How Do We Make Money With What We Were Trained To Do?

Ron Raducanu DPM FACFAS

Let’s talk money, ladies and gentlemen. More specifically, how do you make money with what you were trained to do?

I posed this question to a classroom full of students who participated in a Practice Management Club lunch meeting at the Temple University School of Podiatric Medicine. We were talking about practice management considerations when dealing with the pediatric population. After we discussed this at length, I posed the question of what type of practice these students were looking to get into after residency. One of the students very astutely said, “a practice that makes money!”

I then asked how exactly how he intends to make that money. The room went still and silent. No one in that room had a clue. Either that or they were too shy to speak up (which is really more likely, I would hope).

What They Don’t Teach You In Residency

The real issue here is that we are bent on training the podiatric equivalent of “Super Surgeons” with some of our younger colleagues spending as long as five years in residency and fellowship. However, I’m sure only a few of these surgeons really know the impact that performing these complex surgeries has on their wallets (or their employers’ wallets for that matter). I talked about this when discussing practice management to these students and apparently, what I said caused quite a stir.

The other issue is that while learning these complex surgeries, there are equally complex ways of getting paid for what you do in the office. Very few in residency learn the intricacies of how to avoid landing yourself in hot water while trying to get paid for what you do. Needless to say, our cutting toenails costs the government a lot of money so they are fickle about how they pay for these things.

Does the new practitioner know what that even means? Who is going to teach them these things? Should they have taught this in school? Is the onus on the people they train with to teach them how to actually make a living with their newfound skills? Does the new practitioner know what the differences in coding between cutting mycotic nails vs. dystrophic nails vs. non-dystrophic nails? Does the new practitioner know the combinations that can actually pay more or less, or land you on the paying end of an audit or worse?

You must know this stuff. You also must know that if all you’re doing is cutting nails, you can’t bill for an office visit unless there is a new diagnosis that justifies an office visit evaluation. You also have to know that you must link this new diagnosis with your office visit and a modifier (you know what those are, right?) to make sure you aren’t chasing a denial, which ultimately costs you money. The list goes on and on.

I always find it interesting when I hear about the questions residents are asked when they are interviewing for employment positions. The interviewers ask about their surgical skills and training in the OR. I scratch my head about this. When I am eventually in the position to consider hiring young new residency graduates, I will ask them different questions. I would want to know their ideas about how they will augment the income of the practice.

Do they know how to code for the services they provide? Who do they expect will teach them this stuff? Do they know the slight difference between a second level office and a third level office visit? Do they know what a global period is and which procedures have shorter or longer global periods?

For example, if you are performing a partial nail avulsion, there is no global period. However, if you perform a permanent partial nail avulsion, there is a global period and if you aren’t careful about how you reschedule this patient, you will not get paid for the follow-up visit.

Removing a benign lesion like a verruca actually pays less in the OR than in the office. Sadly, many of us can’t have a laser (which is how I like to treat this) set up for this in the office, if the conservative treatment fails. Also, the injection for this hurts and since I end up performing this mostly on kids, I make a compromise for the comfort and satisfaction of my patient and his or her family. To the operating room they go, even if it costs me money. Once again though, having happy patients means they come back and encourage others to come as well. Dollars and cents, folks. It adds up.

Why You May Be Financially Better Off Staying In The Office

Let’s say you perform a Charcot reconstruction and the patient has to stay in the hospital overnight. This means two hours (or more) in the OR and a few hours waiting for your case to go down. You also stay after your case to make sure the patient is okay, and ensure he or she gets a room and is comfortable. The next day, you have to round on the patient and spend time writing a discharge summary, etc. For a full half-day of your time for one case, you might get $1,000. That doesn’t include all the post-op visits this patient is going to have to come in for, potential complications you will deal with, and the myriad of other issues you will have to deal with for this one patient. Forget about the huge liability this patient population incurs and that you have now effectively “married” this patient.

