How much are you getting for 28296 or 28285 today. In network fees are ridiculously low.
Surgery-Does it pay anymore?
- Thread starter mandrew
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I don't mean this unkindly, but none of us know you and your posts are so short its hard to derive any context or understanding about your situation. Complaining about reimbursement is a regular part of this forum, but I'm not sure what you want. Yes, its bad out there. Also, Weirdy wants us to stop freaking out, getting worked up, and tirading in every post. Most contracts technically say don't discuss rates. Most things now are based on Medicare and Medicare's reimbursement is to low even if you multiply it by a positive number.
What would you like to be paid? Have you tried fighting with insurance, negotiating, going out of network? Have you looked into an IPA? Are you willing to do things in your office?
I joined an IPA, but it still doesn't make surgery amazing. My IPA will pounce on anything around 165% of Medicare, but again - those values multiplied against Medicare base are still meh except for in office procedures that you can do in 5-10 minutes.
Also - not rub your old posts in your face but you once wrote this below. Presumably you believe there's still value in a podiatry practice, but I would argue to you that the continued deterioration in reimbursement is further proof that what you stated below can't be true.
What would you like to be paid? Have you tried fighting with insurance, negotiating, going out of network? Have you looked into an IPA? Are you willing to do things in your office?
I joined an IPA, but it still doesn't make surgery amazing. My IPA will pounce on anything around 165% of Medicare, but again - those values multiplied against Medicare base are still meh except for in office procedures that you can do in 5-10 minutes.
Also - not rub your old posts in your face but you once wrote this below. Presumably you believe there's still value in a podiatry practice, but I would argue to you that the continued deterioration in reimbursement is further proof that what you stated below can't be true.
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Nothing wrong with billing related questions.
Carry on.
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Surgery is 15-20% of my groups income. If we look at collections per hour it’s much more profitable to do clinic only, but it’s more about offering all foot and ankle services to our patients so they can come to us for everything, rather than only offering the most profitable services. I think it’s silly to worry about about profit from individual
Cpt codes. Even if our reimbursement for surgery is doubled, it will only increase overall profits by 7-13%. If you wanna make more money, for us it’s more about optimizing clinic and providing a great service overall
Cpt codes. Even if our reimbursement for surgery is doubled, it will only increase overall profits by 7-13%. If you wanna make more money, for us it’s more about optimizing clinic and providing a great service overall
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I agree. Just do the work, make it efficient.
Being efficient and full in an area with good payer mix will easily overcome a few low/no/slow pays from time to time.
It is fine to trim the worst payers or the work comps that you have real trouble getting paid with, but unless you have a significant wait list or PCPs who don't have other options for pod refers, you typically don't have a lot of bargain power. You're a specialist who is expected to offer those services and taking all area payers and doing basically all complaints is the way to do that. With the saturation of podiatry, if you don't, someone else nearby will happily do those procedures or take those insurances.
Fair enough, as I don’t know you either. I am a solo practitioner. I purchased an existing practice that was barely 3 years old and was started cold so the volume was low and it was priced accordingly. I paid about 60% of gross, so I stand by my statement you re-posted. What else would you like to know?
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What would you like to be paid for a 28296 at a facility?
I bought into a private practice myself. I paid less than you (percentage wise... but its technically possible I could pay more in absolute dollars), more than people who start things on their own, and less than people I randomly meet at conferences. Its water under the bridge at this point.
28296 is major foot surgery, imo.
If you consider potential liability, time away from the office and the 90 day global, I am thinking I would like to be paid at least $1500. Many payors are reimbursing less than half that for a procedure that could potentially lead to a $million lawsuit. This elective procedure should never be entered into lightly. What do you consider a reasonable fee for 28296?
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I'm not sure there is such a thing as major foot surgery...
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I met someone years ago who had some joke about how "A major surgery is any surgery performed on me."
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The problem with outpatient surgery being efficient is that as a private practice doc that efficiency is usually outside of your control unless you’re operating at a surgery center.
If it’s a hospital you will get bumped, someone went late before you or is spending more time than they booked (which happens a lot), anesthesia may be short staffed, turnover times could suck, god forbid you operate in a state where unions delay that even further, etc.
Before you know it that bunion that took you 30 mins to do was actually a 3 hour time investment. Yes generally you’ll have multiple cases or a block going which makes it better, but no matter who you are there will always be those times where you end up with a single case or two just ruining your day.
