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heybrother said:
I'll presumably try it again in the future. The kid I used it on failed everything so I don't know why adapalene would be any different. The wart microwave people would have us believe/know that there are HPV variants that are much more difficult to treat - perhaps that's an explanation for why some people are so treatment resistant.


I just wrote my first prescription for an unpleasant diabetic wound. Guess I'll see what I'm in for. I swear the rep wants me to write it for ingrown toenails. 👎to that.

Having reps pushing antibiotics feels really strange compared to being around Infectious Disease doctors pushing stewardship.
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I mean how much better can it be than doxy? What I prescribed it for is probably going to be an amp anyways.
 
My rep was really slick. Conversations with him and me would go this way...

Me: Hey, my patients saw the EOB and are really not comfortable with how much their insurance is getting billed.
Rep: Yeah this is totally not an issue. The specialty pharmacy is really good at getting this covered, so tell them not to worry about it. I'll stop in with some lunch for everyone in your office and we can go over the details.
Me: That's not the point...
Rep: You know what, I'll get you on a zoom call with my reimbursement specialist tomorrow morning. I'll bring some coffees so I can hop on the call.
 
Adam Smasher said:
My rep was really slick. Conversations with him and me would go this way...

Me: Hey, my patients saw the EOB and are really not comfortable with how much their insurance is getting billed.
Rep: Yeah this is totally not an issue. The specialty pharmacy is really good at getting this covered, so tell them not to worry about it. I'll stop in with some lunch for everyone in your office and we can go over the details.
Me: That's not the point...
Rep: You know what, I'll get you on a zoom call with my reimbursement specialist tomorrow morning. I'll bring some coffees so I can hop on the call.
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Tell him to go the **** away
 
DYK343 said:
I like those fish grafts. They work really well to form granulation tissue. Amazingly well actually. Especially under a vac.
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The fish grafts are legit. Just wish I could’ve been an attending back when they were generous
 
Hybrocure said:
Ah, the hand study
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We're basically Great Value hand surgeons anyway.

Don't you love it when you get that random geriatric patient every now and then that tries to get your to cut their fingernails?

go away gtfo GIF
 
Boba Foot said:
We're basically Great Value hand surgeons anyway.

Don't you love it when you get that random geriatric patient every now and then that tries to get your to cut their fingernails?

go away gtfo GIF
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I tell them to do that. GET OUT
 
Boba Foot said:
We're basically Great Value hand surgeons anyway.

Don't you love it when you get that random geriatric patient every now and then that tries to get your to cut their fingernails?

go away gtfo GIF
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Or a family member that keeps mentioning the patients fingernails..
 

APMA Opposes Rhode Island Nurse Scope Expansion​

  • Mar 31, 2025
APMA is working closely with the Rhode Island Podiatric Medical Association (RIPMA) to defeat proposed legislation, H6088, which would permit a nurse to perform routine foot care and other related foot and ankle services in home settings with no podiatric physician supervision. In support of RIPMA, APMA expressed strong opposition to the Rhode Island House Health & Human Services Committee. APMA also organized a grassroots campaign for members, office staff, and patients in Rhode Island to express their strong opposition to unsupervised nurses providing this important and nuanced care.

Read this opposition letter and other past APMA advocacy letters at www.apma.org/CommentLetters. Contact the APMA Advocacy Department with any questions or concerns.
 
MortonExtension said:

APMA Opposes Rhode Island Nurse Scope Expansion​

  • Mar 31, 2025
APMA is working closely with the Rhode Island Podiatric Medical Association (RIPMA) to defeat proposed legislation, H6088, which would permit a nurse to perform routine foot care and other related foot and ankle services in home settings with no podiatric physician supervision. In support of RIPMA, APMA expressed strong opposition to the Rhode Island House Health & Human Services Committee. APMA also organized a grassroots campaign for members, office staff, and patients in Rhode Island to express their strong opposition to unsupervised nurses providing this important and nuanced care.

