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From: Paul Kesselman, DPM


I have provided an in-depth personal response Drs. Rettig and Kerner who were unceremoniously de-activated by the NSC. Unlike when private third-party payers dump you, NSC does allow you to re-activate. There is a lesson to be learned by the misfortunes of these two providers, both of whom will be able to re-establish (Dr. Rettig already has) their enrollment with the NSC - but first some background: 


The NSC has a standard program of 3-year renewals and they claim that they fulfilled their due diligence by mailing you a renewal letter in a very noticeable yellow envelope. The 3-year period was chosen as an initiative by which they claim they can cut down on...


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

Other messages in this thread:



RE: APMA Value and CMS Proposal on Drastic Change in E/M Guidelines

From: Ken Malkin, DPM


As an original trainer of our profession in E/M guidelines, I am grateful that APMA is carefully reviewing this proposed rule. This is the value of APMA. 


This proposal represents the greatest proposed change to the guidelines in over 20 years. Shockingly, CMS wants to create podiatry specific g codes for E/M. The AMA CPT book has never limited a specialty to certain codes. If a physician provided the service that was in their state scope of practice, a code could be used. One of the rationales for this change is that podiatry uses lower level codes statistically (CPT 99213 and lower). In spite of my effort to teach DPMs they were underutilizing CPT 99214, fear of audit limited their use. This proposal is partially a result of this practice. 


This proposal is complex and will be commented on by our profession through APMA. Join or stay a member and get involved. The future of the profession depends upon it. Harry Goldsmith’s wisdom will be missed more than ever. 


Ken Malkin, DPM, Boynton Beach FL



RE: Source for Extra Large CAM or Bledsoe Boot (David E Gurvis, DPM)

From: Marshall Katz, CO


As a certified orthotist, I see many obese patients requiring CAM boots. As a result, I fabricate expansion panels that can be Velcro attached to the existing inner boot. This works great, and can be easily removed. The same is true for the straps. I keep a supply of strap extensions that can be quickly attached and removed.


Marshall Katz, CO, Great Neck, NY



From: Hal Ornstein, DPM


This issue is universal and can surely consume several volumes of books as discussion continues. First and foremost, when hiring an associate, the individual’s personality is key. That personality needs to fit the personality of the practice and meet your expectations. Personality testing is quite easy, inexpensive, and is a good indicator as to whether an associate is a good fit. An Internet search will reveal different tests available. Some of the ones with gold standards in this arena are the Myer-Briggs Type Indicator (MBTI) and the Disc Assessment.


Regular meetings and communication with the associate are also critical. Start by clearly spelling out your expectations in writing, and then meet weekly to discuss how expectations are being met and make no assumptions. Breakdown of this communication can easily result in one or both sides being unhappy.


I applaud Dr. John Chisholm’s post – specifically pointing out that it is wise to pay top dollar and to give the associate the new patients. In addition to top pay, consider giving them a strong benefits package. One may feel that they are giving the associate too much, but in the end, it will come back to you in many ways. There are many success stories with hiring an associate, especially when they are treated with respect, fairness, and as colleagues with common goals.


Hal Ornstein, DPM, Howell, NJ



From: Tip Sulliban, DPM


Don’t forget that you can use the good old fashioned plaster and/or fiberglass cast. 


Tip Sullivan, DPM, Jackson, MS



From: Name Withheld 


Unfortunately, I do not believe there is a magic solution to associateships that work. I have been through 4 different associate experiences in my 13 year career. In every circumstance, I never went into the situation with the intention of a short term situation. In fact, I bought houses in 3 of the 4 places in which I worked before or near the start of the associateship. Two of the associateships I left over money (not paid enough or fairly), and twice I was let go amicably as I was "not earning my keep." Now I am in solo private practice for myself. 


I think the problem with associateships is a lack of understanding between the two parties. The associate is well trained. His or her ego has been built through the residency. The program in some cases may even tell them how much he or she is...


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



RE: MIPS 2019 Payment Adjustment (Alan Bass, DPM)

From: Ron Freireich, DPM


Correct me if I’m wrong, but I believe we were required to report on ALL eligible patients (Medicare part B, Medicare Advantage, private insurance, Medicaid, etc.). However, our “bonus” payments in 2019 will be calculated only on the allowed amounts from Medicare part B patients, not even Medicare Advantage patients.  Take that to the bank, or not.


