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Logging Surgical Cases: to bundle or unbundle ?

by Jarrod Shapiro, DPM
PRESENT Resident Editor
Botsford General Hospital
Farmington Hills, MI

Let’s talk about a topic near and dear to all our hearts: logging. My co-residents and I are constantly debating the best way to log surgical cases with multiple procedures on Residency Resource. For example, if you do a Logroscino bunionectomy do you enter it into your log as one procedure (Bunionectomy with First Metatarsal Base or Shaft Osteotomy) or as two (closing base wedge osteotomy and Reverdin)? How about a Triple arthrodesis? One procedure or three? What about a pan metatarsal head resection or transmetatarsal amputation? Does it matter if more than one incision was used? I don’t know about you guys, but lesser metatarsal procedures are a bit tough to come by, and it frustrates me that a pan met head resection (excluding the digital work) only counts for one procedure.

For those of you new to surgery, in the insurance world, breaking up a procedure like a Triple arthrodesis into its components is called “unbundling,” and it’s illegal. Why? Because you’d be getting paid for three fusions instead of one. That’s not completely true. You’d actually be paid 100% for the first procedure then 50% of each of the others. Getting complicated, huh? The point is our logging system sort of follows this to a degree – and they’re completely wrong to do so.

The purpose of the surgical portion of our residency training is to become competent in performing podiatric procedures. I would argue if you scrub a case where you do a Logroscino bunionectomy, you’ve just learned how to do a base procedure and a Reverdin osteotomy. However, the “rules” would have us correctly log this as one procedure instead of unbundling it into two. I argue this is unnecessary and inconsistent with the other rules. We are required a certain number of “encounters” during our residencies. As we all know “encounters” does not equal “patients.” For example, if you did the history and physical for this same patient you would also log the H&P as an encounter. The current rules would count this as two encounters (H&P + one surgical procedure). I’d argue this case should count as three encounters, not two. Could you not execute each procedure separately in the future? In this case the educational content is equivalent to two separate surgical procedures. I’d argue the same for a triple arthrodesis. If you’re capable of performing a triple, could you not do an isolated subtalar arthrodesis? Have you not obtained the necessary skill? Isn’t that what residency’s about?

As a compromise, I would have them require us to unbundle every procedure, but in the comments box, document that it was part of a larger procedure. That way they’d know we did the subtalar fusion as part of the triple and so on…. Here's how I would document the Logroscino under my system:

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What do you think? Let the residency community hear your opinion…

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As with all PRESENT publications, all issues of Residency Rap will be stored on the PRESENT website, so if you miss an issue or you want to refer back to a prior issue, it'll be at:

http://www.podiatricresidency.com/residencyrap/

Talk to me,

Jarrod Shapiro, DPM
PRESENT Resident Editor
jarrod@podiatry.com

I am a second year resident at the Salt Lake City (was VA) University of Utah residency program. I am one of 4 residents in my year of a PM&S 36 (coming up for evaluation in the next couple of months). I graduated from SCPM. I have been married seven years and have three kids - ages six, four, and two. What a great idea to have this forum! There have been many times I have wanted to give a resident’s point of view on the Podiatry Online forum or PMNews but have second guessed my opinion or did not press the send button because I felt my view was not representative or not fully thought out. I hope that this can be a place where job search strategies can be discussed and other professional concerns can be aired. I look forward to the banter!

I'd like to hear about multispecialty practice opportunities and what inroads outgoing residents are making in cracking this potentially fruitful podiatric job market.

Benjamin Marble, DPM
Salt Lake City (was VA) University of Utah Residency Program
doctormarble@gmail.com

I am at St. Barnabas Hospital in the Bronx. I'm the chief resident this year along with one other resident. We were a pretty large program, but with the new PM&S structure, we had to cut back. We had 21 residents when I began 3 yrs ago, and now we are down to 9. So you can imagine handling all of podiatry and orthopedics in a level 1 trauma center in the middle of the Bronx.

I graduated from the NY school in 2002 (our director likes to use the full length of the PM&S for all). I am married and have a 2-year-old daughter. I think this is going to be beneficial in that it will show those that are always complaining that their program is so bad that there are others out there who are going through the same or worse situation. Don't get me wrong, but those who think the grass is greener on the other side really need to see what they have in front of them before making that decision. Our program is great in trauma, diabetes care, general podiatric surgery, and orthopedics. I feel that we could do more in terms of pediatrics and podiatric orthopedics. But in all reality, unless you market yourself as doing only pediatrics you are not going to get many of these cases. In addition, I feel that our education overall is OK, but with the little time we have to breath, it’s really hard to keep up with all the reading that we should all be doing. I don't mean to complain or offend anyone, but this is my reality. Take care and hope to read from other people out there.

Fernando Quirindongo, DPM
St. Barnabas Hospital
footdoc755@optonline.net

Editor's Response
I have to agree with Benjamin. I first encountered Podiatry Online as a medical student, and to be honest, I was intimidated to email my opinion. What did I know? I hadn’t been out practicing for years. Who’d want to hear my opinion? Well, now we’re all in a different situation. We’re all in the same boat, working our tails off, learning to be complete podiatric physicians, and VERY soon we’ll be out in practice. I believe there’s somewhere around 1200 or so podiatric residents in the country; that’s 1200 other people I could stand to learn something from. What a resource!!

Jarrod Shapiro, DPM
Editor - Residency Rap