Plantar Fibromas

[Dermato Fight Club]

Probably one of my most frustrating conditions to treat. I really offer nothing to the patient. I tell them to basically live with it until it's absolutely affecting their everyday life and then and only then will we discuss surgery of which recurrence is high.

I discuss topical verapamil and hyalurondise injections but it is my understanding insurances do not cover these and they are quite expensive. Does anyone have any other options for treating this condition?

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[Shiyuan]

Plantar fascia stretching, NO arch supports since they push on it (go with something flatter n' soft.. Spenco diabetic insoles or gel stuff)... cortisone injections hit or miss for me. I avoid surgery like the plague... had a patient get scar tissue wrapping her medial plantar nerve so now she has more pain post-op (I feel really bummed about that one).

 

[Redsting]

I hate to jinx myself, but steroid injections have been great for me. One sometimes two and then they are done.

I feel like I don't offer a lot for IPKs. Offload, core it out. I've tried canthrone with mixed results. A few I did a punch biopsy (didn't send it) just to cut it out, of course sutures don't told, they don't want to NWB, so I told them it would end up being wound care after. The few I have done that way have done great once it healed up, but one lady took forever to heal and that wasn't fun. I think some people will do like 5FU, but I haven't tried any topicals like that

 

[DYK343]

Probably one of my most frustrating conditions to treat. I really offer nothing to the patient. I tell them to basically live with it until it's absolutely affecting their everyday life and then and only then will we discuss surgery of which recurrence is high.

I discuss topical verapamil and hyalurondise injections but it is my understanding insurances do not cover these and they are quite expensive. Does anyone have any other options for treating this condition?

I honestly cant think of one that I've treated outside residency that was big enough to cause pain that required surgical excision. The one in residency was a TFP that scheduled it. Probably shouldnt have been excised.

I did have one today that was fairly impressive. Maybe the size of a dime.

Most of the time they are small and painless. I just tell people outcomes and they agree that they are not painful and essentially leave happy with no further treatment. Just worried about the mass on their foot.

I've Rx topical verapamil but I think its extrodinarily expensive and none have used it that I know of.

Ive injected a couple. They never returned. Either due to pain or it resolved. I dunno.

 

[DYK343]

I hate to jinx myself, but steroid injections have been great for me. One sometimes two and then they are done.

I feel like I don't offer a lot for IPKs. Offload, core it out. I've tried canthrone with mixed results. A few I did a punch biopsy (didn't send it) just to cut it out, of course sutures don't told, they don't want to NWB, so I told them it would end up being wound care after. The few I have done that way have done great once it healed up, but one lady took forever to heal and that wasn't fun. I think some people will do like 5FU, but I haven't tried any topicals like that

corns calluses and IPKs suck.

By far the hardest thing I treat outside of sub 2nd metatarsalgia and charcot. Or plantar medial hallux ulcers.

On top of that they are not covered and their treatment isnt either (keratolyitcs, orthotics, pairing, etc). They also keep coming back expecting their IPK to be debrided and insurance to pay for it.

 

[Feeter]

If you remove IPKs with excision in clinic can you bill it as soft tissue mass removal? Or I guess better question is how do you bill that? Seems it's uncovered service.

 

[Feeter]

I remove plantar fibroma in OR and do wide fascia excision with it if they are painful. Have done maybe one a year. It's rare occurrence

 

[Pronation]

If you remove IPKs with excision in clinic can you bill it as soft tissue mass removal? Or I guess better question is how do you bill that? Seems it's uncovered service.

Bilobed flap

 

[Hybrocure]

Very good results with steroid injection. It is my go to for fibromas

 

[wakaflocka88]

If you remove IPKs with excision in clinic can you bill it as soft tissue mass removal? Or I guess better question is how do you bill that? Seems it's uncovered service.

Lol………..

No. I tell them over the counter salicylic acid in hopes it blisters away and don’t come back. I’m tired of explaining the rules. They can see a pedicurist for this. It pays crap on RVU

 

[DMEpod]

Fibroma is ice, stretch, and steroid injection for me. Works ok enough. I explain to pts the misery of taking them out and very likely to recur which keeps them away from want a huge plantar incision.

As far as IPK it is frustrating as people keep coming back for it. I have done central met neck floating osteotomies on a few older pts which works ok enough but they really have to be the right pt for it.

 

[Hybrocure]

On a similar note about IPKs - I don’t think I’ve ever seen any patients leave clinic happier than when you debride one of them out for them. I swear half of them come out skipping down the hallway.

 

[Pronation]

On a similar note about IPKs - I don’t think I’ve ever seen any patients leave clinic happier than when you debride one of them out for them. I swear half of them come out skipping down the hallway.

So kinda like pedicure clients at the salon?

