TFP Thread

[air bud]

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I think you meet the wrong patient it’s going to get you. I just happened to have mine early in my career that I learned my lesson on. I too thought a simple avulsion can’t cause much harm, and as uncle @Feli mentioned I think even the injection did harm as he got a wound by that.

Was this patient neuropathic? Did you even need to numb them up? Doing a simple avulsion on neuropathy it's fine to just rip that baby off, no local needed.

 

[air bud]

Maybe could have looking back but didn’t even consider at the time that even an injection could do that much damage. If I can’t feel pulses I really think from now on it’s slant back/abx/betadine until I have studies.

That’s what the few articles on this essentially recommend full vascular workup too. So I would say that’s standard of care.

I don’t have enough vascular docs in my area to just send them every pad patient so I’m trying to filter them before I hit the “vascular” button like the lizard meme.

View attachment 408852.

Feeling pulses is overrated. You would never do any ingrowns then....i maintain use your brain. This is an ingrown nail. How can you kill a tow with the physical act of removing a nail. First of all, if ever a concern it's a total not a partial. Can generally do a total much less a traumatically than a partial. Anyway....takes time and experience. Obviously this approach works until it doesn't.

 

[DYK343]

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.

I have about 10 vasculopaths that return about every 6-9 months for their partial nail avulsion
No way in hell im doing a matrixectomy.

I have an inherited Vasculopath patient now with a hallux amp and 3/4 of the dorsal foot soft tissue absent due to nec fasc from a matrixectomy another DPM did. STSG this coming friday after a month of kerecis/vac/debridements/and a revasc.

 

[DYK343]

Can generally do a total much less a traumatically than a partial. Anyway....takes time and experience.

Wait... Total is less traumatic than a partial?
What is this technique?

 

[Adam Smasher]

I have about 10 vasculopaths that return about every 6-9 months for their partial nail avulsion
No way in hell im doing a matrixectomy.

I have an inherited Vasculopath patient now with a hallux amp and 3/4 of the dorsal foot soft tissue absent due to nec fasc from a matrixectomy another DPM did. STSG this coming friday after a month of kerecis/vac/debridements/and a revasc.

I think I posted about this before, but I once did a matrixectomy on an 80 year old lady who probably had pad. She developed a patch of skin necrosis at the nail fold that never really healed. I lost her to follow up but heard about her a few months later from another podiatrist with whom I had a cordial relationship. Toe was gangrene. Not completely, but enough to probably require amputation. I didn't get blamed, but I dodged a bullet.

 

[Feli]

I think I posted about this before, but I once did a matrixectomy on an 80 year old lady who probably had pad. She developed a patch of skin necrosis at the nail fold that never really healed. I lost her to follow up but heard about her a few months later from another podiatrist with whom I had a cordial relationship. Toe was gangrene. Not completely, but enough to probably require amputation. I didn't get blamed, but I dodged a bullet.

Yeah.... and this would be the rare circumstance where the toe amp even heals. (most often gets chased more and more proximal)

Just say no on these, guys.

 

[Stormblest]

I am doing Qutenza on 2 or 3 patients this Friday for first time. Will report back in 6 to 9 months

Any update on this. I am looking at maybe trying it on a patient or two.

 

[Adam Smasher]

Any update on this. I am looking at maybe trying it on a patient or two.

I was doing Qutenza on about 10 pts and never got past round 3. Nobody had severe pain. Nobody got any better. A lot of them felt like their time was wasted.

 

[Feli]

I was doing Qutenza on about 10 pts and never got past round 3. Nobody had severe pain. Nobody got any better. A lot of them felt like their time was wasted.

Yeah, but you're missing the point... you got $400 for each application?

 

[Adam Smasher]

Yeah, but you're missing the point... you got $400 for each application?

Nah I just billed 99213s for doing it. I was skeptical about getting reimbursed and being stuck with the purchase price for the drug so I ordered the patches through a specialty pharmacy and stayed out of the buy-and-bill game completely. The specialty pharmacy did give me a very nice travel mug as a gift, however.

 

[air bud]

Any update on this. I am looking at maybe trying it on a patient or two.

I had one guy who I thought might kill me cuz he was in so much pain post-operatively but this guy his nerves were just fried. He was on Suboxone every possible neuropathy drug topical stuff and crazy. He did not come back for a second application.


Just did another lady the other day but I don't have any short-term or even medium-term results.