Believe it or not, you are better off staying in your office for that amount of time, dollars and cents wise. You get paid significantly more for that same timeframe performing partial nail avulsions. This may not be nearly as glamorous but most of us have families to feed and things to do that cost money, like paying back our loans. This is what caused a stir when I laid this out during my lecture.

I love my forefoot stuff. I really do. I tell the docs I work with that if I could perform mostly bunion procedures and first metatarsophalangeal joint implant arthroplasties for the remainder of my career, I would be a very happy man. These procedures have short postoperative courses, the patients tend to be very happy with the outcomes, the liability is low and the time to completion of the patient’s outcome is short. The other procedure that I love and have great outcomes with is ankle arthroscopy. Patients do very well and they are in and out. Happy patients equate to more referrals, which in turn makes everyone happy, including your wallet. These “simple” cases pay very well for the time involved, almost as much as one of your Charcot cases for a much shorter investment on your part.

Less time, less liability, happier, healthier patients and better pay. Sounds good, doesn’t it?

Your employer will appreciate that you understand all of this. Trust me. I’m not saying don’t do what you enjoy. If you really love the complex stuff, go for it. There is a trade-off and if you start out as an employee, you will quickly see why your employer may not be so ecstatic about how many of these procedures you do. Know the liability and the financial impact of what you do.

So where do you learn all this stuff? There are short weekend courses that residents can take to whet their appetites, but there is only so much you can absorb in a couple of days. Listen, I know how hectic school and residency can get. That being said, it is never too early to start learning. I am sure there are plenty of practitioners out there who would be more than happy to have you spend some time with them to learn these things. For some inexplicable reason, the Council on Podiatric Medical Education (CPME) only allows residents to spend a very short amount of time in practitioners’ offices, which is where you will really learn this stuff. Sadly, once again the machine is teaching things that are important but that ultimately won’t help you overcome your financial burden.

The same can be said for my contemporaries in practice now. There are ways to generate income in your office that you may not be taking advantage of. By the way, I’m not a member of the practice management group (yet) and really have no idea what they profess at their meetings to be frank and honest. I do know that trying to sell your patient everything under the sun, as if he or she may never return to you, is a sure way to make sure the patient never does return to you. If you are employed in a practice, the surest way to increase your income is to make sure your patients come back and that they tell others to come to you. From there, it is up to you to make the most out of your reputation.

Final Thoughts

As I said, if you want to do the “big stuff,” go for it. I will send it to you if you like. To quote Stan Lee, “With great power, comes great responsibility.” Spider-Man does it for free. We can’t afford to. The responsibility you take on with the “big stuff” is great and takes fortitude to do it often. Realize though that there will be sacrifices, both personal for you and your family, and certainly financial for you, your employer (if you are an employee) and your family. That is all I am saying.


Good article. One thing I cannot agree with is a supposedly lower complication rate of bunion surgeries. I think there are plenty of lawsuits going on, more than in the diabetic population.

Are you seriously trying to argue that there are similar if not higher complications rates with bunion surgery than with more complex hindfoot procedures? I can confidently say you would be mistaken in that if that is indeed what you are saying, or maybe I've misunderstood. If I have, my apologies.

As usual, great article. Eventually, everyone learns all these things. For some people, it just takes longer, due to exposure.


Very thoughtful article. The coding system has evolved into a mess. A podiatrist who sends in a simple claim must realize that the simple claim subjects him to the RAC, the ZPIC, the Medicaid Fraud Control Unit, etc. The False Claims Act is the workhorse of the feds and some states.

If one is in practice and does not know what I just wrote, I invite an email and we would be pleased to answer your questions.

I urge every colleague to take the courses on coding and belong to Codingline for a start. It is essential and cheaper than going thru these audits and hiring a lawyer.

Regarding the podiatry residency crisis, I invite those who were "un-matched" to email us.
This is the most serious matter that has faced our wonderful profession in a very long time. Let's look for a solution!

Richard Willner, DPM
The Center for Peer Review Justice

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