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07/08/2017    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Screwed by Palmetto GBA NSC


From: Richard Rettig, DPM


 


We received a letter last week from Palmetto GBA, acting as the National Supplier Clearinghouse MAC for the DME program. They claim they sent us a letter in December telling us we needed to revalidate. They admit that they only send out a single letter, and they claim that they are allowed to presume that we must have received it, as it was not returned to them by the post office. They send out no further letters (and no emails at all) until they cut you off from participation. Then, they send you a letter telling you that they retroactively cut you off. The only choice is to re-apply online anew. Apparently, they are allowed to act this way?


 


Richard Rettig, DPM, Philadelphia, PA

Other messages in this thread:


09/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Podiatry Outpatient Infection Guides from the Joint Commission and the CDC


From: Kevin McDonald, DPM


 


Podiatrists should do as much as possible to prevent the spread of infections in their offices.


 


The Centers for Disease Control and the Joint Commission have recently completed guidelines and a manual to prevent the spread of infection in outpatient podiatry settings. This Manual and Pocket Guide represent the most current and evidence-based knowledge and procedures in infection control for podiatry offices. Every practicing podiatrist should consider this information vital and applicable.



 


The Guide to Infection Prevention in Outpatient Podiatry Settings and companion pocket guide are available on the CDC and Joint Commission websites: CDC webpage Joint Commission webpage.



 


Kevin McDonald, DPM, Concord, NC

09/18/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Joel Lerner, DPM


 


I am responding to Dr. Portela's question about hard to get medications. MD Buying Group has been able to supply their members with hard to find meds such as Lidocaine, Xylocaine, Marcaine, and others. It is limited to 3 vials per doctor, but is available. 


 


Joel Lerner, DPM, Palm Beach Gardens, FL

09/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: R. Alex Dellinger, DPM, Allen Jacobs, DPM


 


I use a company called EBM Medical. They only use products that are proven effective. One advantage is you don't have to stock the products in your office. You send a "script" (order), the product gets shipped to the patient, and you get a deposit into your account for the difference in the wholesale price and what your charge is. These are cash price only items. Their main product is a Metanx substitute that is fantastic. They have many products, from topical antifungals to topical creams, wart compounds, etc. You can customize your product list how you see fit.   


 



R. Alex Dellinger, DPM, Little Rock, AR


 


I utilize products from EBM. They actually have all of the products you asked about. They provide an excellent model for dispensing  quality products without the need to maintain in-office inventory. 


 


Allen Jacobs, DPM, St. Louis, MO


09/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Allen Jacobs, DPM


 


Dr. Udell’s question is an important one. Patients with diabetes, PAD, chronic edema, history of recurrent cellulitis, or who are immune-compromised, require active treatment for onychomycosis. The high cost of topical antifungal medications reinforces the need for proper speciation to assure the possibility of response to the prescribed agent. Utilization of topical antifungals should be restricted to early, distal disease. 


 


Personally, I utilize topical amphotericin B compounded with urea, terbinafine, and thymol  (available through EBM), combined with nail reduction for topical management. Oral terbinafine, when appropriate, remains the most effective therapy for management in the adult and geriatric patient. It is the most cost-effective therapy available. The potential adverse sequella of oral terbinafine has been exaggerated by those selling alternative topical agents, or simply not understood by those unfamiliar with the literature on this subject.


 


Allen Jacobs, DPM, St. Louis, MO

09/11/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Kudos to Dr. Charles Morelli


From: Brad Bakotic, DPM, DO


 


The Rhett Foundation would like to give a boisterous shout-out to Dr. Charles Morelli and all of the physicians on his international mission team.


 













Dr. Charles Morelli (L) on medical mission



 


We are both humbled and proud to have sponsored this group through their recent mission, as they selflessly worked and sacrificed to provide podiatric medical care for the people of Nicaragua. This is what it’s all about! 


 


Brad Bakotic, DPM, DO, Alpharetta, GA

09/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Separate E&M Codes for Podiatrists


From: W. David Herbert, DPM, JD,


 


I understand that there have been studies which have established that timely and proper podiatric intervention can reduce the need for foot and or leg amputations. This E&M issue apparently started by CMS might be an opportunity for podiatry to actually position itself in a more advantageous position. 


