Is burnout real during residency? (not trolling)

[HardRoadPaved]

Yeah an MRI is it is not equivalent to RX for risk management. An MRI is no different from an X-ray.

But you're probably documenting their condition is worsening in spite of treatment so now severity bumps up. You put them on rx meds that carry side effects. You need to consider surgical planning in case of x, y, z. 99214 are pretty easy to hit.

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[air bud]

But you're probably documenting their condition is worsening in spite of treatment so now severity bumps up. You put them on rx meds that carry side effects. You need to consider surgical planning in case of x, y, z. 99214 are pretty easy to hit.

Oh 99214 is not hard. I am just saying ordering an MRI does not raise the level of risk management. It is just like a lab or an x-ray or reviewing another docs note.

 

[Pod2death]

You guys are leaving a ton of $ on the table.

Bill for both the E&M and the procedure(s) if you do both... just do different dx codes. If insurance rejects the E&M or the procedures, appeal it. If they reject it a lot, bill on time and up your E&Ms... or just drop those crusty payers. If there are not different applicable dx codes for the E&M then you're not thinking hard enough you can just bill the proc code(s) only.

Heel pain f/u = 99213 for M76.821, M76.822, L85.3 and 20550-RT for M72.2, M79.671 and 20550-LT for M72.2, M79.672 and J0702-RT and J0702-LT (same icd codes as 20550s) and arch supports OTC or night splint or whatever applies (and 99214 if you do PT Rx or order MRI, etc)

Ingrown f/u (slant back didn't work or pt had scheduled it and returns) = 99213 for M20.11, L03.031 and 11750-T5 for L60.0, M79.674

Verruca f/u = 99213 for L85.3, M77.41, M77.42 and 17110 for B07.0, M79.671, M79.672

Ankle sprain f/u = 99213 for M79.671, S93.491D, R60.0 and L1902-RT for same (99214 if you Rx PT and order MRI or something)

I know the conversation has moved past this but I am an associate podiatrist so I read kinda slow.

I just wanted to say, this is a phenomenal post. I'm getting the hang of billing but this alone answered a lot of questions for me. Thank you.

 

[dtrack22]

You need to consider surgical planning in case of x, y, z.

Not level 4 decision making. The actual decision to perform surgery is, not “I told the patient if this injection didn’t work then we’d need to consider surgery as the next step.”

 

[air bud]

Agr

Not level 4 decision making. The actual decision to perform surgery is, not “I told the patient if this injection didn’t work then we’d need to consider surgery as the next step.”

Agree. I don't know if they were trying to say hey these plantar fascia injections don't seem to be working let's get an MRI and consider surgery. That is a level 3

 

[Pronation]

Agr
Agree. I don't know if they were trying to say hey these plantar fascia injections don't seem to be working let's get an MRI and consider surgery. That is a level 3

Ok but what about “hey this urea callus cream doesn’t seem to be working let’s consider DEBRIDEMENT”. That’s like at least a level 3 and a 4 if we need to add in some extra offloading with custom orthotics?

 

[air bud]

Ok but what about “hey this urea callus cream doesn’t seem to be working let’s consider DEBRIDEMENT”. That’s like at least a level 3 and a 4 if we need to add in some extra offloading with custom orthotics?

No off mode for you bro, I love it

 

[HardRoadPaved]

Oh absolutely you cant just give a 1 liner "lets cut if its bad" If you truly have a frank discussion of surgery, outline risks and benefits then you got there.

I love the 2021 rule change. Must be annoying for all the real doctors that treat complex things to see we can level up to more 4s and even 5s since we dont need the history/physical components

 

[Hybrocure]

Oh absolutely you cant just give a 1 liner "lets cut if its bad" If you truly have a frank discussion of surgery, outline risks and benefits then you got there.