If it’s a hospital you will get bumped, someone went late before you or is spending more time than they booked (which happens a lot), anesthesia may be short staffed, turnover times could suck, god forbid you operate in a state where unions delay that even further, etc.
Before you know it that bunion that took you 30 mins to do was actually a 3 hour time investment. Yes generally you’ll have multiple cases or a block going which makes it better, but no matter who you are there will always be those times where you end up with a single case or two just ruining your day.
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Unless you are cutting and repositioning a metatarsal of course.
ignoring the stupid af responses thus far let me actually answer your question op.
Medicare pays 600. So you’ll get 600. Depending on your contract you probably not at 100% of Medicare. Most solo docs…depending on many factors…are closer to 50-70%. So you get paid that. United there’s carve outs for sx.
Also look up individual contract rates you have. Often sx can pay better than Medicare but not by much.
To answer the bigger question… rarely will an insurance pay you significantly more than Medicare and redo a full contract for a few cpt codes. Probably never for podiatry.
But if you feel you’re worth more, go ahead and ask with every single payer.
Medicare pays 600. So you’ll get 600. Depending on your contract you probably not at 100% of Medicare. Most solo docs…depending on many factors…are closer to 50-70%. So you get paid that. United there’s carve outs for sx.
Also look up individual contract rates you have. Often sx can pay better than Medicare but not by much.
To answer the bigger question… rarely will an insurance pay you significantly more than Medicare and redo a full contract for a few cpt codes. Probably never for podiatry.
But if you feel you’re worth more, go ahead and ask with every single payer.
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I had lunch with another podiatrist today and they told me that 20-25 years ago they routinely got $2K for an Austin. Meanwhile, I had an insurance that paid $900 for a 28296 that upped it to about $1200. The reimbursement suddenly felt "so much more fair" - its $300 more after all for the same work. But of course - I wasn't there for the "glory days" so I didn’t even know what I was missing out on or that I’m still $800 down. My suspicion is most podiatrists have an anchoring bias on reimbursement – they know what their best reimbursement is and they’d either like to receive this for everything or they’d like a few hundred dollars more than their best reimbursement.
We’ve discussed the MIS in office cash pay people on here before. I don’t know if they are all bluster and BS marketing– maybe they are just as bad as all the LinkedIn Orthoplastic Fellowship marketers – but they know to ask for more money for surgery. I’ve said on here in the past that we are sometimes “well paid” for what we do, but there’s nothing we can do that you can just do once and be done for the day. The MIS cash pay people claim to turn this on its head. If you could just show up to your office in the afternoon and do one $3-4K surgery in the office – that would probably be more than most people collect in an afternoon.
$1500 sounds nice for a bunion (because I know what I’m currently getting), but I don’t think that’s how someone in finance would value a bunion surgery if it was “invented” today. It’s certainly not how cash pay people value a bunion surgery.
I also think there’s a lot of what we do where we aren’t pricing in all the things that can go wrong in life or surgery or the expense of a practice. I was talking to someone the other day about injections. Consider that Medicare pays about $50 for an injection, or less. Some commercial insurance pays $90. $90 seems great by comparison. Its “just” sticking a needle in a person’s foot after all… in just the right place, just the right way. How much can a shot really be worth and what is good value to a patient. But just because something appears reasonably valued doesn’t mean it’s a good price for a business with an increasing overhead. Tons of BBQ restaurants have gone out of business near me because the price of brisket exploded. They all increased their prices, they all put out apologies explaining what was happening, and in the end people stopped eating at them because it was too expensive, or wasn’t good value, but sometimes an expensive price is just the price of delivering an underlying service.
I don't think the conclusions that most people are drawing are unreasonable in the context of how most podiatrists view surgery.
My problem is - we've become so used to receiving low values from Medicare (and therefore commercial insurance) that we write surgery off as a non-contributor. Think the APMA people who came here. It has become so devalued that even if you double it - you think, eh, still irrelevant. Surgery has value and risk. Patient's value it. It should be worth more reimbursement.
