When do you "break the global"

[heybrother]

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf

You're on call. A new patient shows up your list - admitted septic overnight. Some sort of forefoot gangrene, meth injecting, diabetic, vasculopath, smoker train wreck. Or perhaps another DPM already took a crack at a partial amp or toe amp and the whole thing fell apart (and they don't have priviledges at your hospital or the patient was transfered to you because you have vascular at your hospital). Vascular is going to take a crack tomorrow or maybe they just want to see what happens and tell you they'll follow as necessary. You've never met the patient before. You have no relationship with them or care up to this point. Inevitably they have no PCP, no management of their insulin, and likely a slieue of other comorbidities.

So they get multidisciplinary treatment with hospitalist, ID, vascular, etc. You amp (not a toe code - let's say 28805 with some secondary/staged surgeries) before or after vascular intervenes depending on what has to be done, but let's say either they

(a) leave the hospital already dehiscing/open/
(b) start to deteriorate/necrose immediately upon coming in for their first/early post-op visits.

Forget whether this should have been a BKA or what not - you take over care of patient you met in the hospital on which you've operated/amputated and will be delivering post-op care until next level amputation.

At your first-second whatever post-op this patient already needs debridement/clean-up whatever which will be performed in your office. When do you begin billing for debridement?

I have a variety of scenarios in mind, but I'll start with a disastrous infection to wound/ulcer complication first. From the get go this patient may require some sort of ulcer debridement code. Medicare pays $125 for a 11042 in a private office. An isolated TMA is $700. If you think this patient has insurance you are kidding yourself, but the financial dynamics here are real - there's a lof of care to be delivered for months potentially for free that painfully is worth substantially more than the original surgery.

Urban Legend? If you indicate at first encounter (in hospital) that this patient will require staged care / future debridement /multiple surgeries your post-op debridement codes even in the global are cool?

----
And now for some book bases rules from the text above


Page 6:

What services are included in the global surgery payment?

Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
• Pre-operative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
• Intra-operative services that are normally a usual and necessary part of a surgical procedure
• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Ok - mostly Bummer...


BUT

What services are not included in the global surgery payment? The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures • Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants • Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.


OK - maybe some good and bad in the above.

The first line I bolded would seem to be a bummer for a scenario I've wondered about.

if you did a lapidus that non-unioned. The original diagnosis is hallux valgus, the secondary diagnosis is non-union but its a complication of the surgery... so technically talking about the non-union and 24ing it would be problematic/no-go - except - a non-union isn't part of the normal recovery, just saying. That said, taking them back to the OR and taking down the fusion/redoing it is covered.

However, what's interesting is the idea of added treatment which is not part of the normal recovery of the surgery.

So - what is a normal recovery from surgery?

Do people who immediately start debriding (and bill) justify that the course of treatment is outside the normal recovery?

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Members don't see this ad.

 

[king22]

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf

You're on call. A new patient shows up your list - admitted septic overnight. Some sort of forefoot gangrene, meth injecting, diabetic, vasculopath, smoker train wreck. Or perhaps another DPM already took a crack at a partial amp or toe amp and the whole thing fell apart (and they don't have priviledges at your hospital or the patient was transfered to you because you have vascular at your hospital). Vascular is going to take a crack tomorrow or maybe they just want to see what happens and tell you they'll follow as necessary. You've never met the patient before. You have no relationship with them or care up to this point. Inevitably they have no PCP, no management of their insulin, and likely a slieue of other comorbidities.

So they get multidisciplinary treatment with hospitalist, ID, vascular, etc. You amp (not a toe code - let's say 28805 with some secondary/staged surgeries) before or after vascular intervenes depending on what has to be done, but let's say either they

(a) leave the hospital already dehiscing/open/
(b) start to deteriorate/necrose immediately upon coming in for their first/early post-op visits.

Forget whether this should have been a BKA or what not - you take over care of patient you met in the hospital on which you've operated/amputated and will be delivering post-op care until next level amputation.

At your first-second whatever post-op this patient already needs debridement/clean-up whatever which will be performed in your office. When do you begin billing for debridement?

I have a variety of scenarios in mind, but I'll start with a disastrous infection to wound/ulcer complication first. From the get go this patient may require some sort of ulcer debridement code. Medicare pays $125 for a 11042 in a private office. An isolated TMA is $700. If you think this patient has insurance you are kidding yourself, but the financial dynamics here are real - there's a lof of care to be delivered for months potentially for free that painfully is worth substantially more than the original surgery.

Urban Legend? If you indicate at first encounter (in hospital) that this patient will require staged care / future debridement /multiple surgeries your post-op debridement codes even in the global are cool?

----
And now for some book bases rules from the text above


Page 6:

What services are included in the global surgery payment?

Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
• Pre-operative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
• Intra-operative services that are normally a usual and necessary part of a surgical procedure
• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Ok - mostly Bummer...


BUT

What services are not included in the global surgery payment? The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures • Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants • Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.


OK - maybe some good and bad in the above.

The first line I bolded would seem to be a bummer for a scenario I've wondered about.

if you did a lapidus that non-unioned. The original diagnosis is hallux valgus, the secondary diagnosis is non-union but its a complication of the surgery... so technically talking about the non-union and 24ing it would be problematic/no-go - except - a non-union isn't part of the normal recovery, just saying. That said, taking them back to the OR and taking down the fusion/redoing it is covered.

However, what's interesting is the idea of added treatment which is not part of the normal recovery of the surgery.

So - what is a normal recovery from surgery?

Do people who immediately start debriding (and bill) justify that the course of treatment is outside the normal recovery?

Interesting. I was always under the impression that if your surgical site dehisced in the global period and you chose to heal it through secondary intention (therefore requiring routine debridements) it would be a separately payable service.

 

[dtrack22]

This is one where insurance probably matters. CMS and the CPT codebook/rules differ in what they say is appropriate to bill for in the post-op. CMS makes it clear that a post-op infection, wound dehiscence, etc. are included in the global surgical package. CPT actually says it’s ok to use the 24 modifier for post-op complications. You don’t have to follow CMS guidelines necessarily when billing commercial plans. You can follow CPT rules. The commercial plan might reject your claim and ask for notes and still reject your claim, but I would bill any post-op complication and dictate how it is outside the normal or expected post-op recovery.

I would bet money than lots of folks use CMS’ words against them and actually routinely bill e/m or debridement codes in the global, quoting something like this:

Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery

I don’t think this statement is as generic/broad as it might seem on the surface. But I’ve never seen an explanation or examples of what CMS means by that, so I’m making some assumptions. Sure, you can read that and say, “any additional prescription or procedure I do is billable because it’s ‘not part of normal recovery from surgery.’” I don’t think that’s what it means though. Because of everything else CMS guides and rules say about billing e/m and non-OR procedures in the global, I assume they mean something along the lines of, “Patients disease requires some surgical resection of intestine but the non surgical treatments of the ‘underlying condition’ that might happen during the global period by the same general surgeon can be reported/billed.” I don’t have a great example of what pathology that might be, we don’t really do anything that would fit. I just think everything else that CMS has published re: billing in the global makes more sense if you treat the above quote as an exception for some conditions that require medical and surgical management simultaneously and that’s what they mean by “added course of treatment.” As opposed to, “hey look I found a secret work around for these antibiotics I prescribed for a SSI that Medicare explicitly says is part of the global.”

Of course, Medicare will pay anything that is coded correctly. So I’m sure everyone who comes on to tell me they always get paid for debriding post-op wounds on Medicare patients in the global, is telling the truth. The question is, what would Medicare do if they audited that chart? Ask for their money back or would they let you keep it?

I watch my use of -24 and -25 modifiers in the global with Medicare and Medicaid patients, I do it sparingly. And I dictate the “outside of” or “not part of the normal recovery from surgery.” But I’m not sure if the coders are changing it or sending it through as is.

 

[heybrother]

Thanks dtrack. The below post is essentially in agreement with what you stated.

Post-Operative Complications in the Global Period

What happens when a patient comes back in the global period? This article explains how to code this problem for the best result.

www.aapc.com

 

[dtrack22]

Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery

Ok, I got one. Patient had elective flatfoot recon. You determine a few months out that they still need a custom orthotic (partly because you undercorrected and mostly because they have hit their deductible and you’re in private practice).

Even though you did surgery for their “acquired foot deformity” and that is the “underlying condition,” you determine that their “underlying condition” requires an “added course of treatment which is not part of the normal recovery from surgery.”

The key is that this CMS exception is for treatment of “the underlying condition.” So if you fixed a bunion the treatment that is e/m or minor procedure worthy still has to be a treatment for whatever dx you took them to surgery for. If you fix a bunion then the additional treatment must be for the bunion itself, not hardware pain, or wound care, or cellulitis, or anything that doesn’t have a M20.1X diagnosis code.

Treating the original condition with custom orthotics or an AFO in the global is the best example I can think of in terms of trying to explain what I think CMS means by the above quote. It’s also the only example I can think of. Again, I’ve never seen or read an official example or explanation from CMS explaining that, but it’s what makes sense in my head…

 

[air bud]

well holy crap guys, this is good. this forum can be a place of knowledge instead of "how much money pod make?" and "are fellowships worth it?"
Future ideas for threads:
1. wound care coding with application of skin subs, TCC
2. Why is @CutsWithFury so angry

 

[deleted1097413]

well holy crap guys, this is good. this forum can be a place of knowledge instead of "how much money pod make?" and "are fellowships worth it?"
Future ideas for threads:
1. wound care coding with application of skin subs, TCC
2. Why is @CutsWithFury so angry

CutsWithFury is on a yacht somewhere after the year bitcoin had..

 

[air bud]

CutsWithFury is on a yacht somewhere after the year bitcoin had..

Cardano

 

[GreenHousePub]

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf

You're on call.

Something has gone horribly in my life already then.

 

[NobodyDPM]

well holy crap guys, this is good. this forum can be a place of knowledge instead of "how much money pod make?" and "are fellowships worth it?"
Future ideas for threads:
1. wound care coding with application of skin subs, TCC
2. Why is @CutsWithFury so angry

OMG, totally!! Especially when there aren't any insulting "okay boomer" comments made. NO WAY!!

Imagine that...

 

[DYK343]

Why do boomers hate to be called boomers so much? Its the label on the generation.
Boomers call us millennials all the time but we dont complain about the term.
Never understood that.

Anyways... back to podiatry. This will be a good thread if we can keep it going. Lets not get this one locked down again.

I think im too conservative post op. I bill a lot of 99024 when I could probably squeek a 99213 in there. Good read so far.

 

[heybrother]

Here's an interesting example of differences in commercial insurances (maybe). In this case its between BCBS but 2 different states.

https://www.bcbstx.com/provider/pdf/cpcp014_global_surgical_package_062818.pdf

This is Texas:

Description: The global surgical package includes all the services that a surgeon performs before, during and after a procedure. The global surgical package applies in any setting.

Reimbursement Information:

Global surgery includes all the necessary services normally furnished by a surgeon or by members of the same group with the same specialty, before, during and after a procedure. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. These services include:
 Evaluation and management services subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical). This can include codes ranging from 99201-99499.
 Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia.
 Immediate post-operative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals.  Writing orders.
 Evaluating the patient in the post-anesthesia recovery area.
 Typical post-operative follow-up care.

This is for Illinois

https://www.bcbsil.com/pdf/standards/global_surgical_package_cpcp.pdf

I'm going to refrain from quoting this one because its (a) much longer (b) much closer/essentially identical to the CMS guidelines.


This is from 2016:

https://www.podiatrym.com/pdf/2016/8/Goldsmith816web.pdf

Ongoing Debridement Post Amputation Q: If a podiatrist (or vascular surgeon, for that matter) does an amputation, but leaves the amputation site open, is it okay to bill serial debridements post-amputation on the woundthat is of your creating? If so, what modifier would be appropriate? I see it being routinely billed in my wound center and I am wondering if this is permissible. Response: Yes, it would be permissible to bill for serial debridements in a post-operative global period using a “-58” (staged or related procedure or service by the same physician during the post-operative period) modifier. There are three circumstances that allow for the use of the “-58” modifier: (a) A planned or anticipated (staged) procedure related to the original surgery; (b) A more extensive procedure performance related to the original procedure; or (c) A therapy following a surgical procedure. An example of (a) would be similar to the scenario you present above. Also, you would use a “-58” modifier on post-operative subsequent application of cast codes. An example of (b) would be the amputation of a digit, progressing gangrene, and the need to do a transmetatarsal amputation. Most foot and ankle specialists do not bill example (c). You do not apply a “-58” modifier on procedure codes that are unrelated to the original surgery, or in cases of a complication of surgery (unplanned return to the operative room; “-78”).

 

[CutsWithFury]

Cardano

Cardano is the future. I convinced Air Bud to buy at 0.13 and he sold it after one month of no price improvement. It’s now worth $2.42 as I type. I bought at 0.08 and I’m up 1200%.

In terms of technology Cardano is here to stay and will be a big player as everything goes digital in the near future. I expect Cardano to be trading at $50-100 by 2025 as it supports Fortune 500 companies and possible banks. Cardano also is currently supporting the infrastructure overall in Ethiopia. Most likely will be in Mongolia and the Philippines in the future.

This is your chance to get in on the next Amazon or Apple.

You’ve been told.

 

[NobodyDPM]

Why do boomers hate to be called boomers so much? Its the label on the generation.
Boomers call us millennials all the time but we dont complain about the term.
Never understood that.

Anyways... back to podiatry. This will be a good thread if we can keep it going. Lets not get this one locked down again.

I think im too conservative post op. I bill a lot of 99024 when I could probably squeek a 99213 in there. Good read so far.

Firstly, say "okay Boomer" is derogatory and you know it.

Secondly, I'm not of that generation.

 

[deleted1097413]

Cardano is the future. I convinced Air Bud to buy at 0.13 and he sold it after one month of no price improvement. It’s now worth $2.42 as I type. I bought at 0.08 and I’m up 1200%.

In terms of technology Cardano is here to stay and will be a big player as everything goes digital in the near future. I expect Cardano to be trading at $50-100 by 2025 as it supports Fortune 500 companies and possible banks. Cardano also is currently supporting the infrastructure overall in Ethiopia. Most likely will be in Mongolia and the Philippines in the future.

This is your chance to get in on the next Amazon or Apple.

You’ve been told.

interesting. I do think cardano is number 3 in the big 3. bitcoin, ethereum, and then cardano. I've personally been accumulating as much btc and eth as possible but might dip into cardano

 

[DYK343]

Firstly, say "okay Boomer" is derogatory and you know it.

Secondly, I'm not of that generation.

Lets be honest. Boomers use the term millenial all the time. Was at a beer garden this weekend and the band played a song about how terrible millenials are lol. I think the title was "where did it all go wrong".

The second a millenial uses the term boomer they get all huffy. If we wrote a song about boomers and played it at a venue every boomer in the audience would be up in arms.

Anyways. I dont really care. Back to Crypto.

 

[CutsWithFury]

interesting. I do think cardano is number 3 in the big 3. bitcoin, ethereum, and then cardano. I've personally been accumulating as much btc and eth as possible but might dip into cardano

I foresee Cardano announcing another partnership with a new country at their Summit on 9/25 and 9/26. Possibly they will become the first cryptocurrency to work with the banks and form a central bank of digital currency. Regardless Cardano is in position to gain mass adoption more so than BTC and ETH in my opinion due to how they have built the blockchain from the ground up. ETH has significant issues with cost of transaction as well being not secure and being the victim of malicious hacks losing investors millions of dollars at a time. Yes ETH has first mover advantage but it has significant faults which makes it less likely to be utilized for mass adoption.

Cardano has cheap transactions, lightening fast, secure and is in line to be something that real world corporations can use as it can scale close 1 million TPS with Hydra. It is not going to collapse like Solana did recently.

Increased adoption = increased utility of the blockchain = increases the value of ADA. I also see Cardano decoupling from BTC by 2025.

Crypto is here to stay.

 

[DYK343]

interesting. I do think cardano is number 3 in the big 3. bitcoin, ethereum, and then cardano. I've personally been accumulating as much btc and eth as possible but might dip into cardano

My friend years ago tried to get me into bitcoin.

I thought he was a bit crazy.

It was probably around $3-5 each at that time.

My friend is now retired in his upper 30s lol

 

[dtrack22]

Now that I make good money. I should start paying attention to cryptocurrencies again.

I bought BTC when it was around $800. Sold at the beginning of this year. Paid off my mortgage, students loans and will have some left over even after the 6 figure tax bill that’s coming from the sale. But not even close to retiring, unfortunately…

 

[CutsWithFury]

Now that I make good money. I should start paying attention to cryptocurrencies again.

I bought BTC when it was around $800. Sold at the beginning of this year. Paid off my mortgage, students loans and will have some left over even after the 6 figure tax bill that’s coming from the sale. But not even close to retiring, unfortunately…

dtrack22 introduced me to crypto in 2017 and I’ve been studying it ever since.

I’ll dedicate my first million in crypto to him…almost there

 

[NobodyDPM]

Lets be honest. Boomers use the term millenial all the time. Was at a beer garden this weekend and the band played a song about how terrible millenials are lol. I think the title was "where did it all go wrong".

The second a millenial uses the term boomer they get all huffy. If we wrote a song about boomers and played it at a venue every boomer in the audience would be up in arms.

Anyways. I dont really care. Back to Crypto.

If you didn't care, you wouldn't reply.

I don't remember my ever using any such term towards anyone here. So keep it at the bar, please. Thanks.

You want to use a derogatory term towards me, here? Don't expect any respect.

You want to behave like a profession, and treat everyone as an equal. Great. Let's do that.

 

[DYK343]

If you didn't care, you wouldn't reply.

I don't remember my ever using any such term towards anyone here. So keep it at the bar, please. Thanks.

You want to use a derogatory term towards me, here? Don't expect any respect.

You want to behave like a profession, and treat everyone as an equal. Great. Let's do that.

I never called you a boomer. I just said I dont understand why that generation gets all upset while calling our generation similar derogatory names.

back to crypto...

 

[DYK343]

dtrack22 introduced me to crypto in 2017 and I’ve been studying it ever since.

I’ll dedicate my first million in crypto to him…almost there

I really wish I would have listened to my friend. He never has to work again. I think he sold out when it reached 10k. I bet he is kicking himself now but at the same time he never has to work again. Doesnt live an expensive lifestyle. Normal house. Toyota Camery. Etc.

 

[dtrack22]

I’ll dedicate my first million in crypto to him…almost there

how about you throw me 10% instead?

 

[air bud]

how about you throw me 10% instead?

be a real podiatrist and let him keep 30 percent. if price gets above 5 bucks this bull cycle he gets an extra 10 percent.

Also, LOL boomer is not a derogatory term. and only someone who self-identifies with the boomer gen would keep going on and be offended by it....is a boomer. and a snowflake.

 

[Scrantonicity]

be a real podiatrist and let him keep 30 percent. if price gets above 5 bucks this bull cycle he gets an extra 10 percent.

Also, LOL boomer is not a derogatory term. and only someone who self-identifies with the boomer gen would keep going on and be offended by it....is a boomer. and a snowflake.

Don't forget MustachePods--that's my favorite one that offended a lot of people on these boards

 

[NobodyDPM]

I never called you a boomer. I just said I dont understand why that generation gets all upset while calling our generation similar derogatory names.

back to crypto...

The comment was deleted by the mods. And the thread was locked.

I don't understand, either, so we have that in common.

What does crypto have to do with Podiatry, again? Nothing. Like our issue with the words "boomer" and "millenial".

 

[DYK343]

I do enjoy a good mustache pod. Thats a good one thats been flying around here.

 

[CutsWithFury]

I do enjoy a good mustache pod. Thats a good one thats been flying around here.

I love when mustache pods do podiometric things like try to convince the CDC that they need to have an ICD-10 code for progressive collapsing flatfoot deformity (PCFD). Who cares...... Only in podiatry