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When I was down for my interviews, they paid for my hotel room in its entirety and some food. Guess I was fortunate.

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3rd year resident here

Is it a red flag that a hospital system doesn't want to discuss salary until you visit?? Recently had a zoom interview with a rural hospital system (3 hospitals, about 50-100 beds each). When I asked about potential salary, they told me that can be discussed when I visit. This is a first for me.

I've been talking with 2 other hospitals in the same/bordering states, and they both told me salary/benefits BEFORE offering me to come visit. I'm unsure about going to visit somewhere for multiple days without knowing any salary. Any insight would be appreciated, thank you
Every hospital I interviewed at never told me the salary until the offer was officially given. That is when you start negotiations. I think its unprofessional to refuse to visit a hospital because they didn't tell you salary and benefits. It also gives the wrong impression. As a hospital employer that would be a red flag for me.
 
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This isn't a PP where you can get 20 offers and they are all under $140K. It seems stupid, but just visit them. I'm not hearing a lot of stories of being screwed by hospitals on here. If you can find a compelling lifestyle/location reason - that would be a win. A friend of mine was offered more money than I ever would have thought possible in a starting position by a rural hospital. The arrangement involved a series of streams of revenue from different responsibilities beyond clinical/surgical. Yes, you could visit a bunch of hospitals and they all might offer you $200-250 or whatever, but there might be wilder numbers out there for those inclined to look.

Every hospital I interviewed at never told me the salary until the offer was officially given. That is when you start negotiations. I think its unprofessional to refuse to visit a hospital because they didn't tell you salary and benefits. It also gives the wrong impression. As a hospital employer that would be a red flag for me.
Appreciate both your responses! Glad this isn't abnormal. Every hospital I've already interviewed at so far told me the salary beforehand so this was just a first for me
 
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3rd year resident here

Is it a red flag that a hospital system doesn't want to discuss salary until you visit?? Recently had a zoom interview with a rural hospital system (3 hospitals, about 50-100 beds each). When I asked about potential salary, they told me that can be discussed when I visit. This is a first for me.

I've been talking with 2 other hospitals in the same/bordering states, and they both told me salary/benefits BEFORE offering me to come visit. I'm unsure about going to visit somewhere for multiple days without knowing any salary. Any insight would be appreciated, thank you
Most of the hospitals didn’t tell me the salary until after they were ready to offer me the job. One job or two listed the salary in the posting itself.

The place I’m at now I negotiated the salary up after I was offered the position.
 
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Appreciate both your responses! Glad this isn't abnormal. Every hospital I've already interviewed at so far told me the salary beforehand so this was just a first for me
It is not uncommon to not get the salary/benefits from a hospital until offered the FTE job.
(they screen from a dozen or two dozen.... interview a half dozen or more... offer to A, same offer to B if A didn't accept, offer to C if B declined, etc)

Also not uncommon to have little or no negotiation with a hospital (not common, but not uncommon either... esp large hosp systems, popular areas, many apps). For smaller hospitals, definitely negotiate... for VA, Kaiser, etc types, you won't get far. Some will flat out tell you if you ask that what you got is their standardized offer for your specialty (take it or leave it).

Hospitals almost always pay good/great... go check them out if even somewhat interested. As mentioned, they should pay most/all costs of interview trip. The hospital potential problem with hospital jobs is on the back end: bad call, bad hours, paperwork reqs, bad clinic staffing, bad admin/boss, etc... and you have zero control over any of it. Try to talk to as many current and former DPMs or docs of any kind that work or worked there and sniff that stuff out. The pay is generally not the problem at FTE hospital jobs (it's just that the per hour pay and QOL may be sketchy).
 
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It is not uncommon to not get the salary/benefits from a hospital until offered the FTE job.
(they screen from a dozen or two dozen.... interview a half dozen or more... offer to A, same offer to B if A didn't accept, offer to C if B declined, etc)

Also not uncommon to have little or no negotiation with a hospital (not common, but not uncommon either... esp large hosp systems, popular areas, many apps). For smaller hospitals, definitely negotiate... for VA, Kaiser, etc types, you won't get far. Some will flat out tell you if you ask that what you got is their standardized offer for your specialty (take it or leave it).

Hospitals almost always pay good/great... go check them out if even somewhat interested. As mentioned, they should pay most/all costs of interview trip. The hospital potential problem with hospital jobs is on the back end: bad call, bad hours, paperwork reqs, bad clinic staffing, bad admin/boss, etc... and you have zero control over any of it. Try to talk to as many current and former DPMs or docs of any kind that work or worked there and sniff that stuff out. The pay is generally not the problem at FTE hospital jobs (it's just that the per hour pay and QOL may be sketchy).
I disagree with this 100%

Every hospital I was able to negotiate a better deal (level 2 trauma to community hospitals). The only hospitals you can't negotiate with are Kaisers and VA hospitals (most of them). Every other hospital you can attempt to negotiate a better deal. Most will give you a better deal if they really want you.