 

[DYK343]

On a similar note about IPKs - I don’t think I’ve ever seen any patients leave clinic happier than when you debride one of them out for them. I swear half of them come out skipping down the hallway.

Until they get the bill for non covered callus care.

I either commit insurance fraud or bill the patient.
$170 for 1 callus debridement.
2-4 is $195.
5 or more is $215.

 

[Hybrocure]

Until they get the bill for non covered callus care.

I either commit insurance fraud or bill the patient.
$170 for 1 callus debridement.
2-4 is $195.
5 or more is $215.

Isn’t it covered if you bill it with a pain code? It was my understanding if IPKs are painful and you’re not scheduling them for routine visits and just PRN them its kosher

 

[wakaflocka88]

Isn’t it covered if you bill it with a pain code? It was my understanding if IPKs are painful and you’re not scheduling them for routine visits and just PRN them its kosher

That’s the thing - you and I can sit here all day long trying to figure this coding billing thing out or just say - compound W for 6 weeks, nail salon and bye. It’s not worth my time sitting there explaining the rules over and over again for something that pays me and the organization minimal RVU.

I’ll gladly let other pods commit the fraud if they want, which many do and happily see IPKs back every 2 months and bill it, I’ve seen it all.

On a side note though - not all IPKs are incurable, especially if it’s in sub metatarsal region (does it need a lapidus, offloading osteotomy, hind foot driven deformity, equinus, etc?) but again TFPs will lash out on you if you even mention the above on PM news as we should not be doing what orthopedists will do.

 

[HardRoadPaved]

Isn’t it covered if you bill it with a pain code? It was my understanding if IPKs are painful and you’re not scheduling them for routine visits and just PRN them its kosher

NEVER. Only nails pay with pain code.

Bill the e/m for taking care of the condition but anything more is either cash pay or fraud

 

[Hybrocure]

NEVER. Only nails pay with pain code.

Bill the e/m for taking care of the condition but anything more is either cash pay or fraud

So you can bill E+M but not trim lesion?

E&M pays more lol.

What I’ve been doing for subsequent visit is just billing a 11055 without an E and M. Just the procedure code with the dx being foot pain and corns and calluses. Doesn’t make sense that a trim lesion code exists if someone comes in w a painful lesion and you debride it, it’s fraud? Does not compute

 

[air bud]

Steroid injection or nothing.

 

[Adam Smasher]

Steroid injection or nothing.

Do steroid injections make the IPK go away? Or do they make the patient go away?

 

[Pronation]

Doesn’t make sense that a trim lesion code exists if someone comes in w a painful lesion and you debride it, it’s fraud? Does not compute

Because insurance doesn’t want to pay for pedicures?

 

[DYK343]

So you can bill E+M but not trim lesion?

E&M pays more lol.

What I’ve been doing for subsequent visit is just billing a 11055 without an E and M. Just the procedure code with the dx being foot pain and corns and calluses. Doesn’t make sense that a trim lesion code exists if someone comes in w a painful lesion and you debride it, it’s fraud? Does not compute

Medicare wont cover this. Therefore most other insurances wont either.

So its fraud or find ways to bill an E&M and debride the corn on the side free of charge.

"Oh lookie here I think you have some athletes foot between the toes heres some cream" when in reality they are there for a corn. Debride corn and dont document it or hide it in documentation so billers dont try to bill it.

Thats the only way to get paid thru insurance otherwise its a cash scale as above (at least at my facility) and a negative review online.

 

[dtrack22]

Do steroid injections make the IPK go away? Or do they make the patient go away?

I’m assuming he’s talking about fibromas. There are two separate discussions happening simultaneously so it’s getting confusing.

I inject fibromas with steroid. Will get custom accommodative inserts if covered, otherwise just gentle stretching and OTC accommodative inserts. Will do a couple of injections in a row, about 6 weeks apart if still symptomatic. I caution them on having it removed given likelihood of recurrence and while they may end up elsewhere, I haven’t cut out a fibroma in the past 4 years.

I debride IPKs and apply cantharone. I have patients get and use a 40% urea and self debride at home. If it’s plantar to a met head I have them offload. I have no problem coding them as a benign neoplasms because they aren’t simple calluses. I haven’t found offloading alone to be enough to resolve them. They might get thinner but they still have involvement deeper into the dermis. They often time form on non weight bearing surfaces where pressure isn’t really a contributing factor. I’ll see one more time just for debridement but don’t ever code 1105X. It’s an E/M and 17110 first visit and then a low level e/m on f/u unless there are new complaints. I don’t know that I’ve ever punched one out or cut one out. Patients are generally without pain on f/u.

 

[air bud]

Do steroid injections make the IPK go away? Or do they make the patient go away?

I thought we were talking fibroma?

 

[PTPuser]

Had a doc made me inject an IPK once and the patient came in a month later with a wound...