that essentially said the same thing.

 

[NatCh]

Yeah I know. From gods mouth to your ears.

Narrator: it's not

Don't make me bring in EXDpm...not going to tag him and mess up his chi

Mess up his chi!!!

 

[GreenHousePub]

https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-1.pdf

Providers/suppliers shall only report a biopsy separately when pathologic examination results in a decision to immediately proceed with a more extensive procedure (e.g.,excision, destruction, removal) on the same lesion; or when performed on a separate lesion.

Providers/suppliers shall not report a biopsy separately when it is to assess resection margins or to verify resectability; or when performed and submitted for pathologicevaluation completed after performing the more extensive procedure.

They've changed the wording on this a few times, but I don't think any of this is new. This is from 2024 and I found a 2017 CMS biopsy document that essentially said the same thing.

I've been doing a biopsy of the metatarsal head w core biopsy trochar when I do a toe amputation. So I've been billing wrong?

 

[dtrack22]

Providers/suppliers shall not report a biopsy separately when it is to assess resection margins or to verify resectability; or when performed and submitted for pathologicevaluation completed after performing the more extensive procedure.

But the ACFAS “coding” workshop would never promote fraudulent unbundling…

 

[Hybrocure]

But the ACFAS “coding” workshop would never promote fraudulent unbundling…

Well. Their entire existence is based on surgery.


And surgery as a podiatrist simply does not pay well when done ethically. I get why people unbundle. We are grossly underpaid by insurances for our work, and that is the truth of it.

Every other career scales with inflation but insurances pay us less as time goes on. I don’t blame people for saying F the system.

20 years ago you got paid more for doing a bunion than you do now. How does that make any sense? It’s not because they were getting paid too much before. It’s that we are getting paid too little now

 

[Retrograde_Nail]

Well. Their entire existence is based on surgery.


And surgery as a podiatrist simply does not pay well when done ethically. I get why people unbundle. We are grossly underpaid by insurances for our work, and that is the truth of it.

Every other career scales with inflation but insurances pay us less as time goes on. I don’t blame people for saying F the system.

Nasty Nate can't wait to meet you in prison.

 

[Hybrocure]

Nasty Nate can't wait to meet you in prison.

Lol, thankfully I don’t operate enough to care about unbundling and literally just bill things as usually a single code that I google since I don’t know the tricks.

Perhaps that’s why I hate surgery

 

[Feli]

...surgery as a podiatrist simply does not pay well when done ethically. I get why people unbundle. We are grossly underpaid by insurances for our work...

...thankfully I don’t operate enough to care about unbundling and literally just bill things as usually a single code that I google since I don’t know the tricks.

Perhaps that’s why I hate surgery

Surgery pays fine with good coding (talking ortho codes for insured pts... not MCA wound/amp crap)...
You basically make a bit less per hour doing the actual surgery (esp with associated paperwork and 90d global), but you make it up on DME and higher level E&M - and maybe OTC stuffs - that you would not have gotten otherwise. It also keeps PCPs happy that you can competently fix whatever goes wrong, and that's the biggest gain from OR surgery (for PP docs). With more and more DPMs coming out into an already limited specialty, offering as many services as possible is key.

There is undercoding for surgery, and just plain unbundling... and there is certainly an appropriate middle ground of good and accurate coding. All it really takes is accurate CPTs and mods, proper ICDs to get them paid, and putting highest RVU CPT first line. Here is one forefoot slam (with contralat plate removal from last year) that I just wrote up... not unbundling whatsoever, will pay ok, esp with boot and visits:

28750-LT
20680-RT
28585-T1
28585-T2
28585-T3
28585-T4
28308-LT
28308-LT
28308-LT (all get -59 after first proced)
...it'll all get pad, as it should. Sometimes payer will ask for op report, and good biller can connect those dots. I could've added 28110 or a 28270, but not really needed (capsulotomy might be, can decide post-op and bill it if done).

You don't need the fake skin plasty or tendon lengthens (they are included in capsulotomy MPJ)... or the fake bone biopsies on amps. You don't need the bogus amnio or the plan-to-remove wires sticking out of toes. Surgery pays fine coded accurately.