The job I just got initial base salary offer was $30K less than I ended up with. I also got them to come up from $50 per RVU to $53. They also bought me out of my locum contract which was another $25K. It really depends how bad they want you. You need to assess each hospital and the admin staff to determine what the possibilities are.

For example I have interviewed at some hospitals that are run by a regional CEO who controls several hospitals at the same time. His admin staff are also not local to the hospital. Forget about trying to negotiate with an admin staff like that or even trying to get what you want. It's not going to happen. You have a way better shot negotiating and getting what you need for clinic, staffing etc with a CEO who is local to the hospital or based in the hospital. Please remember this. This is an important wrinkle when negotiating with hospitals.

I would say the negative of hospital employment is little control over staffing and organization. Depends on how bad the hospital is. Not all hospitals are terrible. Usually the small independent community hospitals are bad. Most independent hospitals are barely getting by as most regions have a major hospital system which is buying up all the smaller hospitals. Being employed with a larger hospital system is the way to go in my opinion.

Larger hospital = better resources, more organization, better EMR, better operating rooms, better OR staff, better OR technology, better help. There really is no comparison. My first job was a small independent community hospital where I worked for 5 years. I've now gained employment at a larger system and there is an unbelievable large difference in quality. My life will become infinitely easier. I will have less paperwork. I will have a nurse working my clinic vs an MA. A nurse can handle some paperwork and also answer clinical patient questions without bothering the doctors with telephone encounters or phone calls. This will save significant time and increase my quality of life. The EMR is amazing compared to what I was working with. At my old job I had three separate EMR systems that did not connect to each other. This new job I have inpatient, outpatient, wound care all under the same EMR that speak to each other. This will save significant time with charting.

If anybody states that private practice is better than hospital employment in terms of staffing, clinic flow, etc they really don't know what they are talking about. How many private practice podiatry associates do you know that get employed and start changing the way the private practice operates to fit their needs? I've never seen or heard that.
 
How many private practice podiatry associates do you know that get employed and start changing the way the private practice operates to fit their needs? I've never seen or heard that.

Yeah, I tried to do that at my first job after residency (private practice associate) and let's just say it did not go over well with them.
 
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I recently interviewed w a hospital. Seemed great. Was told it would hear back for a second interview. It’s been a few weeks now and dead silence.

Would you guys recommend I reach out and see what’s up? Or wait it out longer? I heard hospitals usually are slow and lag a lot but I’ve never been in the position so not sure
 
I recently interviewed w a hospital. Seemed great. Was told it would hear back for a second interview. It’s been a few weeks now and dead silence.

Would you guys recommend I reach out and see what’s up? Or wait it out longer? I heard hospitals usually are slow and lag a lot but I’ve never been in the position so not sure
Did they tell you they were interviewing other candidates still? It's possible they are still doing that. Usually dead silence is not a great indication you are getting the job. If it has been 2-3 weeks then it is appropriate to contact them. I would call the recruiter to see what is up.
 
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Did they tell you they were interviewing other candidates still? It's possible they are still doing that. Usually dead silence is not a great indication you are getting the job. If it has been 2-3 weeks then it is appropriate to contact them. I would call the recruiter to see what is up.
Yeah they said they some to get thru still ::: but who knows
 
Yeah they said they some to get thru still ::: but who knows
Agree with cuts, it is most common they communicate well and move fast if they are highly interested wether it is an offer or making arrangements for another round of interviews.

Always a chance they had a delay for some reason, or are waiting to finalize things with their top candidate before getting back with the other candidates. Once you have had an interview it is common courtesy that they eventually let you know the job was filled even if they wait a few weeks to do that….hopefully they still plan to do this at some point (who knows)….but there is definitely nothing wrong with you following up to ask (which it sounds like you did) if they were planning on scheduling more interviews or if the position was filed.
 
I interviewed with a hospital in residency. Went well, they liked me, didn’t hear anything for months but knew they had a few interviews. Reached back out to a VP of something who I met during my interview about 1 month later. No response. Finally ran into the DPM who was leaving that hospital (the reason for the opening) and he let me know that the hospital had been purchased and every single admin I had met had been replaced and they were obviously on a hiring freeze. This was maybe 3 months later. I called the podiatry clinic manager because she was the only person I met who hadn’t been let go. That was depressing because she confirmed everyone had been let go and let me know I was going to be the hire. So instead I got to work for a total POS and make 50-75% less money for 2-3 years than I would have otherwise.

Not saying that’s why you haven’t heard anything but I would never hesitate to reach back out at least to a recruiter, preferably admin, and ask if they have a rough timeline so that you can plan appropriately with your current employer or other positions. They won’t be offended or think you are bugging them. But 2-3 weeks is nothing. Especially if they are doing more interviews. They don’t fly everyone in on back to back days or anything like that. It could take them a month to conduct 2-3 in person interviews. Easily.
 