Ron Freireich, DPM, Cleveland, OH


Dr. Bass wonders if "Exceptional Performers" of MIPS are going to get bonus money. I think it is a travesty that taxpayer dollars would be given to anyone for recording useless information that takes away time and energy from one's occupation, whatever their occupation may be. An exceptional doctor is one who goes above and beyond caring about the well being of their patients. This cumbersome, pointless data entry should be brought to a stop. 


Jeffrey Kass, DPM, Forest Hills, NY



From: John Chisholm, DPM


I have hired 3 new associates in the last 3 years, and we are all getting along fine, so this is my experience, not my opinion:

1. Choose a new graduate of the best residency program you can think of.

2. Pay top dollar. Base the salary on a percentage of collections, and recalculate it often. Pay more than anyone else in your community.

3. Let him/her practice medicine exactly the way they’ve been trained. You should learn from them, not the other way around. 

4. Give him/her all the new patients, especially the most challenging ones, and fill their schedules as soon as you can, even if you have to empty yours. 

5. As soon as your associate is as busy as he/she wants to be, hire another.


My associates are making patients better and making all of us a nice living, and I’m working less and surfing more. 


John Chisholm, DPM, San Diego, CA



From: Elliot Udell, DPM


Unfortunately, the problem not only can occur with a company that goes out of business but can happen if a company decides to update a product and discontinue supporting the older versions. We had this happen with an x-ray unit made by a very responsible company. When the hand "clicker" broke, we had to junk the entire machine.


There should be some law protecting consumers from this happening, and it's not just about instruments and equipment. Software manufacturers are the biggest culprits. If you buy an expensive program and the company goes belly up, you can lose every penny you paid for that program if there is no one to support it.


Elliot Udell, DPM, Hicksville, NY



RE: Boyd Chairs and Business Sense

From: Richard Rettig, DPM


I have a Boyd chair, which is my favorite of 3 different podiatry chairs. They left the podiatry market years ago, which makes little sense as they make dental chairs which are 95% the same. They sell parts for existing chairs, but recently stopped selling the 110v motors. If a motor goes, the chair becomes a large brick. Then you need to buy one from a chair competitor. It makes you wonder why a business makes the decisions that it does. 


Richard Rettig, DPM, Philadelphia, PA



From: Robert Scott Steinberg, DPM


You could start casting, and sending your casts to a local Florida lab, like JSB. 


Robert Scott Steinberg, DPM, Schaumberg, IL



From: From: Raymond S. Murano, MEd, DPM


Dr. Jeffrey Kass points out that ABFAS is the only ticket to OR privileges, at least in New York. I hasten to point out that the Commonwealth of Massachusetts Board of Registration in Podiatry named ABLES as one of the boards recognized by the Commonwealth. 


The naming of any single board as the only viable certifying board would seem to be in direct contravention of Code of Federal Regulations governing “Participation of Hospitals” paragraph 482.12  which covers “Standards and Verification” stating that a hospital's governing body must - amongst other items - comply with subsection (7) that reads “Ensure that under no circumstance is the accordance of staff membership or professional privileges in the hospital solely dependent upon certification, fellowship, or membership in a specialty body or society.” 


Raymond S. Murano, MEd, DPM, Chairman - Massachusetts Board of Registration in Podiatry 



From: Robert Romaine, DPM


I have used an extra depth work boot from P.W. Minor with good results. They are available up to 5E width. P.W. Minor Foreman Steel Toe - Men's Super Depth Steel Toe Boots 6" steel toe work boot  - P.W.-1934  Last: Men's Summit Super Depth® Steel Toe.


Robert Romaine, DPM, Cohoes, NY



From: Ayne Furman,DPM


I understand that the query was asking for surgical advice, but I would like to offer a few conservative care treatment suggestions that I used successfully in my practice that may not have been tried for symptomatic posterior insertional retro-calcaneal exostosis:


1. D/C all Achilles tendon stretching or any exercise that heel drops below the level of the forefoot during the symptomatic stage. It has been my experience that PTs often will give patients aggressive stretching programs for almost any type of foot pathology.

2. Start on modified Alfredson exercises. Do not allow the heel drop below the level of the forefoot.

3. Make sure the posterior heel is off-loaded when the patient is watching TV or reading. Alert the patient not to rest the posterior heel on a coffee table or foot stool.

4. Modify a night time splitting so the heel is off-loaded in bed. Most of my patients noticed significant improvement in their heel pain doing the above (sometimes with the help of a NSAID) within 3-4 weeks.


