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10/25/2017    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: An Open Message to My Colleagues


From: Bradley W. Bakotic, DPM, DO


 


After much internal debate, I’ve chosen to step down as CEO of Bako Integrated Physician Solutions (Bako) and resign from its Board of Directors as the result of principled differences with the company. I will no longer be involved in their educational initiatives or laboratory services. Bako represents the embodiment of my life’s work to this point, and coming to the decision to begin a new chapter in my professional life has been extremely difficult. 


 


That being said, I have not completely excluded the possibility of a future return to Bako should our differences be hashed out. On the heels of the prior somber news, let me relate a silver lining that is giving me a more altruistic sense of...


 


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

Other messages in this thread:


08/16/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Lancing P. Malusky, DPM


 


I advise against matrixectomies with the C02 laser, as it leaves a dry socket and the remaining tissue heals slowly by third intention. I used the Xanar C02 in the '80s, and modified my procedure. The matrix goes all the way to the phalangeal crown. Instead, use the C02 after an SNT-type sharp matrixectomy with a #64 blade to remove and cauterize the corner matrix left by this procedure.


 


Lancing P. Malusky, DPM, Dayton, OH

08/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: It's Time to Clean Up Our Act 


From: Joseph Borreggine, DPM


 


Having previously been on the Illinois Podiatry Licensing board for the last 5 years and serving as its chair for three of those years, I had the opportunity to review a number of cases that were initially brought to the board as patient complaints. I could only opine that these patient complaints were driven by possible perceived high fees for medical services with outcomes that did not solve the patient’s problem. Therefore, with the basis of this type of complaint, not much could be done. But, many cases with similar complaints were more frequent than one would think. 


 


The reason that nothing could be done was due to the inability to “restrict someone’s trade.” Hence, it did not allow me or the board to make any judgment against these podiatrists. So, the complainants were usually just left without any...


 


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

08/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: The -25 Modifier With and Without Nail Care


From: Allen Jacobs, DPM


 


Regarding the discussions on the use of the -25 modifier with nail care, or the use of the E/M codes generally, consider the following:


 


1. You decline to utilize the -25 modifier for fear of triggering an audit. In doing so, you deny patients of needed E and M services.


 


2. IF you re-appoint the patient for a separate office visit, you have created unnecessary inconvenience for the patient, having them return for services which could have been provided at the same time. This is particularly troublesome for the elderly or those for whom transportation needs are difficult to arrange.


 


3. You are unfairly depriving yourself of...


 


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

08/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Elliot Udell, DPM


 


Dr Kass is correct. When it comes to anatomic locations of ulcerations, the determination of what is and what is not in scope for a podiatrist in NYS is absurd. I would love to see how insurance companies would handle a case of an ulceration that was half in scope and half out, and if the podiatrist would treat half of the ulcer and a "dermatolgist" would treat the upper half of the same ulcer.


 


That being said, there is a greater area of scope of practice that our state society should not ignore. Last year, we saw a miserable flu season with many deaths as a result. If pharmacists can give flu shots, why not podiatrists who give injections all day long? Since we treat geriatric patients, this would make sense from a public health perspective.


 


Elliot Udell, DPM, Hicksville, NY

08/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Stephen Doms, DPM


 


While I find the APMA e-advocacy admirable because it is quick and easy, I don't think that "canned" identical emails will get much attention from CMS. I, my staff, and my patients have written letters and mailed them to CMS, our two U.S. senators, and our U.S. representatives in Congress. Podiatric advertisers and sponsors should also write, as podiatry's survival means their survival.


 


A paper letter will be opened, handled, and read by someone at CMS. We customize every letter and emphasize different concerns about the proposed changes to the fee schedule. We also write about identical diagnoses that would be treated identically by DPMs, MDs, and DOs. Equal work, but unequal pay in the proposed changes.


 


Mailing address: Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, PO Box 8016, Baltimore, MD  21244-8016.


 


Stephen Doms, DPM, Hopkins, MN

08/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Laurence Dorman, DPM


 


I couldn't agree more with my colleague Paul Kesselman's post. This is a huge slap in the face to the most highly skilled practitioners of the lower extremities in the country. I know that I am preaching to the choir. I remember how we struggled to achieve parity in all aspects of health care when I was a podiatric medical student more than 40 years ago. The efforts of the APMA with John Carson as our chief lobbyist led to great breakthroughs for the profession. We seem to be headed backward again for no logical reasons other than the fact that we have different initials after our names. 