Read this opposition letter and other past APMA advocacy letters at www.apma.org/CommentLetters. Contact the APMA Advocacy Department with any questions or concerns.
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"important and nuanced care" lol
 
I just received a Quality of Care/Service Concern from United Health Care.

"The allegation states that as of 3/19/25, the office of podiatrist Dermato Fight Club had informed the memeber they would not be able to assist him with trimming his toenails. Please respond to these allegations".

Patient in question is 31 years old, mentally ******ed, with no risk factors. How should I proceed?
 
Dermato Fight Club said:
I just received a Quality of Care/Service Concern from United Health Care.

"The allegation states that as of 3/19/25, the office of podiatrist Dermato Fight Club had informed the memeber they would not be able to assist him with trimming his toenails. Please respond to these allegations".

Patient in question is 31 years old, mentally ******ed, with no risk factors. How should I proceed?
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The world expects us to cut every nail, sir.
 
Dermato Fight Club said:
I just received a Quality of Care/Service Concern from United Health Care.

"The allegation states that as of 3/19/25, the office of podiatrist Dermato Fight Club had informed the memeber they would not be able to assist him with trimming his toenails. Please respond to these allegations".

Patient in question is 31 years old, mentally ******ed, with no risk factors. How should I proceed?
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The only thing insurance companies actually want us to bill them for: 11719 trimming of nondystropic nails... $14 🤣
 
Dermato Fight Club said:
I just received a Quality of Care/Service Concern from United Health Care.

"The allegation states that as of 3/19/25, the office of podiatrist Dermato Fight Club had informed the memeber they would not be able to assist him with trimming his toenails. Please respond to these allegations".

Patient in question is 31 years old, mentally ******ed, with no risk factors. How should I proceed?
Click to expand...
United Health Care?

1743537970263.png
 
Dermato Fight Club said:
I just received a Quality of Care/Service Concern from United Health Care.

"The allegation states that as of 3/19/25, the office of podiatrist Dermato Fight Club had informed the memeber they would not be able to assist him with trimming his toenails. Please respond to these allegations".

Patient in question is 31 years old, mentally ******ed, with no risk factors. How should I proceed?
Click to expand...
Will they cover it with no risk factors? Sounds like a United problem
 
While drawing a shot for a patient, another new patient's daughter came out to argue with me and tell me that she was a coder and that all I needed to do was mark Q9 and nail fungus and her dad's nail cutting would be covered. I could see her phone in her hand while she shook it and she had the Medicare class findings page open (lol, this still makes me smile). My nurse had roomed them and informed them that their nail cutting might not be covered by Medicare. I politely told her I would examine her dad to see if he had a qualifying diagnosis, that I wanted him to get the care he needed, but that Q9 would require exam findings and a systemic diagnosis to support it. She went on a tear telling me its covered all the time and paid for and she doesn't understand why I just won't do it. Again, still haven't been in the patient's room. I gently disengaged and went to give the injection. When I came out, they had left. I'm pretty big on trying to disarm combative patients (to avoid bad reviews), but no sleep will be lost over the nails I didn't get to cut.

Hilariously, the next patient told me she'd pay "anything" for me to cut her calluses.
 
This situation really makes me understand why so many podiatrists just go ahead and cave and do it (and by do it I mean commit fraud).

I would say it’s close to a coin flip on all the patients I see that were being seen regularly by another podiatrist if they qualify or not.

On one hand you make a patient happy, collect some money, and don’t have to be investigated by an insurance company and potentially be dropped because an angry patient complains that you told them they didn’t qualify.

But this is unfortunately where our profession is. Apparently we are against anyone else cutting toenails because we need them to justify so many podiatrists.

Obviously it would be much better if we instead welcomed nurses to cut nails because we are too busy with other MSK pathology etc. but that will never happen with the amount of podiatrists we continue to put out every year.
 
Dermato Fight Club said:
This situation really makes me understand why so many podiatrists just go ahead and cave and do it (and by do it I mean commit fraud).

I would say it’s close to a coin flip on all the patients I see that were being seen regularly by another podiatrist if they qualify or not.

