TFP Thread

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heybrother said:
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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Our nail clinic does it for $35. I’d consider letting them in the clinic if I got some percent of that from the hospital and maybe bumped it up to $75-100 for the sake of my sanity.
 
Bluecollarmed said:
Our nail clinic does it for $35. I’d consider letting them in the clinic if I got some percent of that from the hospital and maybe bumped it up to $75-100 for the sake of my sanity.
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RVU I get about $25.
No overhead though.
Without a 9921x its not worthwhile.

I only accept diabetics with neuropathy for nails. No exceptions. None. If thats not in their chart they are told no by scheduling department. This helps filter a lot of the crap out. It also means they are typically more complex and more worth my time. With this patient population adding a 9921x is pretty standard given how sick most of them are. Rarely do I just cut nails on their visit.
 
DYK343 said:
RVU I get about $25.
No overhead though.
Without a 9921x its not worthwhile.

I only accept diabetics with neuropathy for nails. No exceptions. None. If thats not in their chart they are told no by scheduling department. This helps filter a lot of the crap out. It also means they are typically more complex and more worth my time. With this patient population adding a 9921x is pretty standard given how sick most of them are. Rarely do I just cut nails on their visit.
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You're in good company then. Every true TFP knows there's a 99213 waiting to be discovered admidst the nails, dry skin, cold feet, etc.
 
Anyone have a billing/coding company recommendation? I currently work for a MSG but it doesn't appear that our practice is much of a priority.
 
edog10 said:
Anyone have a billing/coding company recommendation? I currently work for a MSG but it doesn't appear that our practice is much of a priority.
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Get a local, or at least in-state, one.
They'll know the payers (and people at them), have relationships, understand the game much better than any of the 'clearinghouse' national ones.

Not sure how it's up to you if you are employed, though?
 
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
 
MortonExtension said:
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
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Just bill aggressively. If you charge two-three copays in a row on them, most will probably bitch and leave. Of course your online reviews are gonna take a hit.
 
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MortonExtension said:
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
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Medicare doesn't cover eyes, ears, teeth ....or nails. You are busy now....you don't have time for that stuff. Find someone else. You are not obligated to cut someone's toenails. Ultimately you need admin to understand your time is more valuable than cutting nails.
 
You need to manage your schedule. From a business perspective, toenails are useful to fill empty space in your schedule, but they will schedule follow ups 2-3 months in advance and quickly clutter your schedule and crowd out real patients. You need to have designated nail care slots and designated non-nail care slots. Unfortunately, admin/managers are good at pretending to be stupid about how to do this, and you may need to be the person who makes these annotations, no one else will do it for you.
 
MortonExtension said:
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
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You just tell schedulers you don’t see patients looking for nail care and “most” of them will never get scheduled. It’s pretty simple really. Nobody can force you to treat every pathology that is within your scope. Just say no. Of course, a few people will lie to your schedulers or your staff will be in a hurry and won’t ask appropriate questions before putting the patient on your schedule. But that should be pretty limited and when those patients do show up, tell them you don’t perform routine foot care and they wont schedule follow up.
 
MortonExtension said:
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
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Hire an associate... oh wait, you are one. 🙂

Personally, I don't encourage nail pts/refers, but I don't refuse them. They're a fine break, and they have fair to great insurance (as opposed to ER/UC/inpt who might have MCA or nothing at all).

I like to see nearly half my ~16-20pt sched RFC pts on Mondays (just less drama or things that can go wrong), then just 0-4 nail pts/day on Tue Wed Thu (admin/off Fri).

As was said, it's your schedule... if you don't control and structure it, other ppl will.

Wrestling Manager GIF by Howdy Price
 
MortonExtension said:
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
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I had this happen to me at my last practice. I got floooooooded with non qualifying nail care requests. Flooded. It was awful. He did about 30 nail care patients a day and almost all of them wanted to come to my schedule as I was basically across the street and he recommended me.

When I told them no the negative reviews started.

A retiring TFP is a bad thing for your online google ratings.
 
MortonExtension said:
This TFP closed shop near me and all he did was nail care. His patients have found out about me unfortunately. Any suggestions on how to limit them or turn them away gently?
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Same past experience.
I always wondered what the other TFP down the street was doing. Never in the OR. I should have known.
The patients started rolling in. "My insurance says you can cut my nails every XX days".
Lots of these patients had weird insurance replacement plans & who the hell know's "if" or to "what extent" you will get paid.