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I interviewed with a hospital in residency. Went well, they liked me, didn’t hear anything for months but knew they had a few interviews. Reached back out to a VP of something who I met during my interview about 1 month later. No response. Finally ran into the DPM who was leaving that hospital (the reason for the opening) and he let me know that the hospital had been purchased and every single admin I had met had been replaced and they were obviously on a hiring freeze. This was maybe 3 months later. I called the podiatry clinic manager because she was the only person I met who hadn’t been let go. That was depressing because she confirmed everyone had been let go and let me know I was going to be the hire. So instead I got to work for a total POS and make 50-75% less money for 2-3 years than I would have otherwise.

Not saying that’s why you haven’t heard anything but I would never hesitate to reach back out at least to a recruiter, preferably admin, and ask if they have a rough timeline so that you can plan appropriately with your current employer or other positions. They won’t be offended or think you are bugging them. But 2-3 weeks is nothing. Especially if they are doing more interviews. They don’t fly everyone in on back to back days or anything like that. It could take them a month to conduct 2-3 in person interviews. Easily.

Yes agreed. Didn’t hear back from my current gig after 2-3 weeks so I reached out to the ortho chief and they said they were re scheduling a few more interviews thus the delay. So - normal but do reach out.

Side note - spoke to a few pods today from prior connections when I was in pod school and they’re hiring for their large hospital group. Over 100 applicants. Fresh fellows from many of the “top” programs applied, new residents across the board from east coast to west coast applied. Guess what - they don’t want a new fellow or a new grad. They want someone with a few years of work experience. And prefer a candidate whom someone they know can vouch for. Podiatry is a very small profession. Network well and network early on.
 
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Yes agreed. Didn’t hear back from my current gig after 2-3 weeks so I reached out to the ortho chief and they said they were re scheduling a few more interviews thus the delay. So - normal but do reach out.

Side note - spoke to a few pods today from prior connections when I was in pod school and they’re hiring for their large hospital group. Over 100 applicants. Fresh fellows from many of the “top” programs applied, new residents across the board from east coast to west coast applied. Guess what - they don’t want a new fellow or a new grad. They want someone with a few years of work experience. And prefer a candidate whom someone they know can vouch for. Podiatry is a very small profession. Network well and network early on.

But Lowell Weil said if you do a fellowship you will be on par with foot and ankle orthopedists…
 
Side note - spoke to a few pods today from prior connections when I was in pod school and they’re hiring for their large hospital group. Over 100 applicants.
Like we all have been saying…….we sure need another school.
 
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But Lowell Weil said if you do a fellowship you will be on par with foot and ankle orthopedists…
Weil…… it’s been stated too many times on this forum from multiple posters with real world experience on the other side of job posts/search - most groups (pod or ortho) want work experience and someone willing to do everything podiatry. If you think you’re coming in day 1 slapping in TARs and your lapiplasty 4 days a week in the OR, good luck - it ain’t happening. I looked over some of the job applications and their personal statements, CVs etc etc and for some reason they think they’re the next Schuberth and that this job posting desperately needs their expertise because they performed 2000+ procedures from a “top notch” program. Word of mouth and personal connections will most likely land you a good job, not because you went to Yale/Harvard/Weil’s fellowship.
 
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Funny to see the shift over 10 years from everyone chanting about their ortho group jobs now to chanting about their multi-specialty group jobs.
Maybe medicare reimbursement will drastically change and everyone will be chanting about doing nursing home nails in another 10 years.
 
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Weil…… it’s been stated too many times on this forum from multiple posters with real world experience on the other side of job posts/search - most groups (pod or ortho) want work experience and someone willing to do everything podiatry. If you think you’re coming in day 1 slapping in TARs and your lapiplasty 4 days a week in the OR, good luck - it ain’t happening. I looked over some of the job applications and their personal statements, CVs etc etc and for some reason they think they’re the next Schuberth and that this job posting desperately needs their expertise because they performed 2000+ procedures from a “top notch” program. Word of mouth and personal connections will most likely land you a good job, not because you went to Yale/Harvard/Weil’s fellowship.
Podiatry…….the profession where doing a 3 year “surgical“ residency and being average is not good enough.

For most good jobs connections and some experience are huge. Usually for professions that require extensive training this is mitigated to a very large extent and a large reason why people choose professions in the first place. For podiatry…….nope, you better become board certified first, do a fellowship first, have connections or maybe move to the Dakotas if you want a good job.

Your first job will of course due to the definition of average, likely be average. In many professions an average job is also a good job, but unfortunately an average podiatry job is not something you really want.

You would think with 3 year surgical residencies it would be universal to be board certified in surgery in a few years, but many never become board certified in surgery.

By the very definition of average yet again, most of your connections will be average and others will have average connections also. By all means use all the ones you have and try to make new ones.

So doing a fellowship is just another way not to look average, and make a few more connections in a profession where being average is just not good enough.