I love the 2021 rule change. Must be annoying for all the real doctors that treat complex things to see we can level up to more 4s and even 5s since we dont need the history/physical components

View attachment 372182

Idk, my PCP literally just pops in for 5 mins says what’s up, I talk about my pertinent problem, they ignore everything else and bill a level 4 lol

 

[air bud]

Oh absolutely you cant just give a 1 liner "lets cut if its bad" If you truly have a frank discussion of surgery, outline risks and benefits then you got there.

I love the 2021 rule change. Must be annoying for all the real doctors that treat complex things to see we can level up to more 4s and even 5s since we dont need the history/physical components

View attachment 372182

This one page needs to be memorized immediately. This is your coding bible. This is not hard.

Just dont start with your BS about uncertain prognosis bro....

 

[air bud]

Idk, my PCP literally just pops in for 5 mins says what’s up, I talk about my pertinent problem, they ignore everything else and bill a level 4 lol

I have seen 2 specialists recently. Nothing huge came out of it. Level 4. That is their baseline j am sure.

Right now I am billing 33 percent level 4, same for new and established. Just looked at numbers. Should be higher closer to 40 soon, still probably too low.

 

[Hybrocure]

Would you consider new patient ankle sprain a level 4? I generally bill my non op fractures as 4s but for sprains I do 3.

 

[Adam Smasher]

Would you consider new patient ankle sprain a level 4?

acute complicated injury (because it's ATFL and possibly CFL too)
and you prescribe an NSAID (like voltaren gel)

lol I'm joking, I bill a 3

 

[air bud]

Would you consider new patient ankle sprain a level 4? I generally bill my non op fractures as 4s but for sprains I do 3.

A non-op fracture you are making a decision to operate or not operate. A sprain you are not.

 

[Hybrocure]

A non-op fracture you are making a decision to operate or not operate. A sprain you are not.

To be fair it seems about every ortho employed pod in my area is operating on every ankle sprain that comes in their door

 

[bloxxeeey]

To be fair it seems about every ortho employed pod in my area is operating on every ankle sprain that comes in their door

You have too.

 

[Feli]

Would you consider new patient ankle sprain a level 4? I generally bill my non op fractures as 4s but for sprains I do 3.

Those can also be 9920x + 28xxx + DME/splint/strap if you wish.

The 28xxx triggers a 90d global but can be advantageous in some situations (dinky fx that'll only be one or two quick f/u, pts who might not f/u, etc).

New pt sprains are a 99203 unless they had some other significant issues.

 

[Boba Foot]

Those can also be 9920x + 28xxx + DME/splint/strap if you wish.

The 28xxx triggers a 90d global but can be advantageous in some situations (dinky fx that'll only be one or two quick f/u, pts who might not f/u, etc).

New pt sprains are a 99203 unless they had some other significant issues.

Fracture codes are nice but if it's like a Jones and it will probably linger forever, then stay away.

 

[Hybrocure]

Fracture codes are nice but if it's like a Jones and it will probably linger forever, then stay away.

I always do fracture codes on the sketchy Medicaid patients that because there’s a good chance they don’t follow up or will miss a lot of appointments

 

[Boba Foot]

I always do fracture codes on the sketchy Medicaid patients that because there’s a good chance they don’t follow up or will miss a lot of appointments

This is the way.

 

[dtrack22]

Would you consider new patient ankle sprain a level 4? I generally bill my non op fractures as 4s but for sprains I do 3.

Generally a 3

Non op fractures are 4s and I generally bill closed treatment codes and only see patient one more time within 90 days

As for the level 4 discuss surgery thing. It’s a level 4 when you/patient makes the decision to have surgery. Not talking about bunion surgery on the first visit and then the patient saying “I’ll just try to find some wider shoes,” and then you billing a 4 because you provided them with a lapiplasty handout.

 

[HardRoadPaved]

Frequently Asked Questions

Frequently Asked Questions

www.facs.org

Real surgeons bill a level 4

A patient is referred to a surgeon for possible major surgery, and the surgeon decides that surgery is not appropriate based on their evaluation of the patient. Can this still be considered a decision for surgery under the “risk” element of MDM?

Yes, this scenario applies to the MDM element “risk of complications and/or morbidity or mortality of patient management”—which includes both possible management options selected as well as those considered but not selected—after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.

