So much misinformation being spread on this forum. First myth, you can't survive off a practice based mainly on RFC. Yes you can and I will easily explain why and in some instances it pays even better. Second, someone above said "Do NOT bill insurance for
ANY nail care or RFC unless a patient is diabetic with class findings or has PVD with class findings", again this is false as I will explain below. Another false thing I read, "If you did a recent hammertoe surgery on that patient, I assure you the patient does NOT have class findings.", again, false. Hammertoe surgeries are done all the time on diabetic patients with neuropathy that keep getting irritation or an ulcer on the dorsal toe, just to name one example.
Dtrack also mentioned about $68 a patient with his RFC with a few EM visits, what is wrong with that that? It is easy quick work and $68 is a fine. Let's say you see 25 patients for $68 each, and you work 5x a week, and let's just say you get 40% of what you bring in, that's $176,800 for easy, no stress work!
There is nothing wrong with a practice that focuses mainly on RFC. But knowing when and how to bill is important. Here are some common scenarios and points I'd like to make:
1) As others have mentioned, if you are salary based at a hospital I wouldn't waste my time with "nail consults". This was debated to death at my residency program because we were ALLLLLLL about patient satisfaction and many of the other specialties would be like "can you please trim the nails as a courtesy?". We ultimately did away with it and with good reason. But, it's up to you, but we were too busy with more important things to be doing this in massive numbers. For an office, I know many who do no RFC and others who do nothing but RFC, either route is fine and can pay the bills. One of my partners I work with now doesn't do any RFC and he is doing great, and it's better for me as he just sends them to me to do.
2) If you have a young healthy person coming in for "thick yellow toenails" then you can't do "RFC" and use Q-modifiers, THUS you are better to bill 11720 with onychomycosis AND "toe pain" to justify what you're doing, because a thick yellow toenail is usually painful. If a new patient I would also bill a 99202 if just trimming/debriding and giving a cream, and if you are giving oral Lamisil and ordering labs than you could probably bill a 99203. If the patient is adamant about there being NO pain and the nails are barely yellow, and it's purely cosmetic than give them cash prices to pay if they want them trimmed. I rarely bill a 11721 with a healthy patient, because not often is EVERY SINGLE TOENAIL painful, thus it is better to play it safe with the 11720 when "pain" is your justifier. It is ok to bill a 11721 with a healthy patient every now and then if 6 or more are painful and dystrophic, but I would say only use it 10-15% of the time.
3) Q modifiers are great for RFC and medicare patients IF used correctly. First they justify the use of 11721 instead of the 11720 when 6 or more nails are thick, dystrophic, yellow, etc, regardless of pain. You don't need "pain" as a justifier when using a Q modifier. Most the time I am using a 11721 when using a Q modifier because how often are 6 or more nails yellow, thick, long, and dystrophic? A majority of the time they are.
4) Know when to use the Q modifier- they must have CLASS findings, and a majority of my medicare patients for nails and calluses do have class findings. Not all, but a majority and I would assume it's the same for you. A good percentage of them have thin and fragile skin, edema, decreased hair growth, dystrophic nails, absent pulse, etc. BUT YOU MUST DOCUMENT THE CONDITIONS AND THE CLASS FINDINGS IN EACH AND EVERY ONE OF YOUR NOTES, here are those conditions:
MODIFIER Q7, Q8 and Q9
When you are using a Q modifier you are telling the insurance that the RFC is a medical necessity, and you aren't relying on "pain" as the main indicator. NOW, when you use a Q modifier, you can also bill calluses! A lot of people don't know this. Callus debridement is a procedure that is not normally covered no matter how painful they are, which is complete BS because we all have spent a lot of time on a patient with killer IPK when it's not even covered. With the Q modifier you will get reimbursed for nails AND calluses, but you will have to put a "59" modifier on the 2nd procedure. So you would put the Q modifier with the calluses and 59,Q modifier with the nails. List the diabetes or PVD or whatever first. Remember, DO NOT BILL AN E&M with the procedure unless it is a new patient, OR it is a follow up patient with a new, seperate concern (then you use a 25 modifier on the office visit as well).
5) You mentioned you feel you are doing "too many painful nail fungus", well I say if you are using a 11720 than so what? Throw in a few "nail dystrophy" codes instead of onychomycosis as well. What will get you in trouble is if you bill 11721 for "too many painful nail fungus." This has happened and people have been audited and owed a crap ton of money as a result. I would keep your 11721:11720 ratio around 9:1 in the healthy individual, while with Q modifiers and diabetic, PVD, etc I am using 11721 more often with the Q modifier.