Few things I did to cull the herd:
  • If no Diabetes. $65 self pay.
  • If you actually meet some Q codes. RTC every 3-4 months. None of this 62 days mess.
  • If you run into problems in the interim. Call me.
  • Some patients I just informed that my office doesn't have the staff to see them as frequent as they would like.
Of course, always be nice.
The soccer mom with MIS bunion or Achilles repair or her child that you stayed late to do the IGTN won't leave a good Google review.
But, the old ladies daughter will certainly leave a 1-star banger if you didn't provide some top notch, 11721 nail care.

Which makes me really think about the whole Google Review thing......
 
Carbon13 said:
Same past experience.
I always wondered what the other TFP down the street was doing. Never in the OR. I should have known.
The patients started rolling in. "My insurance says you can cut my nails every XX days".
Lots of these patients had weird insurance replacement plans & who the hell know's "if" or to "what extent" you will get paid.

Few things I did to cull the herd:
  • If no Diabetes. $65 self pay.
  • If you actually meet some Q codes. RTC every 3-4 months. None of this 62 days mess.
  • If you run into problems in the interim. Call me.
  • Some patients I just informed that my office doesn't have the staff to see them as frequent as they would like.
Of course, always be nice.
The soccer mom with MIS bunion or Achilles repair or her child that you stayed late to do the IGTN won't leave a good Google review.
But, the old ladies daughter will certainly leave a 1-star banger if you didn't provide some top notch, 11721 nail care.

Which makes me really think about the whole Google Review thing......
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I’ve been hit w the you didn’t trim the nails on time from an infected ulcer patient family member before.

Like sorry. They came in with an abscess and draining pus. Breaking out the nail nippers wasn’t a priority
 
Hybrocure said:
I’ve been hit w the you didn’t trim the nails on time from an infected ulcer patient family member before....
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Those are the best: post op major recon or amps or infection situations or even acute Charcot or trauma... and they want nail care then and there.

It really makes ya look at your white coat and diplomas on the wall, and you just have to contemplate the meaning of life.

Wide Eyes What GIF


It's not the ego part (for me), but it's just that the patient doesn't realize the trivial nature of RFC in the moment (or doesn't realize the gravity of the more major situation?).

...I was fortunate to train with a vascular surgeon who'd trim the nails in the OR after a BKA, bypass fem pop, etc. He used the bone forceps. Dude never once asked me to do it even though he knew I was podiatry resident. He just did it because they needed it. He did have me or the gen surg residents do the closure or a toe amp after bypass or wound debride, etc. The nail care was simply what they needed and what he'd probably seen go to amps before. He'd do it himself as if it was part of the bandaging, and I'm positive he didn't bill for it.
 
Feli said:
Those are the best: post op major recon or amps or infection situations or even acute Charcot or trauma... and they want nail care then and there.

It really makes ya look at your white coat and diplomas on the wall, and you just have to contemplate the meaning of life.

Wide Eyes What GIF


It's not the ego part (for me), but it's just that the patient doesn't realize the trivial nature of RFC in the moment (or doesn't realize the gravity of the more major situation?).

...I was fortunate to train with a vascular surgeon who'd trim the nails in the OR after a BKA, bypass fem pop, etc. He used the bone forceps. Dude never once asked me to do it even though he knew I was podiatry resident. He just did it because they needed it. He did have me or the gen surg residents do the closure or a toe amp after bypass or wound debride, etc. The nail care was simply what they needed and what he'd probably seen go to amps before. He'd do it himself as if it was part of the bandaging, and I'm positive he didn't bill for it.
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It all comes down to nails. Even trimming nails on a BKA
 
Carbon13 said:
Same past experience.
I always wondered what the other TFP down the street was doing. Never in the OR. I should have known.
The patients started rolling in. "My insurance says you can cut my nails every XX days".
Lots of these patients had weird insurance replacement plans & who the hell know's "if" or to "what extent" you will get paid.

Few things I did to cull the herd:
  • If no Diabetes. $65 self pay.
  • If you actually meet some Q codes. RTC every 3-4 months. None of this 62 days mess.
  • If you run into problems in the interim. Call me.
  • Some patients I just informed that my office doesn't have the staff to see them as frequent as they would like.
Of course, always be nice.
The soccer mom with MIS bunion or Achilles repair or her child that you stayed late to do the IGTN won't leave a good Google review.
But, the old ladies daughter will certainly leave a 1-star banger if you didn't provide some top notch, 11721 nail care.

Which makes me really think about the whole Google Review thing......
Click to expand...
I hate Google reviews and these nail patients are the most demanding annoying ones
 
I charge $90 for uncovered nails. I run it through Square so its like 2.5% credit card fee. My Athena fee exceeds 8%.

Not even considering fees (which make the math even worse), Aetna commercial reimburses my practice less than $90 for which of the following visits.