 


There could be E&M codes that only podiatrists could use. Any new enrollee in Medicare would have to be evaluated by a podiatrist within a year of enrollment. If this new enrollee is already diagnosed as a diabetic, maybe requiring this examination sooner maybe appropriate. We must remember this is all about politics! I have been in and around politics enough to know that this could happen if approached properly. The podiatric profession has been able to use the political approach very effectively throughout the years. This is only offered as a possible starting point.


 


W. David Herbert, DPM, JD, Billings, MT

09/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Daniel Chaskin, DPM


 


Kudos to Jeffrey Kass for providing a link to file a complaint. Since most licensed podiatrists are not employed by the VA, I believe that economic parity in Medicare is more important than economic parity in the VA. 


 


Lawrence Rubin hit the nail on the head when he mentioned about CMS discriminating against podiatrists. I believe such economic discrimination departs from federal antitrust law and affects interstate commerce because podiatrists are defined as physicians under federal law. Even in NY state, podiatrists are specialists licensed to perform physical examinations in conjunction with podiatric treatment. This is no different than other specialists performing physical exams in conjunction with their specialties. 


 


The U.S. Dept. of Justice has a website where podiatrists can email to ask the antitrust division to investigate and to advise CMS if they are in full compliance with federal antitrust law. If enough podiatrists send emails or if the APMA sends out a letter to this agency, this might ensure the economic parity that podiatrists always had for many years. I am not an attorney and the above are my personal opinions. 


 


Daniel Chaskin, DPM, Ridgewood, NY

09/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Pillars of Our Profession


From: Richard M. Hofacker, DPM


 


A few weeks ago at the KSUCPM awards banquet, Dr. Richard Ransom took this "classic" picture of a couple of our distinguished colleagues. You might say, they are the "Arnold Palmers" of podiatry. 


 













Seated are Dr. and Mrs. Alan Spencer.  Standing is Dr. Ray Suppan, Sr.



 


Just about everyone in this profession has been taught, consulted, or helped in some way by Drs. Spencer and Suppan. Podiatry owes a great deal to these fine pillars of our profession.


 


Richard M. Hofacker, DPM, Akron, OH  

09/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B


RE: CMS' Discrimination Against Podiatrists


From: Jeffrey Kass, DPM


 



The Sept. 10th deadline is around the corner. CMS has proposed some devastating reimbursement policies that could cripple some practices. The single code for E&Ms has already been discussed. More devastating is the visit and procedure ruleCMS is proposing to reduce the lower allowed amount by 50% of either the E&M visit or procedure when billed the same day with a -25 modifier.


 


If anyone values their financial future, you must take action! I have provided the link to write a complaint in your own words (Some feel sending repeated templates has less effect.). This is not the time to make assumptions that because you belong to an association, the problem will be taken care of for you. This is the time to take two minutes out of your day to potentially save thousands of dollars from being taken out of your pockets for the hard work you perform. Please spare the moment.


 


Thank you to everyone who participates and tries to make a difference.


 


Jeffrey Kass, DPM, Forest Hills, NY


09/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A


RE: CMS' Discrimination Against Podiatrists


From: Lawrence M. Rubin, DPM


 


The decision of the CMS policy-making gurus to try to save some federal dollars by cutting payment for E & M medical care provided by podiatrists is, to say the least, ill-founded and discriminatory. I believe in healthcare cost-containment measures, but only if they conform to existing rules and regulations. This proposed rule does not do this. For it to conform, Medicare would have to first change its definition of the word "physicians." 


 


APMA is expertly representing us in its efforts to maintain parity with the other professionals designated by Medicare as physicians – MDs, DOs, optometrists, and chiropractors. With this in mind, I believe what CMS is attempting to do with podiatry should be a “Heads Up!” to optometrists and chiropractors. If CMS gets its way with podiatry, I bet optometrists and chiropractors will be next on its attack list. I hope APMA is keeping this in mind and discussing this issue with the optometric and chiropractic national professional organizations. Together, we could be stronger. We could be a united force in trying to convince Medicare to maintain present Medicare parity regulations.  