 


There are obviously huge concerns here for those of us who have practiced for many years and are thinking about retirement, as well as younger practitioners just starting in their practices, and podiatric medical students. I encourage everyone to follow up on the E-advocacy site and add your own feelings about this issue. Our profession came about because allopathic medicine never paid much attention to the total care of the lower extremities; that has never changed and the medical community, for the most part, has been very happy with our impact in the treatment of their patients with foot and ankle maladies.


 


Laurence Dorman, DPM, Miami, FL

08/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Relaxing Scope of Practice Restrictions


From: Jeffrey Kass, DPM


 


Medpage Today reported this week that Health and Human Services Secretary Alex Azar said that states should consider relaxing scope of practice restrictions as this impedes healthcare competition, raises healthcare costs for patients, and deprives them of choices. I could not agree more. There are some states where the scope of practice is absurd, New York being one of them. 


 


In a personal communication with the NY State Podiatry Board, I asked if I were treating a leg ulcer contiguous with a foot ulcer and the leg ulcer healed, could I continue to treat the leg ulcer? The response was (paraphrased) ”if I was treating it before, common sense would dictate I could continue to treat it.” I responded with a follow-up. Wouldn't common sense also dictate, if I can treat a leg ulcer with the healed foot ulcer, I could treat the leg ulcer without the foot ulcer ever existing? The Board has yet to issue a response. 


 


With the comments made by Alex Azar, every state with ludicrous scope issues should capitalize on these comments, agree with them, and invoke change. If not now, when?


 


Jeffrey Kass, DPM, Forest Hills, NY

08/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: 20 Years with Sammy


From: Christopher A. Orlando, DPM


 


August 8, 2018 marked 20 years with Sammy. On 8/8/98, Ken himself came to my office to install Sammy. At the time, it was DOS-based! It was the best business decision I ever made. Ken Katz and company have exceeded my expectations and have kept up with all the insane insurance changes and demands. Thanks to Ken and his excellent support staff.


 


Christopher A. Orlando, DPM, Hartsdale, NY 

08/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Paul Kesselman, DPM


 


My esteemed colleagues are right on point. The changes proffered by CMS are nothing but a shakedown to podiatry and if left to come to fruition, we (and every DPM who knows or should know about this) have no one to blame but ourselves. Furthermore, if you think it’s just Medicare, I am afraid you are very wrong. Every payer will do this and I predict it won't matter whether you have an equal pay for equal work provision in your state. 


 


I am also curious how CMS predicts this will only result in a 2% reduction in payments to podiatrists. Can they provide us with the formulas on how they reached this? And why should the DPM (or any physician) who is treating a Charcot foot be paid the same as the physician seeing a patient with a simple...


 


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

08/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 3



From: Joseph Borreggine, DPM


 


According to CMS, “E/M services provided on the same date of service as covered foot care are considered integral to the foot care and are not separately payable unless the service is separately identifiable from the foot care (noted by submitting CPT modifier 25 with the E/M service) and medically necessary. Maintain supporting documentation for the use of CPT modifier 25 in the patient's medical records.” 


 


Hence CMS developed the “Comparative Billing Report or CBR” for this exact reason. What is the purpose of this comparative billing report (CBR)? CBR201608 was created to inform podiatrists (specialty 48) about their billing and payment patterns on claims for... 


 


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

08/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Medicare Unmasked Revisited


From: Joseph Borreggine, DPM


 


The website: https://graphics.wsj.com/medicare-billing/ came out in 2013 in the Wall Street Journal and shows how doctors and other providers compare with peers in their state and nationwide. This information, I believe, is accurate since it came from CMS; most importantly it is public information. I do not think there is any further data beyond 2015 since CMS now has a "physiciancompare.gov" site which is much harder to navigate to find the same data. I tried. 


 


I recommend that my colleagues investigate the WSJ site and see their own data and consider how they compare to their associates in their own community with respect to how much they were paid by Medicare from 2012-2015. You may be surprised to see...