On one hand you make a patient happy, collect some money, and don’t have to be investigated by an insurance company and potentially be dropped because an angry patient complains that you told them they didn’t qualify.

But this is unfortunately where our profession is. Apparently we are against anyone else cutting toenails because we need them to justify so many podiatrists.

Obviously it would be much better if we instead welcomed nurses to cut nails because we are too busy with other MSK pathology etc. but that will never happen with the amount of podiatrists we continue to put out every year.
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What's funny to me about it is that if this person actually knew anything about coding they should simply have argued that he had mycotic nails that were painful and limited his ambulation. But yeah, no real disagreement here.

I want to live in a world where I can drop Aetna, United, and Humana without a spot unfilled on my schedule. I'm at 2/3.
 
i mean technically no matter the Q modifiers if it’s fungal and painful doesn’t it qualify? (I don’t do like any nail care don’t hurt me)
 
As far as Q9s go, it's really murky because qualified pts exist in continuum with non qualified pts.

If they want to complain to me about their burning/tingling/cold/swollen/cramping feet, who am I to say they're fibbing?

And what are trophic skin changes really? What is atrophic skin? How sparse does pedal hair growth need to be? And of course thickened toenails? That's what gets them in the door.

Even if someone knocks on this person's door, examines their feet, and decides it wasn't really a Q9, who's to say they're right and you're wrong? How often do two different doctors offer two different diagnosis/treatment plans?

I suppose this leads to absurd scenarios where a pt could theoretically say "my feet don't feel cold today" and then the doctor says "too bad, come back for a nail trim when they do." This shows what a farce all this "important and nuanced care" really is.
 
MortonExtension said:
i mean technically no matter the Q modifiers if it’s fungal and painful doesn’t it qualify? (I don’t do like any nail care don’t hurt me)
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You're not supposed to bill against a diagnosis of "toe pain" too much because if you reschedule the pt every 9 weeks, an insurance auditor can look at this and ask "how did you know the nails were going to start hurting again in 9 weeks?"

I truly detest these considerations, it makes me feel like an adult film actress negotiating with a producer different contracted rates for where the money shot will end up
 
MortonExtension said:
i mean technically no matter the Q modifiers if it’s fungal and painful doesn’t it qualify? (I don’t do like any nail care don’t hurt me)
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I think it depends on the MAC you're in. I'm pretty sure that without a Q modifier the claim gets automatically denied by Medicare (this is what my billers tell me)
 
MortonExtension said:
i mean technically no matter the Q modifiers if it’s fungal and painful doesn’t it qualify? (I don’t do like any nail care don’t hurt me)
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Essentially - though I believe technically you can only bill the painful mycotic nails which means the code should be 11720 slightly more often then not because what are the odds 6+ nails are painful or that all 10 are painful... So you're at maybe $30. Do you then tell the patient they have to pay for the other nails? If they ask for a callus to be trimmed do you tell them its uncovered.
Adam Smasher said:
As far as Q9s go, it's really murky because qualified pts exist in continuum with non qualified pts.

If they want to complain to me about their burning/tingling/cold/swollen/cramping feet, who am I to say they're fibbing?

And what are trophic skin changes really? What is atrophic skin? How sparse does pedal hair growth need to be? And of course thickened toenails? That's what gets them in the door.

Even if someone knocks on this person's door, examines their feet, and decides it wasn't really a Q9, who's to say they're right and you're wrong? How often do two different doctors offer two different diagnosis/treatment plans?