Would many prefer to be employed with a good job.……certainly. Is opening a practice harder than it used to be……..not impossible, but certainly harder. It also makes life a bit challenging if one wants to buy a house and an SUV and start a life without a few years of self employed income to demonstrate.

The path for many will still be to work as an associate and open your own practice a few years later. There are many challenges with being a solo doctor, but it will no longer matter now that in the job market you would only be considered average. Be careful as there are many unethical ways to make money which might catch up to you in time. Some do these things out of pure greed and others just to pay their overhead and make an average podiatrist’s salary.

Are there other healthcare professions with equal or less training where one can be average in their profession, but also have many good jobs to choose from……yes.
 
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Weil…… it’s been stated too many times on this forum from multiple posters with real world experience on the other side of job posts/search - most groups (pod or ortho) want work experience and someone willing to do everything podiatry. If you think you’re coming in day 1 slapping in TARs and your lapiplasty 4 days a week in the OR, good luck - it ain’t happening. I looked over some of the job applications and their personal statements, CVs etc etc and for some reason they think they’re the next Schuberth and that this job posting desperately needs their expertise because they performed 2000+ procedures from a “top notch” program. Word of mouth and personal connections will most likely land you a good job, not because you went to Yale/Harvard/Weil’s fellowship.

You do know I was being sarcastic right?
 
90%+ of fellowships are a scam. handful of worthwhile ones.
 
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What are the handful worthwhile ones?
I mean there are some good one....but love this line from a new one I just looked up.....

The fellows will be responsible for all podiatry trauma call and in patient rounding before and after office and clinic

LOVE IT.
 
I mean there are some good one....but love this line from a new one I just looked up.....

The fellows will be responsible for all podiatry trauma call and in patient rounding before and after office and clinic

LOVE IT.

What an honor to be a resident…I mean a fellow
 
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The hospital potential problem with hospital jobs is on the back end: bad call, bad hours, paperwork reqs, bad clinic staffing, bad admin/boss, etc... and you have zero control over any of it. Try to talk to as many current and former DPMs or docs of any kind that work or worked there and sniff that stuff out. The pay is generally not the problem at FTE hospital jobs (it's just that the per hour pay and QOL may be sketchy).

Yes. People talk a lot about how amazing hospital jobs can be, but make sure you actually understand that's based mostly on the better pay. Personally I think inpatient SUCKS and it would take a VERY hefty salary to get me to consider it again
 
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Yes. People talk a lot about how amazing hospital jobs can be, but make sure you actually understand that's based mostly on the better pay. Personally I think inpatient SUCKS and it would take a VERY hefty salary to get me to consider it again

Inpatient consults, ER consults, referrals from other physicians at your hospital.

All that volume at the tip of your fingers.

Compare that to being a private practice podiatrist where you will never get a fair shake and the other podiatrists in your group who have more seniority will screw you over.

There is no comparison. The only time this doesn’t work well is if you are employed by a terrible hospital. Independent small community hospitals are quite frankly the worst environments to be employed in as a podiatrist. You are always going to get bumped. You are going to have to fight for block time. It will be a disaster. Larger hospital systems are where it’s at for employed podiatrists.

The median MGMA hospital salary of 300-310k, RVU production bonuses, medical benefits, 401k 5% match…etc etc etc

I think most podiatrists would accept this offer over and over and over.
 
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Yes. People talk a lot about how amazing hospital jobs can be, but make sure you actually understand that's based mostly on the better pay. Personally I think inpatient SUCKS and it would take a VERY hefty salary to get me to consider it again
I don’t do inpatients. No call. Only private call if certain docs or ER docs need something. Better yet - start a fellowship and have your fellow do all inpatient work, as airbud mentioned above. Plenty of suckers will apply for a chance to be a fellow at a hospital system.
 
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I love inpatient infections. That’s where you can make it rain RVUs. Anybody who says different must hate money.
Not so sure the associate podiatrist loves it on the poorly insured or uninsured patients who case management is trying to approve for Medicaid.
 
Not so sure the associate podiatrist loves it on the poorly insured or uninsured patients who case management is trying to approve for Medicaid.
Hospital employed with RVUs.... especially getting 100 percent....they don't care what type of insurance you have. Hell my last job my state Medicaid didn't cover podiatry and I still got paid on those RVUs...love infection.
 
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Yes. People talk a lot about how amazing hospital jobs can be, but make sure you actually understand that's based mostly on the better pay. Personally I think inpatient SUCKS and it would take a VERY hefty salary to get me to consider it again
"based mostly on the better pay."

You mean based on one of the most important aspects of the job?

Just to clear things up, inpatient absolutely does suck for the podiatry associate who gets paid pennies on the dollar (or nothing for the tons of uninsured patients) however RVU based pods make an absolute killing off of inpatients.

Basically it goes like this...
RVU based = do as much surgery as possible
not RVU based = peddle as much crap in clinic as possible
 
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"based mostly on the better pay."

You mean based on one of the most important aspects of the job?

