Advertisement - Members don't see this ad
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.
-
Practice your interview with the new SDN AI Interview Coach. Choose a school, answer by voice or typing, and receive a personalized feedback report. Available now to all SDN members. Try the AI Interview Coach.
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.
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.
Advertisement - Members don't see this ad
Wait... Total is less traumatic than a partial?
What is this technique?
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.
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.
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.
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.
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.
pays a whopping 2 wRVU
Advertisement - Members don't see this ad
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.
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? 🙂
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.
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.
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?
Depends on where you are and who is standing behind you.
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.
Last edited:
It's a poo dollar bro
Also almost always
Can I get a TFP consult? Been scrubs/running shoes since COVID started, active but not a big runner. Wear pattern says I’m a mild supinator. I’ve mostly been Brooks Ghosts or similar with regular PowerSteps.
Any recs to maximize my biomechanics since I’ve got some old knee issues? Custom orthotics via the local mustache?
Haven’t done glasses/contacts in years, but I can throw some reasonable TFO knowledge out in return.
Any recs to maximize my biomechanics since I’ve got some old knee issues? Custom orthotics via the local mustache?
Haven’t done glasses/contacts in years, but I can throw some reasonable TFO knowledge out in return.
This means you're normal. During gait, the foot is supposed to supinate during heel strike, then pronate through midstance, then re-supinate as you propulse forward. So wearing out the posteriorlateral aspect of the outsole is consistent with a supinated foot in heel strike and a normal gait pattern.
Whether you are a pronator or a supinator, the answer always seems to be powerstep orthotics. Pronators benefit from the varus heel posting and arch support. Supinators benefit from the semiflexible shell material dampening the impact of heel strike. The arch support will medialize the ground reactive force vector as it passes through the knee joint which will take your biomechanics to the next level.
What's your take on Lasik surgery? I have a couple of ophthalmologist patients (not a joke, crazy how many of you cross paths with me) and they say it restores distant vision but close up is out of focus, so you end up passing restaurant menus to the person next to you saying "read me this"
Very much age dependent on your ROI. Refractive surgery as a whole (LASIK/PRK/SMILE etc.) is generally very successful and well tolerated.
Usually you correct for distance because the patient is young enough to still have accommodation - basically your natural lens is still flexible enough to change your prescription to catch up with the near stuff. You lose that as you age, which is why tons of people wind up with reading glasses, usually 45-50+.
If you get it done before 30, best bang for your buck, no worries about near vision.
I concur... Brooks makes good shoes, but Hyperion and Ghost and and Glycerin and some of those are for the whipper snappers.
Most mid/older adults will do better with Adrenaline GTS, Addiction GTS, Beast/Ariel GTS, etc (more support + wider heel, more forgiving for balance and change of direction). It's just a fact of life that our support structures like posterior tibial tendon, plantar fascia, ligaments, and other degrade as we age - as does balance/proprioception... hence the 0.5 bigger shoe size around mid age and maybe again later as a senior also (foot arch lowers, foot gets effectively longer, people think "my foot grew a size").
Most of the major shoe brands have at least a few good models, but Brooks and Asics are probably the best overall (NB was, still has some good ones .. but added more questionable ones).
The arch insoles are all about the same... PowerStep ProTech, SOLE red, WalkHero, etc all work fine... but when even the PStep ProTech are about $20/pr for supplier/pods and $50-$70 for anyone, not a huge place to cheap out.
Last edited:
Other big pearl - if you need glasses but can tolerate contacts, you’ll almost always see better with the contacts. You get a more stable starting point for light entering the eye, so fewer high order aberrations, meaning better fine details.
Advertisement - Members don't see this ad
Gonna study this for boards thx
An ophthalmologist presents with chronic heel pain from walking to the bank. Physical exam and imaging are unremarkable. Do you:
A. Initiate further work up
B. Discuss ergonomic shoe and insole options
C. Recommend grafts because reasons
D. Discuss the importance of memes
You forgot "PRP injection"
This is why I still don’t have my board certification
I appreciated the brevity of these options though I would have enjoyed some classic podiatric excess.
I have a young patient with severe onychotillomania who is otherwise medically healthy. Behavioral Health referred them to me for removal of all 10 toenails. The patient has already picked off nearly the entire nail plate on all digits.
I genuinely don’t want to touch this with a 10 foot pole.
What would you do?
I genuinely don’t want to touch this with a 10 foot pole.
What would you do?
BeaverBlade
Full Member
Suggest PCP, therapy, psychiatry. The kid probably needs medicated or behavioral therapy.
I would not remove the nails if there is no infection.
Yeah refer back. This is dumb. Some people have trichotillomania and dermatotillomania which behavioral health can manage on their own, but because it's toenails and we're podiatrists we get sucked into the vortex of this nonsense.
Three residency and we have this crisis….
TFP for the newbies.
I officially entered the real world, and during residency I honestly had very little exposure to diabetic patient, unless they ended up in the emergency room seeping puss. Little conservative exposure in training.
What are your thoughts on diabetic shoes? Have you found them to be helpful overall, or are there any red flags or pitfalls you’ve come across throughout your career?
One thing I recently learned is that TMA fillers can sometimes cause pressure sores, and someone suggested using a rolled sock instead. Has that been your experience?
Also, do you routinely use felt for offloading?
I officially entered the real world, and during residency I honestly had very little exposure to diabetic patient, unless they ended up in the emergency room seeping puss. Little conservative exposure in training.
What are your thoughts on diabetic shoes? Have you found them to be helpful overall, or are there any red flags or pitfalls you’ve come across throughout your career?