Ayne Furman, DPM (retired),  Alexandria, VA



RE: Extra Depth Steel-Toed Shoes (Charles Halverson, DPM)

From: Donald Blum, DPM, JD, Kevin Pearson, DPM


Dr. Comfort carries a boot that is toe protected. Go to their website. I am sure other diabetic insole and therapeutic shoe distributors carry this type of product as well. Dr. Comfort advertises "Protector - Finally a Steel-Toe boot that blends art and technology. Durable leather, a NEW tough high abrasion, oil-resistant outsole and rugged good looks."


Donald Blum, DPM, JD, Dallas, TX


I have had success with Dr. Comfort's Protector boots for some deformities. However, a significantly contracted hallux may not be able to be accommodated in a steel toe shoe and may require an IPJ fusion.


Kevin Pearson, DPM, Stockbridge, GA 



Re: Costco Selling "Custom" Insoles 

From: Robert Scott Steinberg, DPM


I posted this on Costco's Facebook page. If you feel the same, please post on your Facebook page and on Costco's page:


I was in Costco on Saturday, June 16, 2018, and realized they could save tons of money by getting rid of pharmacists and optometrists! Anyone can read a prescription, count pills, and make people better, right? Digital devices can scan the eye and come pretty close to correcting vision and improving eyesight, right? Of course, they are not going to do that, but they do invite into their stores, people with no licences to advise people that they can make their feet feel better by standing on a mat and have the bottom of the feet mapped. Then produce devices that may cause injury to the foot, ankle, knee, and low back.


So, what if it has a 90-day guarantee?  The damage from devices like these might not show up for months. If you want to try something quick and easy, and inexpensive for foot pain, pick up a pair of rather stiff insoles at a sporting goods store. If they don't work, you're only out $35-$40 bucks, not the $130 Costco charges for their ridiculous insoles. If you have foot or ankle pain, you deserve to be seen by a licensed expert, a doctor of podiatric medicine and surgery.


Robert Scott Steinberg, DPM, Schaumburg, IL



RE: Using an Orange Light to Better Visualize Lesions

From: Daniel Chaskin, DPM


Skin cancer on the feet can result in death. In some patients, a parallel ridge pattern on the dermatoglyphic areas of the feet indicates a high probability of skin cancer. Sometimes, examination under a polarized or non-polarized white light just might not provide a clear diagnosis.


I discovered that an orange light may be helpful in distinguishing between the parallel furrow and parallel ridge patterns. I believe other colors might also give similar, if not improved, ability to give a more accurate diagnosis. 


Daniel Chaskin, DPM, Ridgewood, NY



RE: Unreasonable Chart Review

From: Bryan C. Markinson, DPM, Ron Freireich, DPM


I am stunned at the naïveté of any of my colleagues who are reassured that the SOLE purpose of these audits are to obtain additional diagnoses to obtain evidence of a more severe level of illness in a covered population so that the insurers can get more money to cover the population. The prosecutors have UNLIMITED power and if any of these "innocent" audits suggest a trend of impropriety as an in incidental finding, start loosening your collar!


Bryan C. Markinson, DPM, NY, NY


What a crime! I have noticed over the last several years that chart notes from many medical doctors, especially ones that are employed by a hospital system, contain a laundry list of diagnoses. Many of these diagnoses are not active, and in fact may have been from years ago. If one were to actually read the note, the doctor is not managing every one of those conditions.


So our reimbursements keep going down and the insurance companies keep making more money “managing” more medically complex patients when they may not be as complex as they report to the primary insurance company. It sounds like the insurance company doing the audits needs to be audited themselves.  


Ron Freireich, DPM  Cleveland, OH



From: From: Charles M Lombardi, DPM


I applaud any advancement of podiatry and have always worked to advance the profession. That was not the point in my post. It should have been podiatric physician, not surgeon, since most positions in the VA (FULL TIME) require board certification as far as I am aware (I may be wrong, but would like to see the documents). I believe this new title may be a slippery slope as opposed to clean language "podiatric physician." .


That being said, I am presently considered a podiatric surgeon under NYS Medicaid and still don't get paid for my services, so please explain how this helps the majority of podiatrists in New York or other states that do not pay for podiatric services or surgery. I am just not sure how you make the jump to it helping the majority of podiatrists. 


Charles M Lombardi, DPM. Bayside, NY



From: Michael L. Brody, DPM


Dr. Steinhauser is 100% correct in the reason for all of the chart reviews. The term is known as "Risk Adjustment", the amount of money the insurance company receives is modified by the risk status of the patient population. In chart reviews, they are looking for medical conditions that were not reported as an ICD-10 code on the bill.