Just to clear things up, inpatient absolutely does suck for the podiatry associate who gets paid pennies on the dollar (or nothing for the tons of uninsured patients) however RVU based pods make an absolute killing off of inpatients.

Basically it goes like this...
RVU based = do as much surgery as possible
not RVU based = peddle as much crap in clinic as possible
This is the way
 
"based mostly on the better pay."

You mean based on one of the most important aspects of the job?

Just to clear things up, inpatient absolutely does suck for the podiatry associate who gets paid pennies on the dollar (or nothing for the tons of uninsured patients) however RVU based pods make an absolute killing off of inpatients.

Basically it goes like this...
RVU based = do as much surgery as possible
not RVU based = peddle as much crap in clinic as possible

100% accurate. The amount of procedures you can generate is substantial.

Let me break it down from a hospital employed RVU podiatrist perspective.

Patient examples:

A) Uncontrolled diabetic with great toe abscess from non healing sub great toe ulcer. Osteomyelitis involving distal and proximal phalanx.

Case 1:
- great toe amputation (procedure 1)
- open bone biopsy, deep, of 1st met head (procedure 2)

Foot grossly contaminated so you pack open and bring back to OR in 1-2 days…

Case 2:
- secondary of surgical wound, extensive complicated (procedure 3)
- flexor tenotomies of toes 2-5 as lesser toes are more likely to hammer with loss of great toe leading to distal toe ulcers if left untreated (procedures 4-7)

—————

B) Uncontrolled diabetic with sub 1st MTP ulcer. Non healing despite wound care, TCC, diabetic shoes and inserts etc. No acute infection. No osteomyelitis on your imaging workup.

Case 1:
- tibial sesamoidectomy (procedure 1)
- strayer gastroc recession (procedure 2)
- peroneus longus tenotomy (procedure 3)

—————-

C) diabetic patient with multiple infected toes/ forefoot abscess with osteomyelitis due to non healing ulcers

Case 1:
- transmetatarsal amputation (procedure 1)
- open bone biopsy, deep, metatarsal bones 1-5 (procedure 2-6)

Pack TMA open due to grossly contaminated foot. Return to OR once biopsies result or in 1-2 days if you feel you got the bone infection controlled/removed

Case 2:
- strayer gastrocnemius recession (procedure 7)
- secondary of surgical wound, extensive complicated (procedure 8)


I gave you three typical limb salvage scenarios and generated 18 billable procedures from these 3 patients. It’s not fraud. It’s not even aggressive. It’s being thorough and can justified 100% of the time. If you are at a high volume hospital you can do this over and over and over and generate a ton of productivity for yourself and making the hospital a ton of money as these cases don’t require hardware. The hospital gets money from your imaging orders, vascular testing, consultations to vascular/ IR, and even consults to PT after you done doing surgery to determine safety to return home vs SNF. You order these things. Don’t tell medicine to do it because then you won’t get credit for it when the hospital reviews all these metrics. They track everything. Not just what you are doing in the clinic or OR but more importantly the other down stream revenue generators (imaging, DME, labs, referrals to other specialists, vascular testing, etc etc etc etc etc). PLAY THE GAME.

I just gave you a template for instant job security and how to make money at the same time as an employed podiatrist. This is why these jobs are coveted. You don’t have to be the next greatest “fellowship trained reconstructive foot and ankle surgeon”. When you pretend you are not a podiatrist and don’t or can’t do limb salvage you look dumber than you already are. You are not valuable to a hospital. If they wanted someone to do just MSK they would be better off hiring foot and ankle ortho because they can take general ortho call as well.
 
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100% accurate. The amount of procedures you can generate is substantial.

Let me break it down from a hospital employed RVU podiatrist perspective.

Patient examples:

A) Uncontrolled diabetic with great toe abscess from non healing sub great toe ulcer. Osteomyelitis involving distal and proximal phalanx.

Case 1:
- great toe amputation (procedure 1)
- open bone biopsy, deep, of 1st met head (procedure 2)

Foot grossly contaminated so you pack open and bring back to OR in 1-2 days…

Case 2:
- secondary of surgical wound, extensive complicated (procedure 3)
- flexor tenotomies of toes 2-5 as lesser toes are more likely to hammer with loss of great toe leading to distal toe ulcers if left untreated (procedures 4-7)

—————

B) Uncontrolled diabetic with sub 1st MTP ulcer. Non healing despite wound care, TCC, diabetic shoes and inserts etc. No acute infection. No osteomyelitis on your imaging workup.

Case 1:
- tibial sesamoidectomy (procedure 1)
- strayer gastroc recession (procedure 2)
- peroneus longus tenotomy (procedure 3)

—————-

C) diabetic patient with multiple infected toes/ forefoot abscess with osteomyelitis due to non healing ulcers

Case 1:
- transmetatarsal amputation (procedure 1)
- open bone biopsy, deep, metatarsal bones 1-5 (procedure 2-6)

Pack TMA open due to grossly contaminated foot. Return to OR once biopsies result or in 1-2 days if you feel you got the bone infection controlled/removed

Case 2:
- strayer gastrocnemius recession (procedure 7)
- secondary of surgical wound, extensive complicated (procedure 8)


I gave you three typical limb salvage scenarios and generated 18 billable procedures from these 3 patients. It’s not fraud. It’s not even aggressive. It’s being thorough and can justified 100% of the time. If you are at a high volume hospital you can do this over and over and over and generate a ton of productivity for yourself and making the hospital a ton of money as these cases don’t require hardware. The hospital gets money from your imaging orders, vascular testing, consultations to vascular/ IR, and even consults to PT after you done doing surgery to determine safety to return home vs SNF. You order these things. Don’t tell medicine to do it because then you won’t get credit for it when the hospital reviews all these metrics. They track everything. Not just what you are doing in the clinic or OR but more importantly the other down stream revenue generators (imaging, DME, labs, referrals to other specialists, vascular testing, etc etc etc etc etc). PLAY THE GAME.

I just gave you a template for instant job security and how to make money at the same time as an employed podiatrist. This is why these jobs are coveted. You don’t have to be the next greatest “fellowship trained reconstructive foot and ankle surgeon”. When you pretend you are not a podiatrist and don’t or can’t do limb salvage you look dumber than you already are. You are not valuable to a hospital. If they wanted someone to do just MSK they would be better off hiring foot and ankle ortho because they can take general ortho call as well.
Can confirm this is true
 
Agree with Cutswithfury. Easy to do 7k wRVU in limb salvage hospital practice specially if you are doing charcots and general podiatry as well. Need a good team of colleagues and wound care RNs and management team. Otherwise you'll wanna throw yourself off of a cliff. Currently do 7k wRVUs but definitely feel the fatigue/burnout. I guess the trick is longevity of your career as there is opportunity cost with early burnout in ****ty hospital job even with higher initial payout.
 
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100% accurate. The amount of procedures you can generate is substantial.

Let me break it down from a hospital employed RVU podiatrist perspective.

Patient examples:

A) Uncontrolled diabetic with great toe abscess from non healing sub great toe ulcer. Osteomyelitis involving distal and proximal phalanx.

Case 1:
- great toe amputation (procedure 1)
- open bone biopsy, deep, of 1st met head (procedure 2)

Foot grossly contaminated so you pack open and bring back to OR in 1-2 days…

Case 2:
- secondary of surgical wound, extensive complicated (procedure 3)
- flexor tenotomies of toes 2-5 as lesser toes are more likely to hammer with loss of great toe leading to distal toe ulcers if left untreated (procedures 4-7)

—————

B) Uncontrolled diabetic with sub 1st MTP ulcer. Non healing despite wound care, TCC, diabetic shoes and inserts etc. No acute infection. No osteomyelitis on your imaging workup.

Case 1:
- tibial sesamoidectomy (procedure 1)
- strayer gastroc recession (procedure 2)
- peroneus longus tenotomy (procedure 3)

—————-

C) diabetic patient with multiple infected toes/ forefoot abscess with osteomyelitis due to non healing ulcers

Case 1:
- transmetatarsal amputation (procedure 1)
- open bone biopsy, deep, metatarsal bones 1-5 (procedure 2-6)

Pack TMA open due to grossly contaminated foot. Return to OR once biopsies result or in 1-2 days if you feel you got the bone infection controlled/removed

Case 2:
- strayer gastrocnemius recession (procedure 7)
- secondary of surgical wound, extensive complicated (procedure 8)


I gave you three typical limb salvage scenarios and generated 18 billable procedures from these 3 patients. It’s not fraud. It’s not even aggressive. It’s being thorough and can justified 100% of the time. If you are at a high volume hospital you can do this over and over and over and generate a ton of productivity for yourself and making the hospital a ton of money as these cases don’t require hardware. The hospital gets money from your imaging orders, vascular testing, consultations to vascular/ IR, and even consults to PT after you done doing surgery to determine safety to return home vs SNF. You order these things. Don’t tell medicine to do it because then you won’t get credit for it when the hospital reviews all these metrics. They track everything. Not just what you are doing in the clinic or OR but more importantly the other down stream revenue generators (imaging, DME, labs, referrals to other specialists, vascular testing, etc etc etc etc etc). PLAY THE GAME.

I just gave you a template for instant job security and how to make money at the same time as an employed podiatrist. This is why these jobs are coveted. You don’t have to be the next greatest “fellowship trained reconstructive foot and ankle surgeon”. When you pretend you are not a podiatrist and don’t or can’t do limb salvage you look dumber than you already are. You are not valuable to a hospital. If they wanted someone to do just MSK they would be better off hiring foot and ankle ortho because they can take general ortho call as well.
Also there is the added wRVU for the high level consults associated with the patients.

-Multiple tests orders and independently interpreted
-Discussion of management with another health care professional
-Assessment requiring independent historian
-Treatment complicated by social determinants of heath
-Surgery with identified risk factors
 
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Also there is the added wRVU for the high level consults associated with the patients.

-Multiple tests orders and independently interpreted
-Discussion of management with another health care professional
-Assessment requiring independent historian
-Treatment complicated by social determinants of heath
-Surgery with identified risk factors

Inpatient consults still basically require you to bill on time though. For now. Unless you are like air bud and faking full physical exams. Luckily next year inpatient e/m drops HPI and exam requirements next year and goes to straight MDM/Complexity like the outpatient codes.
 
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Yes. People talk a lot about how amazing hospital jobs can be, but make sure you actually understand that's based mostly on the better pay. Personally I think inpatient SUCKS and it would take a VERY hefty salary to get me to consider it again
Spoken like someone who has never been offered a hospital job. Let me tell you, I would NEVER go back to PP. MSG/Hospital is the way to go For podiatrists.
 
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Agree with Cutswithfury. Easy to do 7k wRVU in limb salvage hospital practice specially if you are doing charcots and general podiatry as well. Need a good team of colleagues and wound care RNs and management team. Otherwise you'll wanna throw yourself off of a cliff. Currently do 7k wRVUs but definitely feel the fatigue/burnout. I guess the trick is longevity of your career as there is opportunity cost with early burnout in ****ty hospital job even with higher initial payout.

Hospital dynamics are critical to be able to pull off a busy limb salvage practice.

My first practice was at an independent community hospital but it had a wound care facility and the nurses there were great and made it very easy to crank out a lot of encounters. The issue with being with a small independent hospital is that these patients never had the same PCP/endo and you had to reach out a lot to these practitioners to coordinate care. This would be the bane of my existence as you were dealing with physicians from different hospitals or physician groups. Different personalities and feelings about podiatry, etc. Trying to optimize a patient for surgery was challenging.

If you work out of a large hospital system that’s a tertiary referral center then majority of these patients have PCPs and other specialty doctors that are in the same healthcare system. It’s way easier to communicate to these other physicians. Sometimes as simple as sending a text through an encrypted text messaging application affiliated with the hospital.

I definitely agree that limb salvage can be mentally draining because majority of patients don’t listen which is the main reason they are there in the first place. At the same it can be equally rewarding for the few patients who do listen and end up having successful surgery saving their own limb.
 
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100% accurate. The amount of procedures you can generate is substantial.

Let me break it down from a hospital employed RVU podiatrist perspective.

Patient examples:

A) Uncontrolled diabetic with great toe abscess from non healing sub great toe ulcer. Osteomyelitis involving distal and proximal phalanx.

Case 1:
- great toe amputation (procedure 1)
- open bone biopsy, deep, of 1st met head (procedure 2)

Foot grossly contaminated so you pack open and bring back to OR in 1-2 days…

Case 2:
- secondary of surgical wound, extensive complicated (procedure 3)
- flexor tenotomies of toes 2-5 as lesser toes are more likely to hammer with loss of great toe leading to distal toe ulcers if left untreated (procedures 4-7)

—————

B) Uncontrolled diabetic with sub 1st MTP ulcer. Non healing despite wound care, TCC, diabetic shoes and inserts etc. No acute infection. No osteomyelitis on your imaging workup.

Case 1:
- tibial sesamoidectomy (procedure 1)
- strayer gastroc recession (procedure 2)
- peroneus longus tenotomy (procedure 3)

—————-

C) diabetic patient with multiple infected toes/ forefoot abscess with osteomyelitis due to non healing ulcers

Case 1:
- transmetatarsal amputation (procedure 1)
- open bone biopsy, deep, metatarsal bones 1-5 (procedure 2-6)

Pack TMA open due to grossly contaminated foot. Return to OR once biopsies result or in 1-2 days if you feel you got the bone infection controlled/removed

Case 2:
- strayer gastrocnemius recession (procedure 7)
- secondary of surgical wound, extensive complicated (procedure 8)


I gave you three typical limb salvage scenarios and generated 18 billable procedures from these 3 patients. It’s not fraud. It’s not even aggressive. It’s being thorough and can justified 100% of the time. If you are at a high volume hospital you can do this over and over and over and generate a ton of productivity for yourself and making the hospital a ton of money as these cases don’t require hardware. The hospital gets money from your imaging orders, vascular testing, consultations to vascular/ IR, and even consults to PT after you done doing surgery to determine safety to return home vs SNF. You order these things. Don’t tell medicine to do it because then you won’t get credit for it when the hospital reviews all these metrics. They track everything. Not just what you are doing in the clinic or OR but more importantly the other down stream revenue generators (imaging, DME, labs, referrals to other specialists, vascular testing, etc etc etc etc etc). PLAY THE GAME.

