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02/01/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Name Withheld 


 


A few years ago, a well-respected practitioner passed away in an untimely manner. He had a long standing practice that was busy from day until night, a modern office in a building affiliated with a top hospital and well-trained staff. His practice continued in the interim with help from volunteers, but when his family tried to sell it, they could not get a reasonable offer for the practice; not even an unreasonable one.


 


Instead, someone who purported to be “a friend” opened up a new office in the same building and poached the patients with a blitz of advertising. Setting up the new office and the professional marketing campaign cost maybe 20% of what he would have paid the family. Within a couple of months, he enjoyed the same busy practice, in a modern office, affiliated with a top hospital and with a well-trained staff. And he had paid pennies on the dollar.


 


I came to believe at that moment, after decades in this business, that a practice has no inherent value. It is no longer the “retirement account” waiting for us. If I had it to do over, I wouldn’t consider buying a practice. I would open one near an older practice and with marketing’s help become the newest, best-trained, most modern option available. Face it. Patients love the next new thing. Only our older patients look for long-term relationships, and they aren’t going to help sustain a practice. Patients these days look on Yelp for ratings to make their healthcare choices!


 


Name Withheld

Other messages in this thread:


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 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

08/10/2018    

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.

08/09/2018    

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

07/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


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

07/17/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


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

06/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


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

06/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



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

06/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



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.

06/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Robert Scott Steinberg, DPM


 


Dr. Feldman, I find your post arrogant, smug, and condescending. I suggest you think about those who came before you. There is no reason board costs are so high. Let the boards charge more for re-certification, instead of extracting the "last ounce of blood" from the young DPMs. You owe your colleagues an apology.


 


Robert Scott Steinberg, DPM, Schaumburg, IL 

06/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Richard J. Manolian, DPM


 


Welcome to the opioid epidemic. You quickly will get used to the online Rx history requirement as we have had in Massachusetts for a few years, and it will be enlightening as to what your patients are up to. 


 


I had some patients that we pull up where they’ve had 50 to 100 Percocet or Vicodin just prescribed only a few days before surgery that we are about to perform. I simply tell them you will not be getting a controlled substance prescription following this procedure based on that, and they understand fully.


 


Richard J. Manolian, DPM, Cambridge, MA

06/06/2018    

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



From: Ivar E. Roth DPM, MPH


 


I recently interviewed associates with three years of residency training. The spectrum of graduates training was from excellent to below average. One may ask how a graduate of three years of surgical training could be average or below average. The answer is that many programs just do not have the surgical load or variety that is necessary to come out as a fully trained “surgeon”. Many whom I interviewed felt they needed an additional year as a fellow to feel confident. Sadly, three years of training may NOT adequately prepare graduates for practice and or sitting for the boards. From what I saw from the current crop of residents is  that many were under-trained and not ready to become full scope podiatric “surgeons”.


 


Ivar E. Roth DPM, MPH, Newport Beach, CA

06/06/2018    

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



From: Len La Russa, DPM


 


We, as podiatrists, are all worried about the dwindling number of pre-med applicants applying to podiatry school. Could part of the problem have anything at all to do with the 50% passing rate for ABPS certification? Orthopods don't have that problem. Or is it possibly the chance that there might not be a position available for residency? The low passing rate is much easier to fix than the residency crisis, which is less of a crisis now. Another impediment to getting talent to apply to podiatry school could easily be addressed by increasing the pass rate so that it is no longer such an embarrassment. 


 


Len La Russa, DPM, Americus, GA

05/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Robert Scott Steinberg, DPM.


 


Lawyers do not bill Medicare for billions of dollars. Lawyers aren't the ones ripping off Medicare. And Florida is the epicenter for Medicare fraud. Don't take it so personally.


 


Robert Scott Steinberg, DPM. Schaumburg, IL

04/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: John S. Steinberg, DPM


 


We apologize for what your friend experienced. However, it is unfair to turn this misinformation into an accusation that Georgetown is somehow discriminatory towards podiatric surgery. I am the co-director of the Center for Wound Healing at MedStar Georgetown University Hospital. Our team is composed of podiatric surgeons, plastic surgeons, vascular surgeons, nurse practitioners, and numerous other specialists.


 


MedStar Health is a system of over 36,000 employees with 10 hospitals, so I cannot speak for every circumstance, but I can tell you that podiatric surgery is well established here and is not in a discriminatory status. I believe it would be best for you and me to speak directly about what happened rather than have this debate on PM News. Please contact me at 202.444.3059 and I would be happy to reach out to your friend to provide assistance.


 


John S. Steinberg, DPM, Washington, DC

04/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: An Open Letter from Greg Sands of Ortho-Rite to His Customers


From: Greg Sands


 


Within a few short months, and after a catastrophic fire that completely blindsided me, Ortho-Rite is up and running. It’s good to be back! I am not sure how the fire started. What we do know is that the paper storage is where it started. Paper storage is a ticking time bomb. How it started will remain an unsolved mystery. 


 


The first thing I want to do is thank my customers for their loyalty and support. I know that the fire has disrupted practices and hurt patients nationwide. I was overwhelmed and shocked, but I focused all my energy to rise above the ashes and rebuild. The building bureaucracies of this new town kept us from operating sooner. To circumvent the red tape, we worked a night shift to get things going. We have cleared the hurdles and we are now producing. Three months of anguish and stress have finally come to an end. I will do anything I can to make whole anybody who was adversely affected.


 


It was tough getting restarted after going for so many years. For the rest of my time in this industry, Ortho-Rite will be committed to make it up to all of you who were compromised. I am truly sorry for what happened. I want to maintain and exceed the level of product and service that you were used to. My entire team remains intact and eager to take care of everybody as usual. 


 


Greg Sands, Owner of Ortho-Rite

04/17/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Simon Young, DPM


 


I agree with Dr. Jacobs. The one word he used that must be analyzed is “normal”. Insurance companies rate you in relation to your peers. If let’s say, 90% only do C & C, then anyone who does more and deviates from the norm and bills for it falls out of “NORMAL”. The more standard deviations away from normal, the more ABNORMAL your practice is and they don’t question and evaluate why a practitioner is more observant and caring, but instead can consider it fraudulent. 


 


We as a profession “old” or “new” must change NORMAL. No one will admonish you for raising  a patient's pants legs and looking for abnormalities for referrals, if needed. This will save lives and hopefully garner respect. It’s sad we don’t look at legs routinely, no matter what the state laws. It’s preposterous to think we only did it for whirlpool treatments!


 


Simon Young, DPM, NY, NY

04/16/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Kudos to Amerx Healthcare


From: Ted Mihok, DPM


 


I would like to thank the Amerx Healthcare Corporation for contributing wound care products to our Lions and Rotarian's Joint Service Project in Mexicali, Mexico on April 4 and 5. They have been a partner for over ten years and their generosity is greatly appreciated. The service project has been going on for over 42 years and consists of both medical care and construction in and around Mexicali, MX.  


 


Ted Mihok, DPM, Alameda, CA

04/12/2018    

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



From: Jeffrey Kass, DPM


 


I am not sure if all the negative comments about Costco orthotics are well guided. I, like most of my colleagues, watch shark tank - and I say kudos to the people who came up with the idea. It's rather ingenious, and from a business point of view, I think they will make money. I think it's ludicrous to point to the inferiority of the product without having seen it or tried it. That is sheer jealousy. Some of my colleagues have been known to have their secretaries cast patients, yet no one is up in arms over that. I'm not sure that I can even agree who the experts are or if there are any when, as Dr. Shavelson points out, there are no studies proving anything. 


 


The more important question is - should the profession have been able to deem orthotics prescription products to be prescribed only by doctors, and did the profession let us down in that regard? What exactly is the Costco process? When the operator is quizzing the patron on what ails, can this be construed as a medical exam that the operator should not be doing? 


 


Jeffrey Kass, DPM, Forest Hills, NY

04/12/2018    

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



From: Brian Kiel, DPM


 


I, just like many podiatrists, see patients who have been treated by Costco and urgent care facilities. I, like Dr. Jacobs, will not deal with devices that others have made. I explain that it is a useless device and I cannot and will not take responsibility for them. On the other hand, if someone comes into my office with a boot and a fracture, or an improperly treated condition of the foot, I don't feel that we can or should refuse them. If another facility screwed it up in the first place, then they probably won't get it any better the second. It is our responsibility to do everything we can to help that patient. Of course, proper charting regarding the prior care is critical, but we have an ethical responsibility to care for those patients.


 


Brian Kiel, DPM, Memphis, TN

04/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: David S. Wolf, DPM


 


I respectfully disagree with Dr. Udell's post, "How would you feel if that person leaves your practice and gets a job working for an MD across the street and the doctor starts advertising that he or she now provides foot care by a well-trained PA or NP." These "podiatric insecurities" are still unfortunately part of the paranoia that was ingrained into our training and psyche. When podiatrists whom I have trained moved down the street, it never negatively affected my patient load; it only increased my bottom line. 


 


Competition is good and healthy as it raises awareness of what a podiatrist's scope of practice is. With the obesity crisis in this country, there will be more work for all of us (think wound care,diabeties, plantar fasciitis, etc.). 


 


Having NP/PAs you have trained who work in a PCP's office will only enhance your practice as they will know what services that they and their new boss do not want or know how to do. "The more the merrier".


 


David S. Wolf, DPM, Houston, TX

04/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Tina R. Sechrist


 


Our office has been working on this issue as a mass adjustment project with Palmetto GBA since early March.  The following has been posted on the claims issue log of Palmetto:


 


Issue Identified 3/26/2018: It has been determined that a routine foot care service edit, based on the Routine Foot Care Local Coverage Determination (LCD), L37643, has been edited incorrectly and only allowing one CPT/HPCPS code identified in the LCD per patient, per claim. This issue affects claims for dates of service on or after February 26, 2018.


 


The editing will be updated to reflect the LCD’s intent, which is to allow any medically necessary routine foot care services for a given patient once within a 60-day period. Providers must bill all routine foot care services for a 60-day period together on one claim for one date of service. The CMS Mutually Exclusive Edits to prevent improper payment when incorrect code combinations are reported will continue to apply to each date of service billed.


 


Provider Action: 3/30/2018: There is no provider action. This CPIL will be updated once the editing has been updated and Palmetto GBA will perform adjustments on affected claims. 


 


Tina R. Sechrist, East Cobb Foot & Ankle Care, Marietta, GA
Health Fusion


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