Treazzze Medical AdductaLapiSpotWeld CME case :)

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ExperiencedDPM said:
Why are you having dinner with Paul Dayton? Business, pleasure or romance?
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Can the romance not be pleasurable?
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ExperiencedDPM said:
Seriously, are you really meeting with him?
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Yeah. It's a Treace thing so there will probably be a couple other DPMs there. Romance not guaranteed (but not explicitly forbidden).
 
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NatCh said:
Yeah. It's a Treace thing so there will probably be a couple other DPMs there. Romance not guaranteed (but not explicitly forbidden).
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Damn, has the potential to be a TREACE orgy. Just make sure whatever you do it includes a 3D reduction. And be gentle with your “joint seeker”.
 
You’ll all love this one. I was just sent 3 cases to review for the same provider. 3 different patients.

Asked for the same set of codes (that made no sense) for each patient. The notes are verbatim. The IM and HA angles were exact for each case.

Other than the name and date of birth the notes were 100% the same.
 
ToeFather said:
Can he adopt me
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I’ve also personally spoken with Paul. He really downplays his role with TREACE. But if you look up his royalties for intellectual property, he’s already made several million.

So getting adopted by him won’t be a bad thing. $$$$$
 
ExperiencedDPM said:
I’ve also personally spoken with Paul. He really downplays his role with TREACE. But if you look up his royalties for intellectual property, he’s already made several million.

So getting adopted by him won’t be a bad thing. $$$$$
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Yeah I think the last year it was reported he was just over $1 million in compensation for that particular year, most of which were royalty payments. If there was a stock deal like with early Paragon investors then it’s many multiples of that yearly figure.

I would not be working, but then again I don’t care anywhere near enough about podiatry to keep doing it the second I could make as much or more money doing something else.
 
dtrack22 said:
Yeah I think the last year it was reported he was just over $1 million in compensation for that particular year, most of which were royalty payments. If there was a stock deal like with early Paragon investors then it’s many multiples of that yearly figure.

I would not be working, but then again I don’t care anywhere near enough about podiatry to keep doing it the second I could make as much or more money doing something else.
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wait podiatry isn't a calling for all of us? instead it's just a job..? for which it is becoming more and more difficult to obtain even a middle class lifestyle with?

listen up pre pods.
 
Why do the new bunion surgery codes talk about sesamoidectomy? How often does anyone even do that?

Example:
CPT 28297—Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
 
NatCh said:
Why do the new bunion surgery codes talk about sesamoidectomy? How often does anyone even do that?

Example:
CPT 28297—Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
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Its included not because people do it but to ensure that people don't try to bill separately for it.
 
heybrother said:
Its included not because people do it but to ensure that people don't try to bill separately for it.
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Ohhhhh. Makes sense (I guess) but doing a sesamoidectomy would be more work than doing “just” the Lapidus. Seems like one should be able to bill for it. I guess not.
 
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NatCh said:
Ohhhhh. Makes sense (I guess) but doing a sesamoidectomy would be more work than doing “just” the Lapidus. Seems like one should be able to bill for it. I guess not.
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Its the bummer of billing. Its supposedly also not technically a lapidus unless you include resection of the medial eminence but in general the 28297 and 28740 have identical reimbursement. I suppose the flip side is that we should be grateful to be paid for these codes without having to go to the bother of doing the unnecessary sesamoidectomy component. We just don't get paid more if we do.
 
Yes, all the bunionectomy codes state “with sesamoidectomy, IF performed”.
 
heybrother said:
Its the bummer of billing. Its supposedly also not technically a lapidus unless you include resection of the medial eminence but in general the 28297 and 28740 have identical reimbursement. I suppose the flip side is that we should be grateful to be paid for these codes without having to go to the bother of doing the unnecessary sesamoidectomy component. We just don't get paid more if we do.
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What caught my attention was the idea that I might want to do a sesamoidectomy as a part of doing a Lapidus at all. It’s just not something that I’d consider unless maybe the sesamoid was fractured but I can’t recall ever having that scenario. Maybe everyone else is.

If the description had said “with ostectomy of spur, when performed “ or something like that then it would have made sense to me since osteophytes often accompany bunions.
 
Don’t forget that the CPT codes are created and owned by the AMA. They create the CPT descriptors. It is not an insurance document. And creating or changing a code takes YEARS. I’ve been working on attempting to create a new code for many years.
 
ExperiencedDPM said:
Don’t forget that the CPT codes are created and owned by the AMA. It is not an insurance document. And creating or changing a code takes YEARS. I’ve been working on attempting to create a new code for many years.
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When can we expect new codes for using the Dremel? Or what about applying the lotion to the skin?
 
heybrother said:
Its the bummer of billing. Its supposedly also not technically a lapidus unless you include resection of the medial eminence but in general the 28297 and 28740 have identical reimbursement. I suppose the flip side is that we should be grateful to be paid for these codes without having to go to the bother of doing the unnecessary sesamoidectomy component. We just don't get paid more if we do.
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I recently listened to a coder say its not a bunion unless you resect the medial eminence.

So if you do a lapidus and you dont resect the medial eminence its a 1st TMT fusion but if you go down to the MPJ and shave the bump its now a lapidus.
 
Pronation said:
Or what about applying the lotion to the skin?
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You’d have to ask Buffalo Bill. Personally I always rub the lotion on the skin just so I don’t get the hose again.

NatCh said:
Could you please expound on the significance of this part?
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Sounds like the AMA is screwing us for a change instead of the usual suspects… insurance companies, administrators, DYK’s billers, Podiatry practice owners, clipboard nurses, etc.
 
NatCh said:
Could you please expound on the significance of this part?
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CPT codes and descriptors were not created by insurers. It’s not a document or manual that was created by the insurance companies to screw us.

You can thank the AMA for creating the CPT codes, descriptors and edits. They did piggyback their edits off of NCCI policy.

But the codes and descriptors are all thanks to the AMA who owns the manual.
 
ExperiencedDPM said:
CPT codes and descriptors were not created by insurers. It’s not a document or manual that was created by the insurance companies to screw us.

You can thank the AMA for creating the CPT codes, descriptors and edits. They did piggyback their edits off of NCCI policy.

But the codes and descriptors are all thanks to the AMA who owns the manual.
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Not an insurance document yet we have to follow the document? Man…
 
Have you guys seen the adductoplasty system?
 
NatCh said:
Have you guys seen the adductoplasty system?
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Only on the weekly brochures they keep dropping off.

Side note - does anyone correct metadductus in conjunction with your bunions (not using this $9000 jig)? If not do you feel it compromises your lapidus correction down the road?
 
wakaflocka88 said:
Only on the weekly brochures they keep dropping off.

Side note - does anyone correct metadductus in conjunction with your bunions (not using this $9000 jig)? If not do you feel it compromises your lapidus correction down the road?
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I got to mess around with it on a cadaver yesterday. You know those pronounced skewfoot patients where the toes all abduct like 30 degrees or more? I've never been satisfied with the end results of a Lapidus alone on those. There's not much room to reduce the IM angle, and if you straighten out the hallux (e.g., for fusion) their hallux and 2nd toe make a "peace" sign✌️. You end up leaving the hallux in valgus just so the finished product doesn't look stupid.
 
NatCh said:
You end up leaving the hallux in valgus just so the finished product doesn't look stupid.
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And they’re usually pain free and happy.
 
Here's the simple truth about adductoplasty - in the vast majority of the x-rays they show on their website the patient did not need to have an adductoplasty performed. Patients with mild metatarsus adductus but a maintained 1-2-IM who are good candidates for lapidus will perceive themselves as greatly improved with just correction through the 1st TMTJ. They'll walk faster. They'll have less swelling. They are at much less risk of complication, non-union, nerve pain etc. Anyone who is older and is agreeable for 1st MPJ fusion should probably do that instead if clinical correction can be achieved with it. Patients with historic metatarsus adductus and painful bunions who were treated by a podiatrist often had something ridiculous done to them like an Austin that did nothing. If old podiatrists were so much better at biomechanics why couldn't they see/understand this, PM News.

This is a niche product. It could be wonderful for the right person. The right person though is going to be very rare - very large deformity, immaculate health / ideally very young, completely flexible/reducible forefoot deformities and finally and most important and therefore I'm obviously joking - they'll need to have the best of the best insurance. Gold plated? No, platinum plated. Did you know pound for pound Treace plates cost more than platinum? Its true.

Without touching severity - I divide patients with metatarsus adductus into 2 types of feet. Metatarsus adductus with maintained 1-2 IM (described above). The bummer cases though are metatarsus adductus with no 1-2 IM. Obviously there are more variations that are important - like you can have all of the above and have a short 1st ray. I also haven't said a word about true Skew/Z/Serpentine foot which amusingly two Treace reps I spoke to had never heard of.

Final thing. On good insurance - a distal 1st ray osteotomy in my area is worth $1200. A 1st MPJ fusion or a lapidus are worth $1400ish. A 28730 is worth $1700. The 28730 code just includes so many possibilities but the reimbursement on it when you start having to work multiple joints is just a mess. The reimbursement on it is great if you are fraudently throwing a spotweld screw but not so much if you are having to prepare multiple joints and add incisions.
 
heybrother said:
Here's the simple truth about adductoplasty - in the vast majority of the x-rays they show on their website the patient did not need to have an adductoplasty performed. Patients with mild metatarsus adductus but a maintained 1-2-IM who are good candidates for lapidus will perceive themselves as greatly improved with just correction through the 1st TMTJ. They'll walk faster. They'll have less swelling. They are at much less risk of complication, non-union, nerve pain etc. Anyone who is older and is agreeable for 1st MPJ fusion should probably do that instead if clinical correction can be achieved with it. Patients with historic metatarsus adductus and painful bunions who were treated by a podiatrist often had something ridiculous done to them like an Austin that did nothing. If old podiatrists were so much better at biomechanics why couldn't they see/understand this, PM News.

This is a niche product. It could be wonderful for the right person. The right person though is going to be very rare - very large deformity, immaculate health / ideally very young, completely flexible/reducible forefoot deformities and finally and most important and therefore I'm obviously joking - they'll need to have the best of the best insurance. Gold plated? No, platinum plated. Did you know pound for pound Treace plates cost more than platinum? Its true.

Without touching severity - I divide patients with metatarsus adductus into 2 types of feet. Metatarsus adductus with maintained 1-2 IM (described above). The bummer cases though are metatarsus adductus with no 1-2 IM. Obviously there are more variations that are important - like you can have all of the above and have a short 1st ray. I also haven't said a word about true Skew/Z/Serpentine foot which amusingly two Treace reps I spoke to had never heard of.

Final thing. On good insurance - a distal 1st ray osteotomy in my area is worth $1200. A 1st MPJ fusion or a lapidus are worth $1400ish. A 28730 is worth $1700. The 28730 code just includes so many possibilities but the reimbursement on it when you start having to work multiple joints is just a mess. The reimbursement on it is great if you are fraudently throwing a spotweld screw but not so much if you are having to prepare multiple joints and add incisions.
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Niche product is a very accurate description. Like the idea that this was their 2nd product....makes zero sense. This is not a thing the market was missing.
 
NatCh said:
Not an insurance document yet we have to follow the document? Man…
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It’s not truly a document. But I’m sure you are aware of CPT codes. Those are mandatory and accepted by every insurance company. However, the CPT manual, codes, edits, etc., was created by and owned by the AMA.

My point is that we can blame insurance companies for a lot of things, but if you’ve got a beef about the CPT codes and what’s included, etc., blame the AMA.
 
Bunion King of NY? Look for my car in the neighborhood and look at MY license plates…I’m the BUNION EMPEROR!
 
What are we doing with this beaut XR below?
74F active pt with bunion surgery ~40yrs ago, chronic recurrent ~5mm ulcer and callus base of prox phalanx that another nearby DPM was debriding + PO abx for years (makes us all look like rock stars, huh?). MPJ moves fairly well saggital plane, not much transverse ROM pain and semi-reducible (states no pain or callus medial IPJ since it's flexible enough at MPJ). The complaint is the callus/wound on and off for years. For today, I just sent for XR and gave little o-shape pads that I got free from an ortho clinic that closed (they do TFP non-op stuff too).

...I'm thinking present MPJ fusion at f/u in a couple weeks, she will likely reject that, do exostectomy medial base of phalanx with medial capsulotomy, EHL lengthening... honorary mention to central akin (or consent for that if soft tissue work does nothing. Keller might work but seems overkill due to joint moving surprisingly well. 🤔

varus.jpg
 
Feli said:
What are we doing with this beaut XR below?
74F active pt with bunion surgery ~40yrs ago, chronic recurrent ~5mm ulcer and callus base of prox phalanx that another nearby DPM was debriding + PO abx for years (makes us all look like rock stars, huh?). MPJ moves fairly well saggital plane, not much transverse ROM pain and semi-reducible (states no pain or callus medial IPJ since it's flexible enough at MPJ). The complaint is the callus/wound on and off for years. For today, I just sent for XR and gave little o-shape pads that I got free from an ortho clinic that closed (they do TFP non-op stuff too).

...I'm thinking present MPJ fusion at f/u in a couple weeks, she will likely reject that, do exostectomy medial base of phalanx with medial capsulotomy, EHL lengthening... honorary mention to central akin (or consent for that if soft tissue work does nothing. Keller might work but seems overkill due to joint moving surprisingly well. 🤔

View attachment 371638
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Exostectomy/resect the part of the prox phalanx causing the ulcer. I’ve had similar patients where I just resected portions of proximal phalanx and while it looks janky/floppy as they heal it fills in and they’ve been happy. You could probably just buzz out the proximal 1/3rd of the phalanx to let it float and be fine. Which is essentially a Keller anyways.
 
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Feli said:
What are we doing with this beaut XR below?
74F active pt with bunion surgery ~40yrs ago, chronic recurrent ~5mm ulcer and callus base of prox phalanx that another nearby DPM was debriding + PO abx for years (makes us all look like rock stars, huh?). MPJ moves fairly well saggital plane, not much transverse ROM pain and semi-reducible (states no pain or callus medial IPJ since it's flexible enough at MPJ). The complaint is the callus/wound on and off for years. For today, I just sent for XR and gave little o-shape pads that I got free from an ortho clinic that closed (they do TFP non-op stuff too).

...I'm thinking present MPJ fusion at f/u in a couple weeks, she will likely reject that, do exostectomy medial base of phalanx with medial capsulotomy, EHL lengthening... honorary mention to central akin (or consent for that if soft tissue work does nothing. Keller might work but seems overkill due to joint moving surprisingly well. 🤔

View attachment 371638
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1st mpj fusion or bust. It's your job to convince her why it is the smart choice short term, long term, biomechanically etc. You aren't practicing in Malibu bro. Give the patient what she needs not what she wants.
 
air bud said:
1st mpj fusion or bust. It's your job to convince her why it is the smart choice short term, long term, biomechanically etc. You aren't practicing in Malibu bro. Give the patient what she needs not what she wants.
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Agree wholeheartedly. Or you can do the exostectomy, watch it drift further into varus and treat the new wound at the tip of the toe for the next decade.
 
@Feli have a similar scenario as yours above except my patient has a pancake foot. Offered him a MPJ and possible combo IPJ fusion to slightly de rotate the toe and take pressure away from the entire medial side of proximal phalanx.
 
heybrother said:
You gotta put the toe into a little varus for it truly to be straight.
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This is true radiographically, but Pronation is working on a paper regarding the TH angle (toenail-hallux angle, midline of toenail vs midline of distal hallux clinically). Sure, most folk have a toenail parallel to the long axis of the distal hallux... but upon mini-goniometric analysis, that's not all patients! Cosmetics must always be considered for the Keryfix surgery nails and similar by fellowship keratin nail fold professionals. Restoration of the TH angle is critical for proper post-op appearance in sandals or Crocs. It will either be added to ABPM exams or be its own CAQ... undecided as yet.

...and this varus pt called back today - very next day after new pt visit - saying they want surgery (I haven't even talked to them about the XR and what surgery would be yet). I guess the callus/wound for years shtick must have been pretty annoying. :shrug:
 
DYK343 said:
Any neuropathy?
If so I shy away from fusion.
Causes problems. Would go exostectomy
If no neuropathy fuse that toe.
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NatCh said:
Agreed. 1st MTP fusion or get the hell out of my office.
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air bud said:
1st mpj fusion or bust. It's your job to convince her why it is the smart choice short term, long term, biomechanically etc. You aren't practicing in Malibu bro. Give the patient what she needs not what she wants.
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Yes, it turned out she was game for first MPJ fusion... glad for that. I started out asking her if she planned on walking for many more years or just a couple more. 🙂

wakaflocka88 said:
@Feli have a similar scenario as yours above except my patient has a pancake foot. Offered him a MPJ and possible combo IPJ fusion to slightly de rotate the toe and take pressure away from the entire medial side of proximal phalanx.
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I told her she'll probably just get IPJ problems from the varus in the future otherwise if we just did exostectomy. We shall schedule MPJ1 fusion, excision lesion (cystic callus base prox phalanx), bone bx sample, and Tailors bunionectomy (why not, she has a callus there too).

The hallux base callus turned out to be a viscous ganglion mess today. She'd said wound history for years, but it's basically a tract to the MPJ... will need to make the MPJ incision to ellipse it out and lose it, that skin is too beat up to be viable since this has gone on years.
 
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