I will say that podiatry is one of the only surgical specialties that does most or all of their own pre/post op appointments and non-op appointments (as opposed to midlevels or non-op docs and assistants/tech doing most of them). That part is a major drag and why many DPMs claim surgery does not pay (esp if they're associate and their owner does not cut them in on DME or dumps owner/partner post-ops on them).

 

[Hybrocure]

Surgery pays fine with good coding (talking ortho codes for insured pts... not MCA wound/amp crap)...
You basically make a bit less per hour doing the actual surgery (esp with associated paperwork and 90d global), but you make it up on DME and higher level E&M - and maybe OTC stuffs - that you would not have gotten otherwise. It also keeps PCPs happy that you can competently fix whatever goes wrong, and that's the biggest gain from OR surgery (for PP docs). With more and more DPMs coming out into an already limited specialty, offering as many services as possible is key.

There is undercoding for surgery, and just plain unbundling... and there is certainly an appropriate middle ground of good and accurate coding. All it really takes is accurate CPTs and mods, proper ICDs to get them paid, and putting highest RVU CPT first line.

I will say that podiatry is one of the only surgical specialties that does most or all of their own pre/post op appointments and non-op appointments (as opposed to midlevels or non-op docs and assistants/tech doing most of them). That part is a major drag and why many DPMs claim surgery does not pay (esp if they're associate and their owner does not cut them in on DME or dumps owner/partner post-ops on them).

You make great points and I agree with that. The unfortunate truth is the bulk of new graduates trained as surgeons are going to be thrown into a world of getting paid less for surgery due to DME exclusion or associate cuts.

I’ve seen my reimbursements from surgeries and literally been like..wtf. I drove to the hospital, got my case delayed, did the case (which is the shortest part of the whole ordeal) then for some reason end up back home two hours later for less than a new patient plantar fascia visit.

 

[Feli]

You make great points and I agree with that. The unfortunate truth is the bulk of new graduates trained as surgeons are going to be thrown into a world of getting paid less for surgery due to DME exclusion or associate cuts.

I agree... and a DPM will also get almost no benefit from the PCP goodwill part as associate.

If they get bu$ier, they just line owner pockets more and more... and owner probably hires another associate.

 

[HardRoadPaved]

offering as many services as possible is key.

Swift microwave, cold laser, nail fungus aresenal of Formula 3 and NAG laser, in-house fungus lab testing, wound grafts, PADnet, butterfly ultrasound guided injections, fungus medicine water bath, dermal fillers, diabetic shoes, end density nerve fiber testing, Vitamin B megapills...

oh and in-house x-ray

 

[Feli]

Swift microwave, cold laser, nail fungus aresenal of Formula 3 and NAG laser, in-house fungus lab testing, wound grafts, PADnet, butterfly ultrasound guided injections, fungus medicine water bath, dermal fillers, diabetic shoes, end density nerve fiber testing, Vitamin B megapills...

oh and in-house x-ray

Omg, lol... I just mean as many pathologies treated as possible.

I have zero of those things and do ok. (I have a better ultra than butterfly CostCo one, but I maybe do 20% of my injects with it)

 

[Hybrocure]

Omg, lol... I just mean as many pathologies treated as possible.

I have zero of those things and do ok. (I have a better ultra than butterfly CostCo one, but I maybe do 20% of my injects with it)

You don’t have in house X-ray? I couldn’t imagine practicing without it

 

[Feli]

You don’t have in house X-ray? I couldn’t imagine practicing without it

I'm in a hospital... you can't have 'competing services.' (fam docs can't have blood lab, I can't have XR, etc etc)

MSK is not considered competing (they do ABI, diag u/s, etc) at hospital rad dept.

 

[Hybrocure]

I'm in a hospital... you can't have 'competing services.' (fam docs can't have blood lab, I can't have XR, etc etc)

MSK is not considered competing (they do ABI, diag u/s, etc) at hospital rad dept.

Oh I thought you were PP for some reason

 

[Feli]

Oh I thought you were PP for some reason

I am... hospital suite.
Tons of PP docs do that (rent office or even buy "condo" in adjacent professional building or hospital itself).
It's more expensive and you don't get XR, but it makes marketing and visibility and comm a lot easier... and way easier and faster on surgery days.

It is really the best of both worlds (imo): support and location of the hospital without the admin junk or hassles or limits of being their employee.