I suppose this leads to absurd scenarios where a pt could theoretically say "my feet don't feel cold today" and then the doctor says "too bad, come back for a nail trim when they do." This shows what a farce all this "important and nuanced care" really is.
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I don't disagree with you. While the lady was yelling at me I looked into the room and saw that his shoes were still on (fire my nurse) but that his leg appeared swollen/pigmented/with varicose veins. Its entirely possible that if I'd made it into the room that he'd have qualified. He was upper 80s. A lot of old people look like they hit the tissue B findings through age alone.
Adam Smasher said:
I truly detest these considerations, it makes me feel like an adult film actress negotiating with a producer different contracted rates for where the money shot will end up
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Podiatry Pornstars. All scenes, $32.
Dermato Fight Club said:
I think the simplest thing to do is just say you have neuropathy and not admit to feeling anything.
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You technically still need some vascular embarrassment findings. Maybe you could use those stupid LOPS G codes.
pod squad said:
I think it depends on the MAC you're in. I'm pretty sure that without a Q modifier the claim gets automatically denied by Medicare (this is what my billers tell me)
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Airbud was literally getting to combine 11055 + callus + pain in his prior MAC/LCD. What a world.
 
In other news, my Nuzyra prescription fell apart. I wrote it on a Friday. I gave the pharmacy my cell phone number. No call. The rep came on Monday asking us to send notes and to fill out paperwork. He said the patient's insurance didn't qualify but if he made under like $51K it would be free. I immediately sent the notes and everything they asked for. Then the patient's wife called and said he had an important meeting and couldn't come to his follow-up. What? A day or later the company sent us an email claiming they'd been asking us for things and we hadn't sent it so they'd cancelled the prescription. Then the rep text me telling me he was so sorry that things fell through and to please consider them in the future. This was the same rep I'd told that I would be sending the prescription and he'd told me he'd follow on it and make sure it succeeded.

I didn't reply because what's the point - maybe I would want to try again in the future, but all I could think was - WTF, I did everything that was asked of me. Did the patient cancel because he's crazy or because he was pissed about the expensive prescription - I'll never know. Next person gets 2 generics unless there's a really damn good reason.

--
Had some people that I've written fluconazole for off label for onychomycosis. Interestingly quite a few articles on it. Definitely not perfect, but will be curious to see how they do / have another prescription oral option. If someone has an article that burns me down on this let me know, but I read 3 or 4 articles. One of them essentially states all dosing options ie. 100-400 mg, once weekly, are similar. Another implied 400mg once per week was more effective.
 
the sample antibiotics my Nuzyra rep gave me is worth more than my car.

My first rx for it turned into a disaster as well. I’m not using them again. The rep is very very persistent.
 
Dermato Fight Club said:
This situation really makes me understand why so many podiatrists just go ahead and cave and do it (and by do it I mean commit fraud).

I would say it’s close to a coin flip on all the patients I see that were being seen regularly by another podiatrist if they qualify or not.

On one hand you make a patient happy, collect some money, and don’t have to be investigated by an insurance company and potentially be dropped because an angry patient complains that you told them they didn’t qualify.

But this is unfortunately where our profession is. Apparently we are against anyone else cutting toenails because we need them to justify so many podiatrists.

Obviously it would be much better if we instead welcomed nurses to cut nails because we are too busy with other MSK pathology etc. but that will never happen with the amount of podiatrists we continue to put out every year.
Click to expand...
It's ****ing sad. Clinging to nails because they flooded the market with podiatrists
 
Adam Smasher said:
As far as Q9s go, it's really murky because qualified pts exist in continuum with non qualified pts.

If they want to complain to me about their burning/tingling/cold/swollen/cramping feet, who am I to say they're fibbing?

And what are trophic skin changes really? What is atrophic skin? How sparse does pedal hair growth need to be? And of course thickened toenails? That's what gets them in the door.

Even if someone knocks on this person's door, examines their feet, and decides it wasn't really a Q9, who's to say they're right and you're wrong? How often do two different doctors offer two different diagnosis/treatment plans?

I suppose this leads to absurd scenarios where a pt could theoretically say "my feet don't feel cold today" and then the doctor says "too bad, come back for a nail trim when they do." This shows what a farce all this "important and nuanced care" really is.
Click to expand...
Yeah. The reality is you could qualify a lot of people if wanted to and coached....but much easier to just tell them GTFO. Play dumb. My interpretation of the rules ...
 