 

[dtrack22]

Frequently Asked Questions

Frequently Asked Questions

www.facs.org

Real surgeons bill a level 4

A patient is referred to a surgeon for possible major surgery, and the surgeon decides that surgery is not appropriate based on their evaluation of the patient. Can this still be considered a decision for surgery under the “risk” element of MDM?

Yes, this scenario applies to the MDM element “risk of complications and/or morbidity or mortality of patient management”—which includes both possible management options selected as well as those considered but not selected—after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.

Yes, you bill a level 4 at the time of surgical decision making. Determining that surgery is not an option for the patient, even though it may be the recommended treatment for the particular condition, is the same as determining with the patient they would like to undergo surgical intervention. Still not what your original example said

You need to consider surgical planning in case of x, y, z.

Not, thinking about planning “in case of x, y, z.” Maybe that’s not what you meant to convey re: the surgical decision making component of a level 4 visit. But it’s what I was responding to. And it’s not the same as or equivalent to the example you gave above

 

[HardRoadPaved]

Yes, you bill a level 4 at the time of surgical decision making. Determining that surgery is not an option for the patient, even though it may be the recommended treatment for the particular condition, is the same as determining with the patient they would like to undergo surgical intervention. Still not what your original example said



Not, thinking about planning “in case of x, y, z.” Maybe that’s not what you meant to convey re: the surgical decision making component of a level 4 visit. But it’s what I was responding to. And it’s not the same as or equivalent to the example you gave above

Yea. Just need it to be a real convo. No lapiplasty pamplets.. Although the worst is when "patient education" was included in prior e/m rules...

 

[DYK343]

...I would love my billers to read this thread...

 

[GreenHousePub]

You have too.

Why?

 

[Hybrocure]

Why?

Generation of RVUs I guess. Doing a scope brostrom on every ankle sprain that comes in your door = $$

 

[heybrother]

I always assumed the key was to order an MRI as early as possible and then say the findings must be fixed.

 

[Feli]

I have seen 2 specialists recently. Nothing huge came out of it. Level 4. That is their baseline j am sure.

Right now I am billing 33 percent level 4, same for new and established. Just looked at numbers. Should be higher closer to 40 soon, still probably too low.

Yes, correct.

Whenever my partner or I see a specialist, it's a 99214 (both no daily meds, good health, etc), and I would assume they do that on time or just probably because it's we don't visit often and it's usually new dx or decision for minor procedure or short term Rx or whatever. It is definitely their norm, though. When I was 1099 and self-pay, I once complained at checkout a 7min visit (f2f time) with lab result and no meds and no Rx is not a 99214 and $150 or whatever their cash pay price was, but they insisted it was.

Internists and int med specialists with minimal procedures are even more aggressive with the E&M because they don't have a ton else to bill and they're usually juggling more Rx and sicker pts. I saw a lot of 99215 (plus Rx mgmt cpt codes on the visit) when I worked MSG with Endo and IM.

...I think I'm probably around 10/60/30/1% for 99212/3/4/5 codes in my office. I would be higher on level 4 if I would prn more pts that are nearly better (ingrown, verruca, sports med stuff), but I tend to bring them back and do 99213 or even 99212 once in awhile on visits to verify fully healed issue (PT worked, orthotic fixed heel pain, etc). I don't do 99205 unless it was some disaster I had to admit and spend a ton of time on and could bill it on time (60+mins on pt + imaging + correspondance to admit + chart + etc). Those were more back in IHS... but still infrequent.

There are plenty of "coding experts" who say podiatry should do 99213 and -14 roughly equal, but they're mainly just billers for small offices or TFPs who branded themselves "experts," so I'm not sure that's good to take them as the gospel. A lot depends on practice type and pt population.

 

[MicroPod]

PGY2 here, just finished up a week of call at our main hospital and based on rough calculations I spent around 110 hours working between call responsibilities, clinic, and covering attending cases. Some weeks can definitely be rough. Also the hospitalists at this hospital are starting to refuse to admit some of the diabetic foot patients so now we are having to admit and manage.