 


Lawrence M. Rubin, DPM, Las Vegas, NV

09/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Doctors' Pay Cuts Never Mentioned


From: Jeffrey Kass, DPM


 


On Thursday, President Trump announced that he wanted to cancel pay raises for civilian federal employees who were due for a 2.1% increase. He wanted to do this to save money as the federal budget deficit continues to skyrocket. Why should any federal workers get raises at all, while doctors continue to get docked 2 percent while we are still in sequestration (Not to mention the 2 percent to lose if the new E&M proposed guidelines go through)? 


 


Any time news like this hits mainstream media, the medical community has an opportunity to tell America how they have been taking a 2 percent hit for years, yet never is anything mentioned.


 


Jeffrey Kass, DPM, Forest Hills, NY

09/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Pedicure Drill for Podiatry


From: Robert D Teitelbaum, DPM


 


For several years, I have been using an incredibly inexpensive ($3.00 or less) pedicurist drill in each of my treatment rooms and in my ALF/NH bag. I found them just by searching for "Pedicure Drills" on my laptop and getting multiple ebay sites with these drills that use 2 AA batteries. First, you discard all the multiple heads that are supplied. Then, you can use dental (that's right--dental) burrs from Henry Schein's Dental division - which is older and much larger than the podiatry section. I had my dentist order S.S. White stainless steel burrs that come in a ten pack and are 1.5 mm in diameter. They are not expensive. These burrs fit right into this drill by a friction lock--as do the accessories that come with it.  


 


Why this little drill is better than a 120 volt rheostat-driven one is exactly because it is not that powerful. When you have nail borders that cannot be curetted easily or painlessly, it is precisely the instrument to use. You can de-bulk a hypertrophied border to the point that you can then do an angled cut to give your patients relief. These burrs are very sharp and effective, so the constant, moderate speed helps to keep you in control. Along with this find, I discovered many smaller 120 volt drills that each of our suppliers offer, but at major price reductions. This confirms the old idea that "if it used by a 'doctor', we can double the price."


 


Robert D Teitelbaum, DPM, Naples, FL

09/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Drug Pricing Insanity  


From: Robert D. Teitelbaum DPM


                                                                                                                                          


I was interested in prescribing Ertaczo cream for my patients, as it seems to be effective for dermatophytic and candidial organisms. When I searched for it on Google, I was taken aback by the amazing prices. For a 60 gram tube, the average price was $830. Even in real estate, they deal in "comparables" for recently sold homes. How many of you out there prescribe antifungal cream in this range? I was told some years ago by a pharmacy tech here at my CVS store in Naples that, "Medicine is a racket." How true, how true.  By the way, my practice does not support that point of view. And this example can only enhance one's suspicion, of "Big pharma."


 


Robert D Teitelbaum DPM, Naples FL

08/31/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Vito Rizzo, DPM


 



As a healthcare professional and now having the distinct advantage of serving in the U.S Congress, Brad Wenstrup should be leading the charge in reforming healthcare and advocating to put medical professionals back in charge. He should take no contributions from insurance companies that have a record of putting profits before patients and should be focused on eliminating the channeling of healthcare dollars into any other purpose than patient care. He should never stand behind or support policies that undermine the protection of the sick and less fortunate. Being a representative can be easy if certain principled actions are followed.


 


Vito Rizzo, DPM, Bay Shore, NY


08/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Lawrence M. Rubin, DPM


 


Name Withheld believes that CPT code 99214 should not be billed by podiatrists. I disagree. Medicare and generally other insurance payers consider podiatrists to be foot and ankle physicians licensed to practice the "medicine" referred to in our Doctor of Podiatric Medicine degree. E/M code appropriateness is based primarily upon the "nature of the presenting problem" and the depth of the history, examination, decision-making, and in some instances, time expended. This applies to all physicians who provide E/M services. Podiatrists are not excluded. 