 


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

08/09/2018    

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



From: Jeffrey Kass, DPM


 


I agree with Dr. Siegal's comments regarding seeking equal pay for equal work. I also feel this should not be limited to Medicare and their particular payment system. It is ludicrous that all other payers do not have a standard payment system. Different providers within the same specialties are paid at different rates. This is something the medical community at large should have stopped dead in its tracks when it first started.


 


Jeffrey Kass, DPM, Forest Hills, NY

08/09/2018    

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



From: Allen Jacobs, DPM


 



Dr. Adam Siegel states that “looking at the profession as a whole... a large proportion of our profession applies 99212 in addition to the routine foot care codes in an attempt to suck a few more dollars out of Medicare.”


 


This is an insult for which Dr. Siegel should forthwith render an apology and retraction. Many patients who present to the office of a podiatric practitioner for nail care do so with concurrent illnesses such as PAD or diabetes. The majority of such patients have concurrent potential limb threatening pathology for which evaluation and appropriate intervention may interdict the progression of...


 


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


08/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Adam Siegel, DPM


 


Dr. Musella seems to be missing the point. The APMA supports equal pay for equal work. If a podiatric physician sees a complicated patient which requires an in-depth history and physical with complex decision-making, the doctor should be paid an equal sum to that of our allopathic and osteopathic colleagues. I’m not talking about routine care patients; I’m talking about complex, sick individuals who require more time and resources. Some practices have more of this type of patient than others. We should not be limited to these lesser codes only because we have a DPM after our name. Separating us into a different, lower paying bucket, as CMS has done with optometry and physical therapy, sets up for a very scary precedent. 


 


As for the 2% fee drop: this estimate comes from looking at the entire profession as a whole. A large proportion of our profession applies 99212 in addition to the routine foot care codes in an attempt to suck a little more from Medicare. Many in our profession feel that applying a 99212 as opposed to a 99213 will keep us “under the radar” (this is a completely flawed and ludicrous way of thinking). The 2% drop is based off of that average, which I believe is unfairly skewed downward due to our (inappropriate) tendency to add low level EM codes to our routine care codes. I believe if you remove these superfluous 99212 codes billed with routine care, the average EM code billed would be in line with many other specialties. I applaud what the APMA is doing thus far and have full confidence that this situation will be rectified. 


 


Adam Siegel, DPM, Lutz, FL

08/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Darryl Burns, DPM


 


They can be found at: www.medid.com


 


Darryl Burns, DPM, Salinas, CA 

08/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Michael King, DPM


 


I caution those of you who are commenting or expecting the documentation to be less with the proposed CMS rule for E & M visits. The clinical presentation IS the clinical presentation and will need to be documented as such. Just because they say they are lessening the burden, don't believe for a minute they will lessen the audit process.


 


Yes, the policy wonks say this is to ease our burden but the patient who presents with significant medical problems is still a sick patient. WE must fight this egregious and discriminatory change in our coding world. WE know how to document; this spear pointed directly at our profession cannot be tolerated


 


Michael King, DPM, Roswell, GA

08/06/2018    

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



From: David E Gurvis, DPM


 


I respectfully disagree with Dr. Al Musella. My most frequent code for a new patient is CPT 99203. I also frequently use 99201 and 99203. On occasion, if the time has been spent in counseling - 99204. I have a similar distribution on established patient visits... 99212 and 99213, for the most part.


 


When appropriate, I do a complete LE neurological, muscle strength and testing, ROM, integument and nails, along with musculoskeletal. I read and document that I have read and gone over with the patient the family history, social history, and ROS. At times, a patient who has waited too long to come in presents with 4 or 5 complaints, and each requires an...


 


Editor's Note: Dr. Gurvis' extended-length letter can be read here.

08/04/2018    

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



From: Al Musella, DPM


 


Take a look at the proposed rules before making comments. They specifically ask about something that is not addressed in the APMA letter. They specifically say on page 345: "We are soliciting public comment on what that total time would be for payment of the proposed new podiatry G-codes. The typical times for these proposed codes are 22 minutes for an established patient and 28 minutes for a new patient, and we could use these times."


 


I think that is reasonable. They predict that the changes will result in a net loss of 2% of our...