Adam Smasher said:
As far as Q9s go, it's really murky because qualified pts exist in continuum with non qualified pts.

If they want to complain to me about their burning/tingling/cold/swollen/cramping feet, who am I to say they're fibbing?

And what are trophic skin changes really? What is atrophic skin? How sparse does pedal hair growth need to be? And of course thickened toenails? That's what gets them in the door.

Even if someone knocks on this person's door, examines their feet, and decides it wasn't really a Q9, who's to say they're right and you're wrong? How often do two different doctors offer two different diagnosis/treatment plans?

I suppose this leads to absurd scenarios where a pt could theoretically say "my feet don't feel cold today" and then the doctor says "too bad, come back for a nail trim when they do." This shows what a farce all this "important and nuanced care" really is.
Click to expand...
Medicare doesnt cover dental, vision, hearing.
How long until they stop covering toenails?
Its a huge expense to them. Ripe with fraud.
 
I still say that seniors will line up behind their walkers on the National Mall in protest if Medicare ever stops paying for toenails
 
DYK343 said:
Medicare doesnt cover dental, vision, hearing.
How long until they stop covering toenails?
Its a huge expense to them. Ripe with fraud.
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Oh this is good. I am going to use this
 
DYK343 said:
Medicare doesnt cover dental, vision, hearing.
How long until they stop covering toenails?
Its a huge expense to them. Ripe with fraud.
Click to expand...
This would reduce the amount of pods by about 50% I would guess. Many would have to find a completely different job.
 
Much as I hate to derail a scintillating discussion about toenails into petty political debating, but I have to comment how funny it is how government creates incentives by subsidizing certain economic activity. Create subsidies, companies arise to collect them. Remove the subsidies, and the companies are shuttered by the unforgiving forces of the free market. In podiatry, our subsidy comes in the form of medicare reimbursement, and we've grown an entire industry around toenails.

Anyone should be able to go to a pedicurist for a quick trim and pay no more than a Supercuts haircut for it. But why pay that when you can get it done for free by Dr Smasher? So the pedicurists are crowded out of the market.
 
Anyone else get non-diabetic patients who demand nail care and demand to come in every 60 days. No idea if I'm getting paid or not but these few patient's keep finding their way back into my clinic.
 
bloxxeeey said:
Anyone else get non-diabetic patients who demand nail care and demand to come in every 60 days. No idea if I'm getting paid or not but these few patient's keep finding their way back into my clinic.
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Technically anyone with PAD and Q findings can do this
 
bloxxeeey said:
Anyone else get non-diabetic patients who demand nail care and demand to come in every 60 days. No idea if I'm getting paid or not but these few patient's keep finding their way back into my clinic.
Click to expand...
Which component of this are you questioning
-The fact they are non-diabetic or
-The fact that they are coming "every 60 days)

1. This is the language concerning frequency in my MAC's online documentation.

Routine foot care services performed more often than every 60 days will be denied unless documentation is submitted with the claim to substantiate the increased frequency. This evidence should include office records or physician notes and diagnoses characterizing the patient's physical status as being of such an acute or severe nature that more frequent services are appropriate.

2. There's actually a huge list of qualifying conditions

LCD - Routine Foot Care (L35138)

Use this page to view details for the Local Coverage Determination for Routine Foot Care.
www.cms.gov www.cms.gov

Routine Foot Care General Information

www.novitas-solutions.com www.novitas-solutions.com

3. And there's also just plain old mycotic nails + pain + infection + limitation to ambulation etc.

Not knowing whether you are getting paid or not is a problem to me. You can't grow into your billing knowledge if you don't know how claims are being processed.

Additionally - some of these patients likely should be being told that they are self-pay. Now - here's the fun question. What do you think you deserve for cutting 10 toenails? What do you think a patient would be willing to pay for it. If you go over to IPED some of the people are accepting cash payments for trivial amounts - amounts in line with Medicare. Its been joked about on here before by Natch that he wouldn't do it for any amount of money, but I've met others who said they'd happily bust a crumbly for $100.
 
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