(a) 99212
(b) 999212, 99213
(c) 99212, 99213, and 99203
 
thoughts on cutting warts out in office? Seems like it should be fine. Numb them up. Cut it out. Blade is already sterile. Maybe prep the area with betadine. See ya one time when the global is up. Could use silver nitrate instead of bovie.
 
Homo sapien said:
I do. I use lido with epi. Numb and cut. Suture if it's huge.
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Good discussion for the TFP thread: do we believe in these dogmas?

1. No epi in digits?
2. What about marcaine in pediatric patients? I was taught no on this but I feel it could be dogma
 
MortonExtension said:
Good discussion for the TFP thread: do we believe in these dogmas?

1. No epi in digits?
2. What about marcaine in pediatric patients? I was taught no on this but I feel it could be dogma
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I have done both. Lidocaine has a short half life so I don't think it will contract long enough to cause ischemia


I'm not mainlining the vena cavae so I use marcaine and lidocaine in kids with no ill effects
 
I use epinephrine in toes and marcaine in children. I once accidently did an epi block on a lady with raynaud's. She had a bad vasospasm but was ok. I won't do that again.

I excise warts in office every now and then. I do recommend closing with 1-2 stitches, because secondary intention healing is painful for patients. Because this is the TFP thread, I should point out that a series of 11710's pay better than one 1142x.
 
Adam Smasher said:
I excise warts in office every now and then. I do recommend closing with 1-2 stitches, because secondary intention healing is painful for patients. Because this is the TFP thread, I should point out that a series of 11710's pay better than one 1142x.
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yeah I only have cut out two that I haven’t been able to treat with just debridements. How often do you guys bring back your plantar wart patients that you’re debriding? I’m doing every two weeks but that may be quite soon.
 
MortonExtension said:
yeah I only have cut out two that I haven’t been able to treat with just debridements. How often do you guys bring back your plantar wart patients that you’re debriding? I’m doing every two weeks but that may be quite soon.
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I do 2 weeks with adapalene. In office I use silver nitrate or cantharone. Sometimes if the pt is in a time crunch I recommend excision then. Fit the treatment course to the person
 
I use epi for my punch biopsies in clinic. Have had too many partial/broken samples grabbing those cores out blind w all the blood coming out. Epi makes a huge difference. I do it for warts too
 
MortonExtension said:
thoughts on cutting warts out in office? Seems like it should be fine. Numb them up. Cut it out. Blade is already sterile. Maybe prep the area with betadine. See ya one time when the global is up. Could use silver nitrate instead of bovie.
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There is just no need.

90% will get better with debride + sali. (some of those get sent home with small jar sali to use between office tx, if they don't have OTC stuff)
5% will be offered canth at some point (then more sali).
5% get cimetidine 12wks (works better in peds than adults, but it can work for both)
Maaaybe 2% are candidates for sharp excision (either don't want more topical, TONS of lesions, and/or they're stuck after the above).

If I'm going to do sharp excision, it's in the OR. I want best visualization, best instruments, best lighting, best hemostasis. For me, sharp is lido (50/50 plain and epi) under the lesions, then
cut full thickness ellipse with pointed ends with 15 blades,
sharp curette (Volkmann type) to scoop out the lesions (try not to violate basement membrane,
send path sample,
bovie,
rinse,
silvadene and dsg.

Can it be done in office? Sure... like anyting, there's a difference between can and should. Those plantar foot injects are PAINFUL. The blood freaks out some ppl (many wart pts are peds). It's a great way to disturb your wait room and frustrate yourself if you do wart sharp excisions, lol. The stakes are high for warts that have resisted many office tx sessions, so I want it done right and optimally. It's an unnecessary risk and not best results to do it in office imo. Again, can vs should.

I would consider sharp excision for a no insurance / high deductible pt... but that'd be a 0.001% wart patients. It would also have to be just a few verruca sites (which almost never get to that point... they heal with basic tx above).
 
Feli said:
Can it be done in office? Sure... like anyting, there's a difference between can and should. Those plantar foot injects are PAINFUL. The blood freaks out some ppl (many wart pts are peds). It's a great way to disturb your wait room and frustrate yourself if you do wart sharp excisions, lol. The stakes are high for warts that have resisted many office tx sessions, so I want it done right and optimally. It's an unnecessary risk and not best results to do it in office imo. Again, can vs should.

L
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A lot of my patients can barely tolerate the debridement. I tell them the injection would be more painful when they suggest it. How do you deal with patients who cry in pain from wart debridements?
 