Michael L. Brody, DPM, Commack, NY



From: Jeffrey Kass, DPM 


Dr. Williams has pointed out there is an alternative to ABFAS. He mentions ABLES. However, unfortunately, ABLES is not according to state law, in some states, going to help you practice above the ankle. For example, here in New York, the law specifically singles out that  one needs to be Board Certified by ABFAS in order to be granted this privilege. One of the largest hospital networks in New York has also recently made ABFAS certification your ticket to OR privileges. 


Jeffrey Kass, DPM, Forest Hills, NY



RE: Change in ABFAS Rules Prevents Recertification

From: Michael Z. Metzger, DPM


I received my (ABPS) certification in 1992. I was required to be re-certified and thought I had done so in 2002. I passed the exam and then learned that under the rules, I could not be recertified unless I submitted cases.  Because I had changed my practice and was not doing surgery back then, I was not be able to get my new certification. 


I wrote to the board officers and never heard anything. I still have no idea how they had the authority to just change the requirements retroactively. The fact that I got my original certification under certain requirements and rules made no difference. By the way, they have since dropped the requirements for cases, but I was still “uncertifiable”. 


Michael Z. Metzger, DPM, Houston, TX



From: Benjamin J. Wallner


I would like to address a few misconceptions that have appeared in the discussion of the VA MISSION Act over the past few days. Dr. Lombardi’s conclusion that only ABFAS-certified podiatric surgeons will receive an increase in pay as a result of the passage of the VA MISSION Act is fundamentally incorrect. Board certification is just one of many factors in determining market pay at the Veterans Health Administration. The section of the handbook that he has quoted refers to how the VA determines whether a physician or surgeon is board certified—not how the physician or surgeon is paid. 


The bureaucratic machine that is the VA looks at myriad sources to determine pay, including Sullivan and Cotter, MGMA, Bureau of Labor Statistics, among a whole host of other sources. The podiatry section at the VA now faces the formidable task of implementing this legislation and...


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



RE: Unreasonable Chart Reviews 

From: Dave Williams, DPM, Gian Steinhauser, DPM


I have seen a big increase in chart requests as well. I submitted 30+ just last week. Dr. Rettig posted, “I, and most doctors, charge the plan for copying the charts and collect enough to make it worthwhile.” I didn’t even know that was an option. What is the process and how much do you charge?


Dave Williams, DPM, El Paso, TX


Our office has also been getting multiple requests for 50-100 charts at one time as well. We pride ourselves on having excellent documentation and an EHR system that makes chart retrieval “easy”, so we don’t worry about the chart reviews. In fact, we welcome them, as we charge the insurance companies $25/chart, to cover the labor and printing costs. Requests for insurance payment refunds are few and far between at our office.


I was informed by an industry insider that the reason the insurance companies are requesting these charts is ...


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



From: Joseph Borreggine, DPM


I am surmising that according to this recently passed VA Mission Act, we are not defined as “physicians and surgeons” as it is for the MD/DOs; rather, we are just no longer defined as just  “podiatrists”. Now we are re-labeled as “podiatric surgeons”.


The question is how is it that this bill creates parity if we are not defined as “physicians”? Or was this just supposed to create parity in the pay scale for podiatrists as compared to our allopathic colleagues? Has the ADA been fighting the same battle as podiatry? And was that why the dentists were re-labeled as “dentists and oral surgeons”? 


If that was the case, then has the APMA thought of imploring the cooperative lobby power of the ADA for any other issues that we equally face? On another more important note: according to Title XIX, optometrists are not defined as “physicians”, just like podiatrists are not. So, should the APMA contact the AOA to see if they can help us do the same with Title XIX, just like we did with the VA Mission Act?


Joseph Borreggine, DPM, Charleston, IL



From: Dave Williams, DPM


There is an alternative to ABFAS. The American Board of Lower Extremity Surgery (ABLES), is a multidisciplinary certifying board consisting of MDs, DOs, and DPMs who specialize in lower extremity surgery. The Board has been operating for more than thirty years and has certified many thousands of physicians who have gained privileges at hospitals in every state of the Union and Puerto Rico, based on their ABLES certification. The Board grants certification in both forefoot and rear foot surgery. If you are frustrated with ABFAS, ABLES is worth a look. 


Dave Williams, DPM, El Paso, TX

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