 

[air bud]

And yes, my hospital and pharmacy is set up where it's financially beneficial for them to do it. So I'm not involved in any of that I just apply it.

 

[Feli]

Nah I just billed 99213s for doing it. I was skeptical about getting reimbursed and being stuck with the purchase price for the drug so I ordered the patches through a specialty pharmacy and stayed out of the buy-and-bill game completely. The specialty pharmacy did give me a very nice travel mug as a gift, however.

64640 (plus e/m) if you do it again.

99213 for 30min treatment, using an exam room probably ~40+ mins, and taking vitals twice? 😳

 

[Adam Smasher]

64640 (plus e/m) if you do it again.

99213 for 30min treatment, using an exam room probably ~40+ mins, and taking vitals twice? 😳

64640 is a nice paying code that the rep tells you to use. It is described in the cpt manual as a targeted destruction of a peripheral nerve however, and I don't believe a patch satisfies that description. Just my opinion.

But it's a stable chronic problem with prescription drug management, so 99213 works in my book. I scheduled people during my lunch break and had my assistants dismiss them after their 30 min was up. Like I said, this worked for basically no one so I didn't bother refining the workflow.

 

[DYK343]

64640 is a nice paying code that the rep tells you to use. It is described in the cpt manual as a targeted destruction of a peripheral nerve however, and I don't believe a patch satisfies that description. Just my opinion.

But it's a stable chronic problem with prescription drug management, so 99213 works in my book. I scheduled people during my lunch break and had my assistants dismiss them after their 30 min was up. Like I said, this worked for basically no one so I didn't bother refining the workflow.

pays a whopping 2 wRVU

 

[Feli]

64640 is a nice paying code that the rep tells you to use. It is described in the cpt manual as a targeted destruction of a peripheral nerve however, and I don't believe a patch satisfies that description. Just my opinion.
...Like I said, this worked for basically no one so I didn't bother refining the workflow.

Yeah, I agree fully. ^^

I don't have the physical space to lose exam rooms that long (nor do I think it'd do much), so I won't be trying it.
But that code is the CPT a fair number of pods are using on it. We'll see how long that lasts.

I will just stick with the basic glucose control, topicals and PO for neuropathy... PT if they're keen to that.

It is basically just another version of amnio grafts on wounds or sclerosing injects for neuromas... do basically nothing but bill fair/good to certain payers. Then, those codes go away - or get lowered significantly - due to mass overuse. Classic podiatry.

pays a whopping 2 wRVU

Yeah, I don't think it's anything viable in the hospital setting... you'd probably just have wound RN apply it and be "supervising" from the next hallway or whatever. That is assuming you believed in it.

It pays a fair bit more in non-facility for many commercial and entitlement insurances, but again... does it work at all? 🙂

 

[DYK343]

I don't have the physical space to lose exam rooms that long

you'd probably just have wound RN apply it and be "supervising" from the next hallway or whatever.

Exactly. Losing a room for 1hr is not in any way shape or form worth it.

Unless it actually worked really well and then I would do it in select patients.

But it doesnt. So.... not worth it.

 

[Stormblest]

I’m not asking if it pays well. I’m asking if anyone had success with it. That is a fair point about taking up exam room space though.

 

[Adam Smasher]

64640 reimbursed me around $200 the one time I billed it, and I think that's nice. For <5min of patient facing time, a templated note, and 30 min of real estate, even getting a 99213 is a no-brainer to squeeze into my schedule while doing admin stuff or grinding toenails in other rooms. It's like seeing $5 on the ground at your feet, is your time too valuable to bend over and pick it up?

 

[619]

It's like seeing $5 on the ground at your feet, is your time too valuable to bend over and pick it up?

Depends on where you are and who is standing behind you.

 

[Hybrocure]

64640 reimbursed me around $200 the one time I billed it, and I think that's nice. For <5min of patient facing time, a templated note, and 30 min of real estate, even getting a 99213 is a no-brainer to squeeze into my schedule while doing admin stuff or grinding toenails in other rooms. It's like seeing $5 on the ground at your feet, is your time too valuable to bend over and pick it up?

I dont pick up any bills off the ground. Seen too many prank videos. Best case scenario you pick it up and feel bad because someone lost it.

Not worth it. Maybe I’m not cut out to be a podiatrist.

 

[air bud]

I dont pick up any bills off the ground. Seen too many prank videos. Best case scenario you pick it up and feel bad because someone lost it.

Not worth it. Maybe I’m not cut out to be a podiatrist.

It's a poo dollar bro