In my locality - a 28296 paid $620ish in 2000. It pays $500 now. That's a 19% reduction through time and that's not even taking into account inflation. I do think talking about inflation dollars is sometimes problematic because there are things in my life that literally have become better and cheaper - for example, computers and even phones. I pay less for a better phone plan today than I paid in 2002. However, inflation is real and my office's health insurance went up like 8% the year before last. I didn’t calculate this year’s increase as a percentage, but personal cost out of my paycheck went up $100 a paycheck (x26)
There’s some talk recently that physician reimbursement should be inflation adjusted although no one has done anything about it. Consider that if reimbursement in 2000 had simply increased by 2% a year – for 24 years- it would not keep up with inflation, but a 29296 would be worth $1000. According to the BLS inflation calculator, $620 should now be worth $1155 now. Good commercial insurance should double Medicare in reimbursement, but Medicare "should" have doubled too.
Nothing is going to change with any of that, but here’s a different way of looking at reimbursement. Consider that certain medical specialties have been given the opportunity to bring procedures into their office / out of facilities to try and save money. I’m specifically referring to some of the atherectomy / vascular codes …that might have gotten vascular surgeons in trouble. Look up 37225. I’m probably cherrypicking, but there are bigger numbers out there.
This Researcher Warned of Unnecessary, Risky Vascular Procedures. She Was Called a “Nazi” and Accused of “Fratricide.”
We haven’t been afforded that opportunity. You can look up the non-facility codes. Medicare will throw you a few hundred more dollars to do a procedure in your office even though they potentially save thousands of dollars on ASC or hospital costs. Consider what you would be willing to do in your own office or in some sort of shared surgery suite with other podiatrists if Medicare would throw you an extra $500-2000 depending on the procedure complexity. I'm not saying we should get vascular surgery money, but there's cost savings we could offer that we won't share in.
We’ve discussed the MIS in office cash pay people on here before. I don’t know if they are all bluster and BS marketing– maybe they are just as bad as all the LinkedIn Orthoplastic Fellowship marketers – but they know to ask for more money for surgery. I’ve said on here in the past that we are sometimes “well paid” for what we do, but there’s nothing we can do that you can just do once and be done for the day. The MIS cash pay people claim to turn this on its head. If you could just show up to your office in the afternoon and do one $3-4K surgery in the office – that would probably be more than most people collect in an afternoon.
$1500 sounds nice for a bunion (because I know what I’m currently getting), but I don’t think that’s how someone in finance would value a bunion surgery if it was “invented” today. It’s certainly not how cash pay people value a bunion surgery.
I also think there’s a lot of what we do where we aren’t pricing in all the things that can go wrong in life or surgery or the expense of a practice. I was talking to someone the other day about injections. Consider that Medicare pays about $50 for an injection, or less. Some commercial insurance pays $90. $90 seems great by comparison. Its “just” sticking a needle in a person’s foot after all… in just the right place, just the right way. How much can a shot really be worth and what is good value to a patient. But just because something appears reasonably valued doesn’t mean it’s a good price for a business with an increasing overhead. Tons of BBQ restaurants have gone out of business near me because the price of brisket exploded. They all increased their prices, they all put out apologies explaining what was happening, and in the end people stopped eating at them because it was too expensive, or wasn’t good value, but sometimes an expensive price is just the price of delivering an underlying service.
I don't think the conclusions that most people are drawing are unreasonable in the context of how most podiatrists view surgery.
My problem is - we've become so used to receiving low values from Medicare (and therefore commercial insurance) that we write surgery off as a non-contributor. Think the APMA people who came here. It has become so devalued that even if you double it - you think, eh, still irrelevant. Surgery has value and risk. Patient's value it. It should be worth more reimbursement.
In my locality - a 28296 paid $620ish in 2000. It pays $500 now. That's a 19% reduction through time and that's not even taking into account inflation. I do think talking about inflation dollars is sometimes problematic because there are things in my life that literally have become better and cheaper - for example, computers and even phones. I pay less for a better phone plan today than I paid in 2002. However, inflation is real and my office's health insurance went up like 8% the year before last. I didn’t calculate this year’s increase as a percentage, but personal cost out of my paycheck went up $100 a paycheck (x26)
There’s some talk recently that physician reimbursement should be inflation adjusted although no one has done anything about it. Consider that if reimbursement in 2000 had simply increased by 2% a year – for 24 years- it would not keep up with inflation, but a 29296 would be worth $1000. According to the BLS inflation calculator, $620 should now be worth $1155 now. Good commercial insurance should double Medicare in reimbursement, but Medicare "should" have doubled too.
Nothing is going to change with any of that, but here’s a different way of looking at reimbursement. Consider that certain medical specialties have been given the opportunity to bring procedures into their office / out of facilities to try and save money. I’m specifically referring to some of the atherectomy / vascular codes …that might have gotten vascular surgeons in trouble. Look up 37225. I’m probably cherrypicking, but there are bigger numbers out there.