 


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

08/04/2018    

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



From: Andrew Shapiro, DPM


 


Dr. Kass appropriately recognizes Dr. Dennis Frisch and the APMA for their efforts, but he should also thank the more than 12,000 united APMA members who have invested in their national and component organizations. Without  the advocacy and work of the APMA and its state and division components, there would be no voice to defend and support the podiatric profession. ATTENTION NON-MEMBERS: It's time you stop relying on others to save your profession. Step up and join now, and be a part of the solution, not the problem!


 


Andrew Shapiro, DPM, Valley Stream, NY

08/03/2018    

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



From: Eric J. Lullove, DPM 


 


I don’t want to sound like a broken record in this post. I cannot stress how important this issue is to all of us. Basically, whether you pay for APMA dues or not, this is as of right now, the most important battle we as DPMs are ever going to fight. I have seen the direct result of how advocacy and involvement at the public policy level works for the day-to-day practicing podiatric physician.


 


It is this very time that EVERY DPM in this country access the APMA e-Advocacy website and send your customized letter to your members of Congress as well as CMS Administrator Seema Verma to immediately close the...


 


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

08/03/2018    

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



From: Jeffrey C Kass, DPM


 



I would like to applaud Dr. Frisch and the APMA for allowing not only members, but non-members and anyone who wants to be part of the letter writing campaign to say "no" to the proposed CMS changes to their reimbursement policy.


 


I know that on a divisional level here in NY, I used to complain that only members of the association were able to partake in letter campaigns to state senators and assembly persons.


 


So, I thank APMA for recognizing the importance of everyone fighting for the cause. I sent in my letter tonight through APMA.ORG and I invite all members or non-members, all active or retired podiatrists, all students and residents to do the same. It literally takes no more than one minute to fill in your info, click send, and might just be the most important minute of the year.


 


Jeffrey C Kass, DPM, Forest Hills, NY


08/01/2018    

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



From:  Dennis R. Frisch, DPM


 


Dr. Kass asks if there is a course of action to ensure the profession is not short-changed when it comes to the changes to E/M codes included in the proposed rule for the Medicare Physician Fee Schedule. In short, yes: Visit the APMA eAdvocacy site today to send a pre-populated, customizable message to CMS. Physicians must send a comment by September 10 to be on the record on this critical issue.


 


APMA has actively communicated with members since the release of the proposed rule and is asking every member, state component, and affiliate to take part in this profession-wide call to action. We encourage non-members to...


 


Editor's Note: Dr. Frisch's extended-length letter can be read here.  

08/01/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Stephen Kominsky, DPM


 


I have to respond to the comment made by Dr. Damien Roussel regarding the “recovery time” following the Lapiplasty procedure. Correct me if I am wrong, and it certainly is not the first time, and hopefully not the last, but isn’t the Lapiplasty procedure simply an amalgamation of devices to accomplish the re-aligment and arthrodesis of the first metatarsal cuneiform joint? And, if that is correct, then don’t the patient and the physician have to rely on the patient’s body to actually fuse that joint?  


 


So, if those presumptions are correct, then please explain to this guy how one very learned doctor can state that “it reduces the healing time from six weeks to one week”? If in fact that is the case, and that is an accurate statement, then I think that every foot surgeon in the world should begin to use this device.


 


Stephen Kominsky, DPM, Washington, DC

08/01/2018    

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



From: David S. Wolf, DPM


 



"The times, they are a changin." The old mantra was "if you did it and didn't document it, you didn't do it; and if you documented it and didn't do it, you did it."


 


Now with the new CMS proposition, the mantra is the converse... you don't have to document it (copy and pasting bullets to satisfy the coders) and you get paid. Go figure.


 


David S. Wolf, DPM, Retired, Houston, TX


07/31/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: E/M Codes and Podiatry


From: Joseph Borreggine, DPM


 


For all the time and energy spent on E/M coding documentation, what does it really matter regarding whether or not podiatry is singled out by CMS having its own “office visit” code? The fact is that CMS is just trying to save money. Medicare is going broke. The current 5 level E/M system has been in place since 1995 and really just was a way to try to pay a physician accordingly based on time spent with the patient and what was actually “performed” on the patient during the exam. 


 


This method of coding has been nothing more than a futile exercise in trying to comply with E/M codes that were used by providing unnecessary documentation to prove that the “checklist” of things required to receive reimbursement was actually “performed” by the physician. The fact is that most of the time E/M...


 


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