I just gave you a template for instant job security and how to make money at the same time as an employed podiatrist. This is why these jobs are coveted. You don’t have to be the next greatest “fellowship trained reconstructive foot and ankle surgeon”. When you pretend you are not a podiatrist and don’t or can’t do limb salvage you look dumber than you already are. You are not valuable to a hospital. If they wanted someone to do just MSK they would be better off hiring foot and ankle ortho because they can take general ortho call as well.
Sounds great until your claims are reviewed. Please read NCCI policy 2022, I believe it’s chapter 4.

Biopsy at the time of another surgical procedure (in the same anatomical region) is inclusive to the primary procedure UNLESS you are waiting in the OR for the results.

So if you perform a TMA and then bill a biopsy to assess margins in the remaining metatarsal stumps and to send for micro/pathology, that is inappropriate billing and unbundling.

Even if there is no CCI edit, NCCI policy overrules CCI. Even in commercial insurers.

If someone tells me that they get paid for this all the time, my answer is that getting paid is no indication the billing was proper.

There are loads of docs billing for an ORIF of a talo tarsal dislocation and they are performing an arthroereisis.

So the bottom line is I understand the points Cuts is trying to make, but I will HIGHLY advise against some of his/hers billing examples.

About a month ago I was involved with reviewing a case where a provider billed a bone biopsy for every procedure and she got paid for most.

She now owes the insurance enough money that she may file bankruptcy.

Remember, she bills a bone biopsy for every single bone case she’s ever performed.

Don’t do it.
 
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Sounds great until your claims are reviewed. Please read NCCI policy 2022, I believe it’s chapter 4.

Biopsy at the time of another surgical procedure (in the same anatomical region) is inclusive to the primary procedure UNLESS you are waiting in the OR for the results.

So if you perform a TMA and then bill a biopsy to assess margins in the remaining metatarsal stumps and to send for micro/pathology, that is inappropriate billing and unbundling.

Even if there is no CCI edit, NCCI policy overrules CCI. Even in commercial insurers.

If someone tells me that they get paid for this all the time, my answer is that getting paid is no indication the billing was proper.

There are loads of docs billing for an ORIF of a talo tarsal dislocation and they are performing an arthroereisis.

So the bottom line is I understand the points Cuts is trying to make, but I will HIGHLY advise against some of his/hers billing examples.

About a month ago I was involved with reviewing a case where a provider billed a bone biopsy for every procedure and she got paid for most.

She now owes the insurance enough money that she may file bankruptcy.

Remember, she bills a bone biopsy for every single bone case she’s ever performed.

Don’t do it.

I understand for TMA since the metatarsals have been cut then billing biopsy is not billable.

But if a great toe amputation is performed and an open biopsy is performed of the 1st metatarsal head this should be billable as it is a different bone. Correct?
 
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I understand for TMA since the metatarsals have been cut then billing biopsy is not billable.

But if a great toe amputation is performed and an open biopsy is performed of the 1st metatarsal head this should be billable as it is a different bone. Correct?
No it is not correct. The biopsy is in the “field” of surgery. You are performing the biopsy to assess margins. And unless you are waiting for those results prior to leaving the OR, it would be inclusive to the amputation. And it would not be appropriate to use the 59 modifier.
 
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It’s actually NCCI 2022 Chapter 1


• Providers/suppliers shall only report a biopsy separately when pathologic examination results in a decision to immediately proceed with a more extensive procedure (e.g., excision, destruction, removal) on the same lesion; or when performed on a separate lesion.

• Providers/suppliers shall not report a biopsy separately when it is to assess resection margins or to verify resectability; or when performed and submitted for pathologic evaluation completed after performing the more extensive procedure
 
let's take a step back and just realize how stupid this is....
The government/CMS hasn’t solicited your opinion or my opinion. NCCI is a government policy that is also used by commercial insurers.

What you may believe is stupid, also prevents a boat load of fraud. Surgical procedures have “component” procedures which are simply included in the primary procedure as per the standards of medical and surgical care.

If you saw the abuse that I get hired to review, you’d have a better understanding of why these policies exist.
 
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Inpatient consults still basically require you to bill on time though. For now. Unless you are like air bud and faking full physical exams. Luckily next year inpatient e/m drops HPI and exam requirements next year and goes to straight MDM/Complexity like the outpatient codes.

I can perform a ROS and work that heart and lung listerner thingy.
 
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No it is not correct. The biopsy is in the “field” of surgery. You are performing the biopsy to assess margins. And unless you are waiting for those results prior to leaving the OR, it would be inclusive to the amputation. And it would not be appropriate to use the 59 modifier.
Define "field"

Is it what is directly visualized? Or is it used as another way to describe an "anatomical area"?

Let's say patient comes with great toe abscess and ulcer sub 5th metatarsal base. MRI workup demonstrate great toe osteomyelitis with questionable findings involving the fifth metatarsal base.

I bring patient to OR and perform great toe amputation and then bone biopsy of the fifth metatarsal base to determine if it is actually osteomyelitis or not. In my opinion this should be billable as the bone biopsy is being taken from a different area of the foot away from the main area of surgery.

Would love to read your thoughts on this scenario.
 
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