This Researcher Warned of Unnecessary, Risky Vascular Procedures. She Was Called a “Nazi” and Accused of “Fratricide.”
We haven’t been afforded that opportunity. You can look up the non-facility codes. Medicare will throw you a few hundred more dollars to do a procedure in your office even though they potentially save thousands of dollars on ASC or hospital costs. Consider what you would be willing to do in your own office or in some sort of shared surgery suite with other podiatrists if Medicare would throw you an extra $500-2000 depending on the procedure complexity. I'm not saying we should get vascular surgery money, but there's cost savings we could offer that we won't share in.
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It's not major surgery but podiatrists statistically certainly get sued more than orthopedists for elective foot and ankle surgery. It is because society and MD/DO do not consider us real surgeons therefore we are easier targets in my opinion. It also does not help we are so grossly saturated and everyone is fighting for a dollar that it won't be hard to find a podiatrist to testify against you. Easy $2-4K fee to review the case and throw you under the bus. Medi-mal is big business.
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The value of surgery is that it brings "prestige" to your practice. If you're a c&c doc, then that's how you'll be known. If you fix some lady's hammertoe, she might come back 6 months later because her son is on the basketball team and she thinks the brilliant surgeon can make custom orthotics for him. If you take your diabetic patients on a pus bus ride, you might get noticed and have more ulcers showing up to your practice that you can do more profitable treatments for. Maybe that's a blessing, maybe it's a curse. Obviously this doesn't work in a saturated area where there are a dozen other DPMs.
Or just do what's right for people, I find a good OR day can out-earn an average office day, while a great office day will smash anything I do on an OR day.
Or just do what's right for people, I find a good OR day can out-earn an average office day, while a great office day will smash anything I do on an OR day.
I have lost interst in bunions and elective surgery. I will still do it. But my interest is gone. Soon I think I will make transition to 100% limb salvage.
Bunions, hammertoes, et doesnt pay enough to justify doing it. 90 day global for $500-600 AND 1-2 hours time (lapidus)?
Nope. Not worth it.
Toe amps are my new money maker.
Inpatient hospital consult 2.0 RVU
Toe amputation 3.41 RVU
2 hospital follow ups 3 RVU
2 outpatient follow ups 2.6 RVU
11.01 RVU total with minimal time and effort.
If they have hammertoes I typically add in flexor tenotomies to prevent transfer ulcers to the other toes which are worth 2.97 RVU each/3 toes 9 additional RVU. Thats 20 RVU for a toe.
1k for a toe + tenotomies (my RVU reimbursement is about $50).
I get at least 1 toe amp consult a day.
Elevating osteotomy for non healing wound
Preop discussion/99214 + wound debridement 11042 2.93 RVU
MIS 3rd met osteotomy 28308 5.48 RVU
2 post op wound debridements 11042 2.02RVU
10.43 RVU for minimal time and effort.
Keller for non healing DFU hallux
Preop discussion/99214 + wound debridement 11042 2.93 RVU
Keller 7.44 RVU
2 post op wound debrideemnts 2.02 RVU
12.39 RVU minimal time and effort
Add in gastrocnemius lengthenings, sesamoidectomies, Peroneal tendon lengthening, or whatever.
And I do not feel I am doing this "to make money". I have patients referred to me from other non surgeon wound providers (as well as other DPMs) who have chronic wounds looking for a permenent cure. So I have a nice flow of steady patients looking for intervention. Im not selling anything. They are coming to me looking for surgical cure.
Its actually very rewarding to give a patient their mobility back. Ulcer for years duration. 5-15 minute surgery +2-3 weeks recovery and they are back to normal life. I feel like patients are more greatful than the bunion patients when you discharge them from the wound center after a limb threatening wound for years duration. I get a ton of thank you cards from patients with their personal stories written. Its very humbling.
It helps I am on RVU system where insurance doesnt matter.
It also helps that I am in the hospital 5 days a week and can typically get a 715 start time and be done by 8AM clinic. Round at lunch on inpatients or squeeze in another toe amp etc. Off at 5-530 most days with notes done. Block 1 day a week for the semi elective limb salvage cases.
Im loving it. Need to be a little bit busier. But im building a program/reputation and its starting to take off.