In regards to you learning from your billing and messing it up when you first started, don't sweat it. As long as this isn't a continuing pattern and you are ok now, focus on the now. But it also depends on how bad the billing was. I found out the billing company for the past 4 months was adding a 99213 for my RFC nail trimmings behind my back. First, they weren't suppose to add anything to my billing without telling me first which they never did. I told them to stop and I sent back the claims, but they still continued and we fired them. But I went back over around 50-60 patients to correct the their billing and pay it back. Being my first year out I trusted what other doctors told me and what billers told me and my god they were wrong. So always double check your billers billing! Trust no one. And yes, technically they can audit your notes your first year or two out and just penalize the crap out of you for every little mistake, but to me this is wrong/unethical as almost every graduating resident I guarantee you messes up on billing because we simply weren't taught this. Nobodys billing is perfect especially just starting out. But unless it is grossly fraudulent than just learn from your mistakes. And by grossly fraudulent I mean people who bill a partial nail avulsion when they just trimmed the nails, etc. I've gone to several coding seminars, spent thousands on them and private meetings on coding, and I AM STILL LEARNING and modifying my notes all the time. I feel comfortable and confident in my notes and billing now after 2-3 years out of residency, but I'm still learning. Look at the bell curve of coding and go just slightly to the right on it, but don't become an outlier and you will be fine.
NOW, to go back to some of the comments earlier that you can't make a good living doing mostly RFC, let's do the math on a practice such as myself and others I know with reasonable numbers without overbilling. Let's say you see 25 patients a day which is what I aim for and is very reasonable. Let's say 16 (a majority) is RFC with half of them being elderly medicare patients with NO Q-modifier. So, 8 of them you get about $35, about 8 of them I'm assuming you're doing 11721 AND/OR a few calluses, and maybe 1 or 2 of them have a "new concern" and you maybe you bill a 99212 on them- so that averages maybe $70 each. Lets say 6 patients are follow up visits for something like plantar fasciitis, ankle sprain, etc and you bill a 99213 with or without x-rays and maybe an ankle brace or injection but let's say it averages out to $90 a patient for those. And let's say 3 patients are new at $200 each. Lets say you work 5x a week, 52 weeks a year and you get 40% of what you bring in- with this scenario you will make over $200,000 a year. HOW IS THIS A BAD LIVING? Very low stress, very easy work, what is the problem? There is no problem. The hardest part is all the friggin paperwork and detailed notes, but that's life. Let's say you want to see 15 patients a day FOUR DAYS A WEEK, you can and SHOULD still make over 6 figures. Why people knock this field is beyond me. Where the tragedy falls, but this is not just podiatry, is the reimbursement for surgeries performed in the OR, so in a way there is more money and less headache when doing mainly RFC.
Here are some important things when billing using a Q modifier, YOU MUST DO THIS, but check with your local coverage/LCD to see what exactly you need, but for my state when I bill a Q modifier w class findings for a DIABETIC, I need the doctors name that manages their diabetes AND the exact date they last saw them assuming it was less than 6 months ago. Also get their morning sugar, last A1C, etc. It sucks getting the date last seen and the doctors name, but I don't make the rules. IF you are using class findings/Q modifier for PVD, you need the name of the doctor and an estimate of the date of the last time they saw this person. Again, make note of claudication, rest pain, etc. Fax that doctor (usually their PCP) a short template/letter requesting they take care of their vascular issues as this is beyond our scope. Done. You only have to fax it once and now you can do routine foot care on them AND have it covered along with calluses but you do have to get that doctor information and date every time.
Some other tidbits that I noticed with others billing and things to avoid:
1) SO MANY doctors I know have horrible notes, I read them not just during residency but as an attending and they are just horrible and don't justify anything. The fact you are trying to learn this stuff and be a better biller you are ahead of the game already.
2) If you do a procedure and office visit for the "same" condition, the procedure takes precedence and you are to bill that over the office visit even if you get paid less. (ex: A follow up patient for a follow up concern of plantar fasciitis and you decide to do an injection- you bill the actual injection NOT the office visit and certainly not both which brings me to point number 3...)
3) Don't bill an E&M AND procedure for the same condition on follow up patients. This will get you in big trouble and a derm group in the east recently had to pay back millions for this. If it is SEPARATELY IDENTIFIABLE sure you can do it, but you can NOT bill 99213 "onychomycosis, toe pain" and 11721 "onychomycosis, toe pain." Do not bill an office visit on a follow up patient for RFC when you are just trimming their nails. You wouldn't believe how many people do this and it's incorrect.
4) Some may disagree with this but I would not have your MAs trim your nails, check with your state on this though. You the doctor should do this. For buffering and smoothening them or whatever with the dremel it's up in the air and probably ok but I just do my own.
5) Keep in mind 11720 and 11721 are not just a trimming but a DEBRIDEMENT so you are debriding them in length AND thickness. Just make sure you are documenting this as if you simply write "long yellow toenails" that is not good enough.