 

[Adam Smasher]

Also the hospitalists at this hospital are starting to refuse to admit some of the diabetic foot patients

as long as everyone's malpractice premiums are paid up, this should work out fine

 

[DMEpod]

There must be a reason they aren't being admitted. Just because someone has an open ulcer is not admission criteria, no matter how many prior auths may be necessary before the outpt toe amp.

 

[Pronation]

There must be a reason they aren't being admitted. Just because someone has an open ulcer is not admission criteria, no matter how many prior auths may be necessary before the outpt toe amp.

Thanks for letting us know about admission criteria. As a total toenail replacement surgeon, I have been battling the hospital when I tell them I am admitting my patients for terminal onychomycosis.

 

[HardRoadPaved]

Also the hospitalists at this hospital are starting to refuse to admit some of the diabetic foot patients

No shoes, no service policy. They dont want the liability if you didnt get them their yearly pair.

 

[Hybrocure]

There must be a reason they aren't being admitted. Just because someone has an open ulcer is not admission criteria, no matter how many prior auths may be necessary before the outpt toe amp.

Yup. A non septic osteo patient can be managed completely outpatient. I think hospitals are catching on to pods admitting non septic ulcer patients just to collect rounding money from the residents work every day.

Too many pods have a new ulcer patient come in to their clinic with a red toe and ulcer probing to bone and just call for an admit rather than start oral abx, imaging, or schedule for an outpatient amp.

 

[Adam Smasher]

Yup. A non septic osteo patient can be managed completely outpatient. I think hospitals are catching on to pods admitting non septic ulcer patients just to collect rounding money from the residents work every day.

Interesting. The 2012 IDSA guidelines advocate hospitalization for any moderate severity (cellulitis extending > 2cm around ulcer) infection. This year's update takes a more nuanced approach. Personally, I try to avoid admissions wherever possible just to save patients on the upheaval to their lives. But sometimes it's the most expeditious way

 

[Shiyuan]

Interesting. The 2012 IDSA guidelines advocate hospitalization for any moderate severity (cellulitis extending > 2cm around ulcer) infection. This year's update takes a more nuanced approach. Personally, I try to avoid admissions wherever possible just to save patients on the upheaval to their lives. But sometimes it's the most expeditious way

If theyre not SIRS I avoid admission like the plague.

 

[Pronation]

Yes, I personally wait until they’re hypotensive and tachy in the office before sending them to the hospital.

Or if they’ve already received their 10 approved grafts then I will admit before they show signs of outpatient septic shock.

 

[Hybrocure]

Interesting. The 2012 IDSA guidelines advocate hospitalization for any moderate severity (cellulitis extending > 2cm around ulcer) infection. This year's update takes a more nuanced approach. Personally, I try to avoid admissions wherever possible just to save patients on the upheaval to their lives. But sometimes it's the most expeditious way

If that was the case every patient in wound care centers would be just permanently an inpatient lol.

So many stable wounds have 2cm of redness around them which people would interpret as cellulitis.

 

[Hybrocure]

Yes, I personally wait until they’re hypotensive and tachy in the office before sending them to the hospital.

Or if they’ve already received their 10 approved grafts then I will admit before they show signs of outpatient septic shock.

What’s the difference between sitting at home or laying in a hospital bed if the patient doesn’t require hospital level support? I know your response is tongue in cheek but there are plenty of patients that get by just fine on oral abx waiting a couple days for an outpatient amp.

MANY of them sat at home that same way for months leading up to the new patient visit.

 

[Adam Smasher]

A lot of it may be logistics. You can get the entire lab/imaging workup done in a day or 2 at the hospital followed by a 2am toe amp. On an outpatient basis, this whole process gets stretched out for weeks.

It also might be medical-legal. Sometimes you just know looking at a toe that it's doomed, but you order the MRI to cover your 6, and outpatient MRIs turn around really slow. Plus you order BUN/Crt per MRI protocol and it turns out the patient is in AKI so now it's definitely an admission because the moderate severity infection plus organ dysfunction = severe infection!