Bunions, hammertoes, et doesnt pay enough to justify doing it. 90 day global for $500-600 AND 1-2 hours time (lapidus)?
Nope. Not worth it.
Toe amps are my new money maker.
Inpatient hospital consult 2.0 RVU
Toe amputation 3.41 RVU
2 hospital follow ups 3 RVU
2 outpatient follow ups 2.6 RVU
11.01 RVU total with minimal time and effort.
If they have hammertoes I typically add in flexor tenotomies to prevent transfer ulcers to the other toes which are worth 2.97 RVU each/3 toes 9 additional RVU. Thats 20 RVU for a toe.
1k for a toe + tenotomies (my RVU reimbursement is about $50).
I get at least 1 toe amp consult a day.
Elevating osteotomy for non healing wound
Preop discussion/99214 + wound debridement 11042 2.93 RVU
MIS 3rd met osteotomy 28308 5.48 RVU
2 post op wound debridements 11042 2.02RVU
10.43 RVU for minimal time and effort.
Keller for non healing DFU hallux
Preop discussion/99214 + wound debridement 11042 2.93 RVU
Keller 7.44 RVU
2 post op wound debrideemnts 2.02 RVU
12.39 RVU minimal time and effort
Add in gastrocnemius lengthenings, sesamoidectomies, Peroneal tendon lengthening, or whatever.
And I do not feel I am doing this "to make money". I have patients referred to me from other non surgeon wound providers (as well as other DPMs) who have chronic wounds looking for a permenent cure. So I have a nice flow of steady patients looking for intervention. Im not selling anything. They are coming to me looking for surgical cure.
Its actually very rewarding to give a patient their mobility back. Ulcer for years duration. 5-15 minute surgery +2-3 weeks recovery and they are back to normal life. I feel like patients are more greatful than the bunion patients when you discharge them from the wound center after a limb threatening wound for years duration. I get a ton of thank you cards from patients with their personal stories written. Its very humbling.
It helps I am on RVU system where insurance doesnt matter.
It also helps that I am in the hospital 5 days a week and can typically get a 715 start time and be done by 8AM clinic. Round at lunch on inpatients or squeeze in another toe amp etc. Off at 5-530 most days with notes done. Block 1 day a week for the semi elective limb salvage cases.
Im loving it. Need to be a little bit busier. But im building a program/reputation and its starting to take off.
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This is the way. Every wound has an offloading solution. Then you still get paid for further wound debridements post op after the offloading surgery.
I still do elective cases and trauma and lots of charcot. But the offloading surgeries will always be there and there will always be providers who don't do it (even DPMs sadly). It's free volume. Thank you very much
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It is all situational.
For PP, you have to do what people who have insurance need done. If that's bunions or neuroma or Haglund or whatever surgery, then you just try to cluster them into a morning. You keep the PCPs happy, patients like it, it pays, and you do get paid pretty well with DME/visits/OTC before and afterwards.
The toe amps and salvage stuff you describe is perfect in your situation (wRVU), but it isn't very viable in most PP situations...
Those patients often have MCA or MCA carriers or no insurance (having a wound or disability or obesity and other DM complications isn't usually conducive to a job, FMLA runs out, etc). The cases tend to start late and/or the consults come at bad times.
I will do that wound/limb stuff (or trauma) occasionally from PP because it's a community service and there is no hospital DPM around to do it. Other PP DPMs do it because they aren't full enough in office or they like inpatient/wound work. Still, it's generally a wretched use of my time if I do an inpatient or ER consult that often pays little/nothing, a surgery that does same, AND I then take some clinic spots away from private insurance or MCR ingrowns, injects, DME, etc. The last part is the heavy hitter... those clinic spots are at a premium and need to be maximized. If I miss a new pt ingrown to do a post op on an uninsured TMA, that is a swing of $500+ lost.
I agree you need to offer surgery to have the best income, though.
In PP, it's about offering more services and making it easy for PCPs to send you all of their well-insured patients.
In hospital FTE pod, it's more about racking up RVUs with the wound/amp stuff and hitting bonuses and job security.
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100% agree. Even for me as someone in private practice these limb salvage and offloading surgeries are still profitable, rewarding and also make me known among PCPs. I once did an offloading case for a diabetic patient and of course wound healed. Previously he was at a wound care center every 2 weeks for 1 year. I now see him every 6 months. He literally brought a whole box of my business cards and gave it to the patients at his dialysis center. That of course has both good and bad implications as I was not expecting or prepared for a sudden influx of ESRD patients. But you get the point.