 


For example, we are frequently faced with having to make complex diagnostic and care management decisions, especially in older, high-risk patients who present with debilitating manifestations of several chronic diseases and their co-morbidities. E/M care for this class of patients could meet the standards necessary to bill higher level codes. I suggest that those who believe that podiatrists should never use codes for providing higher level E/M services review the E/M coding requirements carefully. 


 


Better yet, the APMA and some independent podiatric consultants offer marvelous correct coding seminars and workshops. Their costs are very reasonable, and what you will learn will probably immediately pay for the cost of attending. Just one caution. Higher level codes should not be billed indiscriminately. And when there is an established treatment plan that does not require providing future higher levels of history, examination, decision-making, or time spent in counseling -- they should not be billed. 


 


Lawrence M. Rubin, DPM, Las Vegas, NV

08/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Dan Michaels, DPM, MS


 


With all doctors on a salary and all employed by the government, you would also have several very bad consequences. As in England, doctors would have their day job with the government and have their private practice that is all cash on the side. If someone needed surgery, there would be a 6-month or more wait with the government practice and their private cash practice would be able to deal with the surgery immediately.


 


This would create a tiered healthcare system that would favor the wealthy. There would be a lot more conservative care and much more web surfing by the employed physicians just doing the minimum to get by, and of course the really smart people would leave the field. This single payer system fails everywhere it is implemented. Socialism fails always (e.g. Venezuela). We have the best healthcare in the world.


 


Dan Michaels, DPM, MS, Frederick, Hagerstown, MD

08/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Jon Purdy, DPM


 



I couldn’t sit idle after reading Dr. Kass’ comment promoting universal healthcare with salaried positions. There are reasons monopolism in a free market society is not tolerated in the private sector; the reasons being stifling of ingenuity, lack of price competition, and the elimination of free choice to name a few. To promote it in the public sector is the antithesis of what drives this country’s greatness.


 


Imagine for a minute, a doctor who has no incentive to keep a patient a satisfied returning customer, or to direct staff to provide a welcoming environment. There may be minimum outcomes to obtain, but anything difficult or time-consuming could be written off as a loss. Certainly, one could “hope” all doctors practice to their fullest ability, but that is not reality and an unfortunate consequence of human nature in the absence of incentive.


 


When the government controls the livelihood of individuals and their freedom of pursuit, especially after going through training 99% of humanity is unable or unwilling to do, it will no doubt create a catastrophic physician shortage. If a singular controlling entity wishes to eliminate podiatry, it could do so next week. Take a moment and imagine yourself as a patient in that environment with a serious condition. I certainly can’t. There is corruption in all walks of life including the government or any other controlling body. I am not willing to sell my freedom of individual pursuit because of the actions of others.


 


Jon Purdy, DPM, New Iberia, LA


08/24/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Justin Sussner, DPM


 


Another problem that we see in our office is many of the ER and urgent care foot pathology patients are seen by a lower level practitioner who has no idea or training regarding what they are looking at. And they almost never consult with the MD who is supposed to be supervising them. 


 


This is not meant to be a jab against PAs or NPs, I know quite a few who work for my PCP and my dermatologist, but they have been properly trained and supervised. 


 


Justin Sussner, DPM, Suffern, NY

08/24/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Jeffrey Kass, DPM


 


There has been a lot of discussion regarding illegitimate billing on this forum the past couple of weeks. Perhaps, the answer is universal healthcare with one insurance company with salaried positions for all doctors. While, readers may not like this idea, fraudulent billing is completely eliminated, because there is no billing. 


 


This concept not only eliminates fraudulent billing, it eliminates discrimination in payment. The fact doctors in large groups get paid higher rates than solo practitioners for the same service is equally appalling to me (and should violate anti-trust issues). No system is perfect, but at least with salaries paid, no one will be recouping money.


 


Jeffrey Kass, DPM, Forest Hills, NY

08/23/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Podiatrists vs. MDs as Foot Specialists 


From: Jeffrey Bean, DPM


 


An emergency physician called me today for guidance on a patient with a foot injury. The doctor told me, “It looks like the patient has a fracture of the first "METACARPAL" that might also involve the "HELIX of the SESSAMO". Should I be concerned about a Lisfranc injury?” I had the physician repeat this several times, and was told the same thing repeatedly. I felt it was futile to begin by teaching this MD kindergarten anatomy (leg bone connected to the foot bone). 