Again, I am very keen on not doing this, I'm just quoting the guidelines.

 

[Pronation]

followed by a 2am toe amp.

I see what you did there

 

[MalleableMan]

Yes burnout is real all throughout medicine. Our residencies are no different. Some programs are better equipped to educate and give support for wellness than others. Other places don’t think it’s something that needs to be addressed. This is something every student should take into account when looking into programs. Sorry to derail this thread by getting back to the topic.

 

[MicroPod]

Yup. A non septic osteo patient can be managed completely outpatient. I think hospitals are catching on to pods admitting non septic ulcer patients just to collect rounding money from the residents work every day.

Too many pods have a new ulcer patient come in to their clinic with a red toe and ulcer probing to bone and just call for an admit rather than start oral abx, imaging, or schedule for an outpatient amp.

The attending I was on call with showed me how much they made the past week from consults and cases (they are employed by the hospital, so RVU based). It was something around 15-20k. Not sure the RVU amount. That’s only from the call stuff, they also had clinic every day but Friday. It was a much busier week than normal though.

 

[dtrack22]

The attending I was on call with showed me how much they made the past week from consults and cases (they are employed by the hospital, so RVU based). It was something around 15-20k. Not sure the RVU amount. That’s only from the call stuff, they also had clinic every day but Friday. It was a much busier week than normal though.

They didn’t do 300 wRVU in a week from “call stuff” alone…

 

[DYK343]

But sometimes it's the most expeditious way

If I know a patient needs an amp and has PAD they are getting admitted to bypass the 2 month wait for vascular
If I think it might take off quick and I want an MRI I admit because it takes a week to get an MRI.
If they are a trainwreck of a human I admit for medical management.
About 25% of the diabetics I cut parts off of cant do anything that I tell them. If I order labs and an EKG good luck getting that accomplished. Those patients get admitted - even then they dissappear.

Stable osteo - sure. But more complicated patients I admit.

2cm erythema seems a bit much to me. Maybe they say that because many PCPs dont know what an emergent infection looks like?

ID docs need those consults too though.

 

[DYK343]

They didn’t do 300 wRVU in a week from “call stuff” alone…

My busiest month so far at the new job has been about 600wRVU all in and I was fairly busy...

1200 a month is ~800k salary for that provider. Not impossible but thats long hours.

 

[dtrack22]

My busiest month so far at the new job has been about 600wRVU all in and I was fairly busy...

1200 a month is ~800k salary for that provider. Not impossible but thats long hours.

The person posting said the $15-20k pay was from consults and surgery, “call stuff” only and not clinic. At $55 per wRVU, and $17500 in pay for the week, that’s just over 300 wRVU on nothing but inpatient consults and cases. In one week. There is a 0% chance that it accurate. Even if they got $1000 per day to be on call (they don’t), it’s still 220+ wRVU generated from being on call only. It’s probably a well intentioned post…but it’s bogus

I only have around 80 encounters per week (clinic and cases combined) and I do between 500-600 wRVU. And I’m not busy at all. So I have no problem believing that a 300 wRVU week while on call at a busy hospital is totally possible. I’ve had friends who have had 1000-1200 wRVU months. But that has to include your clinic and scheduled outpatient cases as well.

 

[MicroPod]

It’s totally possible they were including their clinic production as well. However, one of the cases charged over 6k when they were showing me what they billed and the hospital charges. Not sure how insurance offsets that charge though and how that affects RVU production. Reattaching a partially detached big toe (trauma, healthy patient, hope it survives).

 

[AttackNME]

It’s totally possible they were including their clinic production as well. However, one of the cases charged over 6k when they were showing me what they billed and the hospital charges. Not sure how insurance offsets that charge though and how that affects RVU production. Reattaching a partially detached big toe (trauma, healthy patient, hope it survives).

Charged and collected are totally different things. What did he collect?