The elective cases are just there for me to mix and mingle with other specialists in the OR, and let PCPs know what I am capable of.
CleanDryandIntact
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Forgive my ignorance as I’m a lowly pgy1, BUT how does everyone make the decision to take the pt to surgery to offload wound when chances are they’re chronically ill w/ a lot of comorbidities ?
Doesn’t that open you guys up to a lot of complications or healing issues in those patients?
Doesn’t that open you guys up to a lot of complications or healing issues in those patients?
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Lots of these incisions are usually small, which helps. Also, go as minimal on the anesthesia as you can if really bad cardiac hx. Follow them closely after surgery to ensure success... get them on Juven/Vit. C, frequent dressing change "nurse" visits, etc. I could go on...
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You have much to learn, young padawan
But in reality, these are very simple easy procedures but very high yield. You do not need a fellowship to learn this
Even better if they’re neuropathic.
CleanDryandIntact
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For example, if pt had plantar 5th met full thickness wound that probes and you opted to do a floating met. Prior to surgery, do they need to continue wound care or can you take them, float the met and then give wound care recs bc then they’ll be able to actually heal it from a biomechanics stand point?
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I still remember as a 1st year resident thinking - damn, we operate on some old, unhealthy people. Wait till you see some of the 90 y/o corpses that ortho is willing to operate on after they fell out of a bed and broke a hip.
Have a low threshold to ask for help. Don't get surprised the day of - figure things out in the weeks/months before. Make it a point to talk to people about their medical history. If a patient who is having surgery tells you they have "heart problems" - ask what heart problems means. Ask about major medical comorbidities, exercise tolerance, how they did after prior surgeries. A lot of this is bread and butter. It really isn't complicated. But the day you don't do it is the day you get to stand there while the anesthesiologists eyes bug out and the patient is telling you this litany of things that are wrong with them that you never asked about. It is also entirely possible that you did ask - and the patient didn't tell you and then they suddenly remembered that yes, they were in the ICU earlier this year. Gosh, I forget to tell you that doc.
Have a low threshold to ask for help. Don't get surprised the day of - figure things out in the weeks/months before. Make it a point to talk to people about their medical history. If a patient who is having surgery tells you they have "heart problems" - ask what heart problems means. Ask about major medical comorbidities, exercise tolerance, how they did after prior surgeries. A lot of this is bread and butter. It really isn't complicated. But the day you don't do it is the day you get to stand there while the anesthesiologists eyes bug out and the patient is telling you this litany of things that are wrong with them that you never asked about. It is also entirely possible that you did ask - and the patient didn't tell you and then they suddenly remembered that yes, they were in the ICU earlier this year. Gosh, I forget to tell you that doc.
Yes PP vs RVU is different. Being RVU is one point but honestly the biggest plus is that I am already in the hospital every day.
My last job I was not in the hospital and driving in every day for a toe amp (or whatever) follow up sucked.
Running to med/surg floor during a no show and having to drive in is the biggest factor in profitability IMO.
Its not ignorance. Its the right thinking. But this isnt bunion surgery. Its limb salvage.
These patients are train wrecks. Their train is headed full on towards a below the knee amp. I do a LOT of local only anesthesia mostly because I dont want to wait for cardiology to sign off and they are neuropathic anyway. Or I recognize their PCP and know they wont "clear" them unless their A1c is <7.
Also it is a risk. I have a detailed convo with them that they are at risk for amputation/osteomyelitis from the surgery. But they are there with that risk anyways. They are there trying to prevent this.
I have had semi-elective offloading surgeries end up in ampuitations (two - out of 3-5 a week for 2 years since starting the new job heavy in limb salvage). But if I am offering them limb salvage surgery they are high risk to get an amp eventually anyways. So IMO its a wash.
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It's again situational.
When you work for VA/IHS, it doesn't matter (you don't want to hurt anyone... but you're basically lawsuit proof).
When you are hospital employ, you are largely shielded (it's expected you take tough cases, have complications, employer pays your malprac).
For PP, the situation is much different.
You typically pay your own malpractice (either direct as owner/1099... or as employee benefit). Those cases are a risk (pts very sick, poor healing, high amp risk).
The wheelchairs and fall risk pts and morbid obesity and similar don't gel well with an efficient + busy podiatry clinic of mostly private pts who are ambulatory and working (or at least somewhat spry).
Worse, the limb salvage stuff is just not too profitable (nearly all dialysis pts have MCR Adv type plans or MCA).
The wound/amp cases don't jive with the other surgery you're trying to do and block (elective stuff at ASCs and private hospitals that want mainly good insurance, prior auth'd, easy cases, "clean" cases).
It is pretty irresponsible to do cases on ESRD pts if the hospital you're doing them at doesn't have inpt dialysis. 99% of ASCs obviously won't let you do them. You never know when they are going to admit (for staged procedure, surgical complication, medical issue, whatever).
It's likely that you'll have a mix of attendings (PP avoiding wound/amp, hospital employ, maybe PP doing wound/amp), and you will figure out how it works. Some PP attendings figure out how to have a half dozen inpatients and cases (or make their associate go do it), but most just do minimal wound/amp stuff and try to largely be in the office or ASC.
You will see that many of the pts who are fairly simple to operate on in teaching or large or govt hospitals are not as just realistic in small/community setups. It's the logistics, the risk, the money, the med/anesth roadblocks, OR time... many things. You can still do some PP wound/amp work (and many PP pods do... I do a bit), but you have to find a way to make it fairly efficient... the "already in the hospital every day" thing that @DYK343 mentioned is huge. You need an office in, adjacent, or definitely within a mile of the hospital for it to be viable.
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Yup you sure can. MIS 2 min floating osteotomy. I let them FWB couple more weeks of wound care and voila healed. I explain to them in the simplest terms that they are walking on the knuckle bone and we gotta change that. Most of them buy into it if explained properly.
Obviously this is making sure your exam is thorough and there are not other deforming issues contributing
I really dont understand why more people dont think like this.
If you have a wound under the 1st met. We can heal it. But they will continue to have another wound under the 1st met on and off for the rest of their life. Many of which end up in a partial 1st ray amp which cascades to further amps/ulcers later
Simple Longus lengthening or sesamoidectomy solves this issue. Biomechanics is important.
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I heard of a few colleagues also remove sesamoids for sub1 ulcers. Know of any articles available for that?
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Yeah, check their w2.
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I go for PL tenotomy first-line unless they have 1st MPJ OA, in that case sesamoidectomy. If really bad sub 1st i'll combo both together.
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Try first ray resections... those get rid of the ulcer and the osteomyelitis.
THis is my approach too. Ive been burned with the tenotomy before but ive also had it work wonders.
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My got to is PL to PB deep tendon transfer, tibial sesamoidectomy +/- gastrocnemius recession. Works every time.
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We might as well write up a simple guide for offloading procedures to cure wounds. Save people the misery of a wound care fellowship
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Couldn't find anything stronger. Key words were "sesamoidectomy diabetic foot ulcer" on Google scholar.
Hybrocure
Podiatrist 2.0
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The real world study is tons of people do sesamoidectomies for first mtpj ulcers but it just sucks to do as a standalone surgery. You don’t get paid as much and sesamoid dissection blows.
Nobody wants to fiddle around with the sesamoids when they can ramp up RVUs with tendon work or just flat out amp. But honestly often there’s a huge sesamoid pressing right into that ulcer.
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Hope to see some publications on sesamoidectomy for sub1 DFU, I don’t see any data on it.
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It should never be a stand alone procedure. You don't get enough correction on it. PL to PB deep tendon transfer is needed too. If they have severe equinus then a gastroc is indicated as well. Eliminate all sources of forefoot overloading.
What I don't buy is floating metatarsal osteotomies for the first ray in a neuropathic patient and saying that if you make the bone cut a certain way the first ray won't completely dislocate. You can get away with it on lesser mets but to do it on the first met is beyond reckless.
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I get it.
Residency did PB to PL- small incision lateral, anastomose, tenotomize distal PL. They all healed, >2 year f/u, at least 5 patients.
Exactly what Retro said. Gastroc as indicated.
Never had to add tibial sesamoidectomy specifically for sub 1 ulcers but the dissection sucks, and again as mentioned we never do it isolated.
The literature was to just see if anything was out there.
Often times even if real world anecdotes work, quoting literature allows us to learn something and look a little more legitimate when talking to others.
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Gastroc always indicated
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I also want to point out the difference between the sub 1 ulcer from a cavus foot and the pronated/flat foot, large bunion sub 1 ulcer. Tendon transfer for the first and sesamoidectomy is the way to go in the second pathomechanic issue.