 


I told him to apply a fracture boot and send the patient to me or any other podiatrist for appropriate treatment. No wonder I see so many patients with disabling neglected foot and ankle injuries. Most were seen by multiple physicians who...


 


Editor's note: Dr. Bean's extended-length letter can be read here

08/23/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Name Withheld


 


I commend Joseph Borreggine, DPM for revisiting the WSJ physician compare websiteI think it behooves all of us to visit this site and search your city or geographic area to see what kind of billing is being done out there. It is eye-opening and appalling. In my city, there are some DPMs billing hundreds of new patient level 4 (99204) office visits and getting paid for them! How can that be when all the billing seminars/billing gurus out there say that this level of office visit is not even billable by podiatrists? 


 


Why is Medicare paying for these codes? It is clear Medicare is not enforcing its own rules. I hope some of the billing gurus out there will chime in on this. Other DPMs bill almost all...


 


Editor's note: This extended-length letter can be read here.

08/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Paul Kesselman, DPM 


 


This is an extremely complex matter fraught with many mine fields. While the suggestions which have been made might sound appealing, they may not be the best path for you to take. In fact, I’m concerned they may not be the correct way to go at all. I suggest you find an attorney very experienced in anti-kickback statutes and Stark. While the latter may be more familiar to most and possibly only affects your business and Medicare, the former may be less familiar yet applies across the board to all patients, Medicare, other third-party payments, and even self-paying ones.


 


The mere appearance that your salary is somehow tied to the number of your DME referrals and volume of DME your group provides to patients may constitute incentives that some experts may feel is problematic. The best and only advice I can offer is to spend the time and no doubt some money on a healthcare attorney who can safely navigate you through some very complex regulations.


 


Paul Kesselman. DPM, Woodside, NY

08/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Kristin Happel



 


Dr. Hofacker asks if the type of billing he saw on his patient's invoice from another podiatry office is the norm. No, it is not, at least not with podiatrists I bill for in various parts of the country. The Medicare allowed amount for a 11308 in Ohio is $190.97 when performed in an 


office setting. Leaving aside whether or not this was actually performed (I doubt it was, and should have been billed in the 1105X range, if at all), it would appear several things could be at play here to result in this patient having such an outrageous bill. 


 


Without seeing the actual invoice, my guess is one of two things (or both) is going on: 1. The podiatrist she saw is not contracted with her insurance company, and she has no...


 


Editor's note: Ms. Happel's extended-length letter can be read here.


08/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Ron Werter DPM


 


Dr. Hofacker's comments remind me of something that a new patient's daughter related to me recently. A 92 year old gentleman brought in by his daughter came to me because they were outraged with the billing of the previous doctor. She received 2 checks from Anthem Insurance for the one visit of the previous podiatrist of her father totaling $1,550. She told me that she had taken her father to the other podiatrist for the past 6 years for nails and corns. On the last visit to this other podiatrist, when dad was called into the room as usual, she remained in the waiting room. He returned to her after his treatment 15 minutes later and said there's a different doctor. She found that peculiar since there was no notice that the other doctor had left or retired.


 


The father has an insurance plan that pays both in and out-of-network; out-of-net is 60/40. When she called the doctor’s office about the received checks, she was told to...


 


Editor's note: Dr. Werter's extended-length letter can be read here.

08/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Name Withheld


 


Welcome to the world of wRVUs! I’ve been working in this model for the last 5 years. Long story short, my hospital has no interest whatsoever in doing DME. Early on, I tried to explain to a C-Suite member that in my previous group I had collected over 90k in DME. They still balked at any DME. That said, I am compensated well for my time. My production (wRVUs) is at the 50th percentile, as is my compensation (based on MGMA benchmarks). So, at the end of the day, I’m a highly compensated employee who does what my employer wants me to do (see patients and fill my OR block).   


 


Name Withheld
Kerasal


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