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RE: Allowing Podiatrists to Administer Flu Vaccinations

From: Elliot Udell, DPM


This year's flu epidemic is considered the worst in ten years. In NY State, Governor Cuomo has issued a directive to allow pharmacists to give vaccinations to kids as well as adults. If a pharmacist can give a flu shot, even though they do not give injections regularly, why shouldn't podiatrists be allowed to give flu shots? Are there any other professionals who give as many injections as podiatrists do?


Not only are we trained to give injections but because we deal with the elderly population, we would reach people who might not go their pharmacy or primary care doctor and get an injection when necessary. I call on the respective state societies to push their local legislatures to allow podiatrists to administer flu vaccinations.


Elliot Udel. DPM, Hicksville, NY

Other messages in this thread:



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. 



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



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



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 



RE: Medicare Unmasked Revisited

From: Joseph Borreggine, DPM


The website: 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 "" 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.



From: Darryl Burns, DPM


They can be found at:


Darryl Burns, DPM, Salinas, CA 



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.



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



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



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. 



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



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.  



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



From: Stephen Doms, DPM 


While podiatrists are defined as physicians, so are optometrists. When I go to my OD for examination and management of my glaucoma, the doctor writes me a prescription for eye drops. He bills for and receives payment for CPT 99213. Should CMS also carve out a new set of codes for optometrists? They certainly have a smaller anatomical area to care for compared to a podiatrist. Why are we being singled out?


I just looked at the pre-publication PDF of the Federal Register for the CMS proposed changes. You can search for CMS, Federal Register, July 27, 2018. The podiatry information starts on page 359. If my math is correct, these are the calculation of fees for 2019: The "conversion factor" for Medicare in 2019 is 36.0463. The proposed new patient podiatry code has an RVU of 1.35 and an added dollar input of $22.53, resulting in an allowable charge of $72.19. For an established patient, the RVU is .85 with an added dollar input of $17.07, resulting in an allowable charge of $47.71. I hope that my math is way off.


Stephen Doms, DPM, Hopkins, MN



From: Steve Tager, DPM


It sounds like the WAR continues with CMS using the “Divide & Conquer” approach to isolate podiatry from the next battle. Are we not still struggling to gain parity with main stream medicine? Nice fragmentation tactic CMS! Maybe APMA needs to increase the offense instead of continuing to beef up the defense.


Steve Tager, DPM, Cupertino, CA



From: Timothy P. Shea, DPM


In concert with Dr. Malkin's comments and in the spirit of Harry Goldsmith, the recent proposed changes to E/M codes, "specific" for podiatric medicine should raise the concern of every podiatrist in the country. The concept of "separate but equal" policies in the affairs of the government finance can only lead to disaster. In my 45 years in podiatric medicine, every time any policy-making group, whether private or government, has made such policies: practicing podiatric  clinicians have had to work for years to try to get things straightened out; costing much more time and money than if it had been stopped in the beginning.


Going back to 1965 when the then APA made sure that podiatrists were included as "physicians" in the Medicare program, therefore not allowing discrimination in that program, we have ALL benefited from... 


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


Timothy P. Shea, DPM, Concord, CA



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: 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.



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: 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



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



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



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: Richard Rettig, DPM


Dr. Hofaker, I think you misunderstand the situation. Medicare Advantage plans get paid by CMS on a capitation basis per client. They get a higher payment if the patient has a lot of co-morbidities. They know a doctor may send in claims and place a single diagnosis for payment, but there may be many more diagnoses within the note that would allow them to collect more from CMS. So they audit charts to find those diagnoses. It has absolutely nothing to do with your care; you personally are not being audited. They would have no reason to get back to you. Further, I  and most doctors charge the plan for copying the charts and collect enough to make it worthwhile. I look forward to these requests!


Richard Rettig, DPM, Philadelphia, PA



RE: Unreasonable Chart Reviews

From: Rich Hofacker, DPM


I am just wondering about all of these insurance company "chart review" requests and what other pods are doing about it. Medicare and Medicaid do not routinely request them. However, it all started years ago with Medicare Advantage Plan insurance companies. The insurance companies were requesting one or two charts at a time. Now we are seeing 50-70 chart requests at a time. The insurance companies never get back to you in regard to what you are doing right or wrong. They just request more and more charts. I am perplexed by all of this, primarily because I just no longer have the time to reply to all of these frivolous requests that have gone from a yearly time frame to a monthly time frame.


Rich Hofacker, DPM. Akron, OH

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