MortonExtension said:
A lot of my patients can barely tolerate the debridement. I tell them the injection would be more painful when they suggest it. How do you deal with patients who cry in pain from wart debridements?
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I hate to sound like Caesar the dog trainer, but some of that is on you (your being mellow, relaxed). 🙂

I just explain what we'll do (take off some callus dead skin on the surface), clean it, "let me know if it starts to get too tender," and my assist and I will make small talk while I shave it with 15 blades. When they say it hurts, I try to do a tad more, apply the sali with 1" or 2" band aids occlusion + wrap to be left on 24-72hrs.

If they get the take-home sali crm jar, they get print instructions for pumice or emery stick lesions as much as they can tolerate before applying it (q1-2wks for q1-2d each application).
 
Feli said:
I hate to sound like Caesar the dog trainer, but some of that is on you (your being mellow, relaxed). 🙂

I just explain what we'll do (take off some callus dead skin on the surface), clean it, "let me know if it starts to get too tender," and my assist and I will make small talk while I shave it with 15 blades. When they say it hurts, I try to do a tad more, apply the sali with 1" or 2" band aids occlusion + wrap to be left on 24-72hrs.

If they get the take-home sali crm jar, they get print instructions for pumice or emery stick lesions as much as they can tolerate before applying it (q1-2wks for q1-2d each application).
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Yeah I figured it’s just getting the patient to suck it up but was curious if I was missing anything, had a run of 10 year olds and they were obviously way worse to debride
 
SoleSucking said:
Yeah this is basic nail stuff but do you guys ever have to work up PAD for ingrown nails? These are super annoying. 75 year old, controlled diabetic, nonpalp pulses x rays shows calcified vessels even digital ones. Fibrotic slough to the nail border and a small eschar and the toe looks red with the purpleish hue.

Feels like you can’t just do a temporary nail avulsion without going through all these vascular workup steps.. I actually did one once because I justified it by saying “well it’s infected” and because the patient refused vascular studies and it turned to a mess.

is there anything to do in the meantime for these patients besides oral abx/mupirocin or betadine while you’re waiting for vasc studies and a possible vasc referral..

Any like gimmicky soaks/cotton balls or whatever?
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Yeah, stay the eff away from that stuff... I would just betadine + abx for that until they get "optimized" by true vasc workup.

Don't do the workups yourself at all... send them to vasc.

Are these clinic pts? Hospital consults? ECF?

I have had no problems myself on PAD ingrowns as I have avoided them (a couple close calls with slow healing on total or partial nail avulsion), but I've seen many ingrown procedures from other DPMs that went to dry gangrene, osteo, wet gangrene, or worse. I've seen many new grads mess that stuff up... sometimes senior owners too. I don't think it's greed.... just underestimating the effect of PAD on healing a "minor procedure." It is terrible to make an ingrown into cellulitis/wound/gangrene mess that causes a BKA.

As a general rule, I won't do phenol for ingrowns on smokers over ~50yo or anyone over ~80-85yo (avulsion only... sometimes nothing). On those with really suspect vasc exam (any age), you don't even want to do the injection digital block - even that can lead to problems with fragile digital vessels. Those are no-win situations. You don't want to do them at all. If they are seriously infected or trying to force the issue, try to turf to local wound wizard pod (hospital employed or PP and silly enough to take those types of pts and consults). 🙂
 
SoleSucking said:
Yeah this is basic nail stuff but do you guys ever have to work up PAD for ingrown nails? These are super annoying. 75 year old, controlled diabetic, nonpalp pulses x rays shows calcified vessels even digital ones. Fibrotic slough to the nail border and a small eschar and the toe looks red with the purpleish hue.

Feels like you can’t just do a temporary nail avulsion without going through all these vascular workup steps.. I actually did one once because I justified it by saying “well it’s infected” and because the patient refused vascular studies and it turned to a mess.

is there anything to do in the meantime for these patients besides oral abx/mupirocin or betadine while you’re waiting for vasc studies and a possible vasc referral..

Any like gimmicky soaks/cotton balls or whatever?
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I don’t mess with these at all. I had a patient referred to me who got an outside matrix w PAD that ended in a BKA.

Debride the nail. Put them on abx til revasc.
 
I got my doppler off ebay, was about $700

Remember, toenails are just skin appendages, so simple avulsions (no matrixectomy) are going to be safe. Or at least it's a risk/benefits estimation. I've done avulsions liberally in pad pts and have been lucky...so far

I've made this comparison before: to say that a toenail procedure caused an amputation is like saying the assassination of Francis Ferdinand caused WWI. Yes it catalyzed things, but all the stuff happening in the decades prior led up to it and it was bound to happen no matter what.
 
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