One thing I recently learned is that TMA fillers can sometimes cause pressure sores, and someone suggested using a rolled sock instead. Has that been your experience?
Also, do you routinely use felt for offloading?
BeaverBlade
Full Member
bro what
My thoughts on diabetic shoes
Rolled up socks work, but TMA fillers often reimburse better than TMAs.
Felt will get flattened after several weeks. This is one of the TFP-est things I do, but I have sheets of plastizote that retain their durometer better than felt and stick well to insoles and surgical shoes.
if you just do the TMA filler and they are active, it will cause excessive sheer forces at the TMA stump-filler interface due to the shoe wanting to bend at that spot.
you need to make sure it is a rocker bottom shoe with stiff footplate (carbon fiber or similar) below the plastazote insert.
you need to make sure it is a rocker bottom shoe with stiff footplate (carbon fiber or similar) below the plastazote insert.
Bro I don’t know, the lobster life in the real word is something else.
The trauma, 3am puss buss cases and elective surgery seems so much more straightforward than general diabetic care, they don’t get better, it never ends.
A lot of the in clinic lobster work is meant to be on auto-pilot and in controlled encounters. You walk in. You trim. You walk out. You don't volunteer for more unless you are truly concerned. Some people really do need to have their complaints explored, but a lot of people don't. Some people want the patient to drag them off on tangents so that they can bill for the additional complaints, but my suspicion is a lot of people like trimming some dry skin, "forwarding" the last note and moving onto the next patient. It can be lucrative to follow old ladies complaints, but I don't think it leads anywhere most of the time. Having written quite a bit of gabapentin through time on "c&c" patients I ultimately found that in time most patients felt like it didn't really do much. Gabapentin doesn't treat aging.
Advertisement - Members don't see this ad
Personally, I think DM shoes are overused but can be helpful when offloading an isolated met head. I use them fairly judiciously, but it isn't unusual for some PP pods to try and get them on every single diabetic they see. They reimburse well, our practice profits a few hundred dollars per pair/inserts, but the paperwork requirements are very burdensome and they can eat up a lot of staff time. My partners see fewer patients than me but their revenue is comparable or higher because they have no qualms about trying to get everyone in custom dme. This is an area where the hospital pods have it nice. They don't need the money from DME items like DM shoes and custom orthotics. They can recommend OTC products and when a custom item is needed, "here is a rx to a orthotist" and it's someone else's problem.
Even in PP I do sometimes wonder, if the hassle of the program and dealing with patient's shoe complaints are truly worth the return. My staff is always dealing with returns and what not. People don't like the color, don't like the fit, want something dressier. It's exhausting.
Off-topic, but I went to a shoe store recently where my practice frequently sends patients to get quality shoes. It was a nightmare, every salesperson was dealing with a customer with foot complaints. One guy had about 20 boxes of shoes, trying to find a shoe to that comfortably fit his AFO. I watched another lady repeatedly climbing on and off various OTC orthotics, trying to see if one felt better than another. I lingered for about 20 mins and finally left. Can't imagine having a retail store like some of the big PE groups do.
Some of my colleagues use the rolled up sock, some use TMA fillers. I don't particularly feel strongly about either.
Medicare should stop paying for the shoes and OTC inserts but instead cover custom accommodative inserts for neuropathic patients with ulcer/amp history. Would probably save them money and the patients who legitimately need the offloading would get a better version of it.
Literally had a guy in wound clinic who has a Charcot foot, neuropathy, prior wounds and toe amp who can’t get inserts and shoes covered because he’s not diabetic. Guy literally has all the stuff we’re trying to avoid in diabetics already happen to him but nope missing the ICD10.
i've had the same issue for nondiabetic charcot patients. patient has a TMA on one side, multiple toe amps on the other with a TTC nail and a flipper foot. tried to get shoes/orthotics. insurance denied it.
It will get covered by MCR/MCA and most private plans if you write for therapeutic shoes + insoles. The best dx are foot contracture, ankle contracture, or amp ICD sets (wound codes or neurop or pain won't usually work... better as secondary codes only). You can also do L3020 (ICDs being contrature, pain, PF) if it's Medicaid... but tell the store it's soft cork/foam custom offload insoles. The majority of plans won't block something that'll keep people out of hospital and surgery, though. That would make no $en$e.
I'd guess either your coding needs tweaks or the ortho (dme) store is not connecting the dots well and their coder just denies offhand for non-DM without thinking of options ("A conclusion is simply the place where you got tired of thinking."). Any decent DME store (Hanger etc) will have someone who can help out.
It's fixable in nearly all cases. I would say call the store when you have time, talk to orthotist directly, and ask for coding help and to make appeal to insurance... or they can just do reasonable cash price if nothing else - particularly if you give that store any decent volume of dme Rx. It can require talking to the store for best codes or p2p call sometimes on the private plans (ppo, MCR adv, etc) to get the big DME like CROW and OWL boots for non-DM. You may be hosed on some of the HMOs, but the store can still probably try better.
The amp is an automatic cover for many plans, actually. ... but you still use contracture codes. However, you can also do it for deformities from RA, severe OA and post trauma, Charcot, congentital deformities, etc etc without ulcer/amp and without DM dx. The orthotists are the ones to talk to. I did custom insoles for a CMT neuropathy pt last month (I avoid wound care like the plague as I just don't like it and it gives me PTSD now, but the pt had disappeared awhile and then needed 5th ray resect from cavus ulcer).
Last edited:
