Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View
Medical &
Surgical Associates,
Madras, Oregon
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Letters to the Editor
Over the last couple of weeks we have received interesting responses to the Practice Perfect blog. This week we’ll let the podiatric community do the talking. The Practice Perfect editorials are enjoyable for me to write, but my greatest excitement is receiving responses from readers with their opinions and experiences. It is these responses that make our online community truly useful. Read below the comments of our colleagues and write in with your responses either to the blog posts or the eTalk section of Podiatry.com.
—Jarrod Shapiro, DPM
***Radiology and insurance***
I wonder if you could comment on patients who think that the tests we order are costing their insurance company, thus costing them. I have a patient who suffers from bone marrow edema syndrome, had radiographs several months before presenting to me. Patient's MRI and bone scan were alarming, arthrocentesis negative, refuses to get current x-rays despite recommendation by myself and radiologist for comparison to recent imaging studies. She is upset that radiographs 6 months old cannot be utilized, states that she is "spending all this money" for studies, when her previous x-rays done in a private office months ago should be sufficient. Patient is fully insured, is not paying for studies, is a nurse, and should understand the changes that can occur within weeks on radiograph. I have serious concerns that this patient may have leukemia or something of the like, yet she refuses follow-up studies. I told the patient she has to have a repeat MRI at 3 months, as it is the protocol for diagnosis of bone marrow edema, if in fact that is what she has, yet she resists. What can I do?
—Anonymous
Editor’s Response:
My first impression on reading this was that this patient is nuts. How many patients refuse testing citing concerns about costing their insurance company too much? It’s very rare. Then I started thinking about this a bit further. Perhaps there’s more to the story. This patient’s refusal for further testing can be considered from two perspectives as I see it: the psychological (or patient’s) viewpoint and the doctor’s viewpoint. From the patient’s perspective, perhaps the refusal for further tests can be viewed by her psychological state of mind. I would wonder if the patient is afraid of what repeat test results may find. Perhaps she does have a leukemia, and, being a nurse, has some understanding of what she would have to go through during treatment. As a result, perhaps she is in simple denial or transferring her fears onto the insurance aspect of her diagnosis. Perhaps, also, this patient has trust issues, though I don’t see why based on our colleague’s story.
From the doctor’s perspective this is, on the surface, an unreasonable patient who is denying treatment (or at least further investigation). I think this would raise a red flag for most of it, as it did for our colleague. I approach patients like these somewhat simplistically (my brain doesn’t do “complex” very well). Assuming my above assumption is not the reality of the situation, I would explain the potential risks of not following my suggestions, letting the patient know this is her leg and her life – she makes the final decision – and suggest a second opinion. I would then document everything discussed. Remember, failure to diagnose is one of the most common reasons doctors are sued. If the patient dies from leukemia, our colleague will at least be protected. We offer our patients advice, but they are the final arbiters of their care.
—Jarrod Shapiro, DPM
***Art of Coding***
Great Practice Perfect article on PRESENT titled the Art of Coding. Do you think you can expand this topic on PRESENT at some point? There seems to be a lot of confusion re: Medicare covered services, the proper billing for routine care, what procedures are considered routine care, when an ABN should be completed, etc. I have had several discussions with my young member colleagues and there doesn't seem to be a clear understanding among us.
—Nichol Salvo, DPM
Editor’s Response:
I’m not an expert on coding but I’ll comment on Dr Salvo’s questions about routine care billing and coding as I understand it. For those reading this with more experience than me, please feel free to write in with any corrections or modifications to my statements below. I’m going to discuss Medicare routine foot care codes (their name for it, not mine) and coding only. Some private insurers pay for nail debridement and other do not. I would recommend contacting the specific insurers directly for further information.
Ok, first of all not all patients qualify for reimbursement of nail or callus debridement. Your patient must have a diagnosed systemic condition (metabolic, neurologic, or PVD) that would put him at risk for complications if he trimmed his own nails. Age by itself is not enough. If your patient doesn’t quality, have them sign an Advanced Beneficiary Notice (ABN) and explain they will have to pay out of pocket for your services. Otherwise, send them to a pedicurist. I have attached a list of diagnoses that would qualify a patient to see a podiatrist.
Second, for many of the diagnoses, you will be required to document who the patient’s PCP is and a date they were last seen. For example, you might state in your dictation: “Mr ToeNail is seen today for high risk diabetic foot care. Last seen by Dr Bunion on 3/5/10.” Have your staff ask these questions when rooming your patients to save you time. Your patient must have seen their PCP within 6 months or they’ll need to sign an ABN. Let them know their visit may not be covered. No, you cannot have all of your patients sign an ABN. There are also “buzz” words that need to be present in the Plan section of your SOAP note. I typically state the following: “Toenails x 10 were debrided with nail nippers and rotary burr to prevent pain, infection, or difficulty with ambulation.” It’s also necessary to state how you are treating the condition. If it’s onychomycosis, this may be as simple as recommending an OTC antifungal medication.
Third, the physical exam is a component must be documented as well. As always the physical exam must support the diagnosis and treatment.
There are certain codes that must be used when debriding nails or calluses on Medicare patients. You cannot use an E&M code when you’re debriding nails. The codes are 11720, 11721,11719, G0127 for nails and 11055, 11056, and 11057 for calluses. The last 5 codes I mentioned require Q modifiers (AKA Class findings). See the attached code list for an explanation of class findings.
As a resource, I’d recommend referring to the APMA’s website for further information. Also consider billing and coding education from the American Academy of Podiatric Practice Management www.aappm.org or the ACFAS Practice Management Seminar.
One last point. Remember your patients aren’t coming to see you to have their nails clipped. They are seeing you for evaluation and screening of lower extremities at risk for limb loss or further complications. If they need their nails clipped and they don’t have disease that puts them at risk, then send them to a pedicurist.
—Jarrod Shapiro, DPM
***Fellowships***
I was fortunate to complete a 3 year surgical residency program that provided me with excellent surgical and medical knowledge with the top Podiatric physicians in the Country (Dr. Yu and Dr. Grossman). I was also fortunate to obtain a spot with American Health Network, a one year revisional and reconstructive foot and ankle surgery program. When I finished residency, I felt competent to handle any pathology in the foot and ankle medically and surgically. After the fellowship and 1500 surgical cases, my perception of an "extra year of training" was cemented. That extra year, although taxing financially, is well worth it in private practice. I was much more comfortable handling major reconstructive cases on my own. In residency, you have the benefit of extra hands holding position, retracting, etc. A lot of the time, you share cases and responsibility for teaching other residents. A fellowship concentrates on one individual. You can improve your skills, learn to work independently, appreciate various techniques and pick up new skills (this is only natural after performing such a high volume of cases). I can speak about my fellowship from experience in the fact that it is fellow directed and focuses on improving deficiency. I was treated like a colleague, my opinion was respected, and I was also able to do a mini- fellowship within the fellowship (4 week trauma rotation in Israel).
There is no doubt that the education is worth it. I'm in a multispecialty practice now, and there is a different level of appreciation from my partner physicians for that extra year of training.
Having said that, there is a false perception that when you graduate, you will have the red carpet rolled out for you from your local hospital. That is not the case and it is location dependent. Whether you do a two or three year residency, one or two year fellowship, you still remain a podiatric physician and have to prove your skills and knowledge daily.
In terms of salary, again it depends on the location and situation; there is an in-direct monetary effect from knowledge. The eyes see what the mind knows; you can recognize pathology and have a higher comfort level in treating it well, which in turn results in higher patient satisfaction, more referrals and eventually increased income.
I think at some point, accreditation should be pursued. However, there are limitations to that as well. I have to caution residents that a fellowship should be focused on the fellow and not just an extra pair of hands in the office and OR. I think that's the only concern I would have about non-accredited programs in terms of "fellow abuse". There are a number of excellent programs that are not accredited, including my graduating program, Dr. Hyer in Columbus, Ohio, and Dr. DiDimonico in Youngstown, Ohio. Just food for thought, thanks
—Suhail Masadeh, DPM
[email protected]
Editor’s Response:
What more needs to be said? My thanks to Dr Masadeh for his insightful comments about fellowship training. For those who have done fellowships, please write in and describe your experiences. I’m sure there are many who would benefit from your experience and wisdom.
—Jarrod Shapiro, DPM
Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. Best wishes, and I’ll see you at the ACFAS in Fort Lauderdale next year.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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