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01/01/2015
RESPONSES/COMMENTS (NON-CLINICAL)
From: Robert Kornfeld, DPM
I am genuinely impressed by, and have the utmost respect for, the hard work presented here by Dr. Isaacs. However, in my opinion, it is NOT Medicare that needs to be convinced of this information. It is the patient population. And quite frankly, they don't care. Why? Because the greater majority of podiatrists are performing these services on their patients and billing for something other than what is being done. While I understand why DPMs are doing this, it ultimately works AGAINST the profession. Patients, therefore, do not have to become their own activists when there is nothing for them to dispute with the government. As far as they're concerned, this is all covered by Medicare already.
There is power in numbers. How many podiatrists are there vs. how many podiatry patients are there? It is the patients who have all the power, not us. No amount of correct and appropriate information from our profession will sway the government. However, if every office appropriately billed their patients for these "non-covered" services, we can initiate a huge outcry from the foot suffering elderly. Every day, I read PM News and thank God I have opted out of Medicare and do not participate with insurance companies. I am amazed at how much you all are willing to put up with!
Robert Kornfeld, DPM, Port Washington, NY
Other messages in this thread:
11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Jon Purdy, DPM
I had a similar frustrating experience when I sent myself for my first routine colonoscopy. I was told an exam was necessary and received one from their PA. A little palpation here and there and an order for stool examination. To my protest, I was told the doctor will not do the procedure without it. I complied and received my first bill for a CPT 99204. I questioned the validity of that exam level with the office manager to no avail.
On the day of the procedure, the doctor asked if I was ready and said they would be taking me back. I said what about my results? He looked confused. I told him I was told he would not do the procedure without the stool path and he said “that is not true.” So I underwent my procedure irritated about the entire process thus far. In recover the doctor said, “everything looks great, but there was one spot of inflammation I needed to biopsy.” It was a “Where’s Waldo” game to discern anything in the photo, but I know that extra $350 comes in handy.
So they made some good money on me while I was stuck with unnecessary bills, frustration, and inconvenience. This just verified to me of what is out there, and what I do not do to my patients.
Jon Purdy, DPM, New Iberia, LA
11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Jeff Pinsky, DPM
I read the linked article “An insider describes the medical field”, and must say, it opened my eyes. Not so much in what it said; we’ve all had lumps, bumps, and detours in our career paths, and seen how medicine has changed; but in the very many comments left by other readers. I knew the “The American Thinker” was a politically right leaning publication, but hadn’t browsed its pages in years. I laughed at many of the responses, but not the classic comedic laugh; more of the Greek tragedy type of laugh. The volume and tone of the responses to the article gave me a glimmer into what the future holds.
As to how pre-operative patient consultation time has changed, as podiatrists we all spend/spent more time with patients than our MD brethren. As we get farther away from individual practice and more into corporate medicine, we have more demands to generate more revenue with higher patient volume (and lower reimbursement per patient) and faster throughput. Long appointment wait times (6 months+ is not unheard of), high no-show rates, narcotic prescription diversion, and poor patient compliance are all a larger part of our practices than they were in years past. Reminiscing about what used to be is not going to advance podiatry (nor medicine as a whole). We need to take action. Unfortunately, I have no idea what that action may be.
Jeff Pinsky, DPM, Petersburg, VA
11/19/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: David Secord, DPM,
My pre-op experience when approaching a surgical case mirrors Dr. Lang’s in that I also try to go into explicit detail with the patient about pre-op, peri-op and post-op expectations. I try to encourage the patient to bring whomever is going to be assisting them during their convalescence, so that they are also in on the whole explanation. I have a volume of graphics which are employed and given to the patient for guidance. I also have bone models in the office to help explain anatomy, physiology, and to give a 3-D representation of the structures involved.
Once everyone is satisfied, I let the patient know that this isn’t the end. A week before the procedure, we have a pre-op visit and we will go over this whole thing again. It is inevitably the case that they have some time to mull things over and have generated new questions. At that pre-op visit, I let them know that they should pick up the pain med and have it with them at the post-anesthesia care unit. That way, I know that they have what they need to stay pain-free as the local wears off and the narcotic can take over. My goal in this is to have the patient know almost enough about what to expect and what is involved that they could do the procedure themselves [hyperbole, obviously.] The patients seem to appreciate the time and effort spent.
David Secord, DPM, McAllen, TX
11/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Bret M. Ribotsky, DPM
I encourage everyone who’s eligible to consider firstnet.com. It runs on the AT&T system, but uses a different band system than every other cell phone. It uses band 14 which gives it higher priority with no throttling, regardless of how crowded the location you are in. It's designed to use for all first responders. When I joined this over a dozen years ago, it required me to have ER responsibility.
And with all this added benefit, it was less expensive even with the standard discount. It surprises me that not more people knew of this. I talked about this in my last year or so of lecturing before my accident.
Bret M. Ribotsky, DPM, Ft. Lauderdale, FL
11/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: My Surgical Experience as a Patient
From: Joel Lang, DPM
I recently had an outpatient surgical procedure under general anesthesia. While the procedure itself went well and I have largely recovered, I feel there are lessons I can share regarding this experience. I was told to show up early for the procedure to complete about eight pages of medical information forms and releases. So, at a time when I was most anxious about the procedure itself, I had lots of forms to complete.
Between the time I was told in the office that the procedure was necessary and the actual arrival at the surgi-center for the procedure, I accumulated several additional questions for the surgeon and the anesthesiologist. Both were very busy with their schedule at that time and had only limited...
Editor's note: Dr. Lang's extended-length letter can be read here.
11/15/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Paul Hilbert, DPM
I receive the healthcare provider discount from AT&T. When I switched from Verizon a few years back, the "in-store" rep asked my profession. I told him that I am a podiatrist. I have received the discount ever since.
Paul Hilbert, DPM, Navarre, FL
11/14/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Meghan McClelland, MBA
Dr. Fitzgerald, thank you for alerting APMA and the profession to your concerns about AT&T’s discriminatory policy. Following your call to APMA on this subject last week, our Health Policy and Practice team is working with AT&T to amend its policy. We will follow up with more once there is a resolution!
Meghan McClelland, MBA, APMA Executive Director and CEO
11/13/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: AT&T Discriminates Against Doctors of Podiatric Medicine
From: Thomas Fitzgerald, DPM
The AT&T Healthcare worker 25% discount discriminates against doctors of podiatric medicine (DPM). Website: The AT&T promotion includes: Doctors (MD, DO), state licensed/certifiednurses (example: RN, LVN, LPN, ARPN, ARPN/nurse practitioner, CNS, CNM, CNA) and physician assistants (PA-C) but not podiatrists.
Thomas Fitzgerald, DPM, Santa Rosa, CA
11/07/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: Podiatry, A One Trick Pony?
From: Rod Tomczak, DPM, MD, EdD
Many medical specialists created a surge of new patients by alerting the public to a possible catastrophic malady germane to their specialty and only they are properly trained to handle the problem. Gastroenterologists are the magicians of guiding the colonoscopy around flexures and blind turns, although you can now get a pseudo-colonoscopy delivered to your front door in a brown wrapper box. Twenty-five years ago, urologists taught us that PSA was not something to be considered when picking a bunion procedure, and it was imperative to get one every year or so. Dermatologists discovered that hydrocarbons caused a surge in melanomas, and we all needed a biopsy of that lesion on our back, and to be sure there weren’t additional lesions someone missed, we better have a dermatologic screening.
What used to be crisis dentistry where you only visited the dentist when you were in excruciating pain is now replaced with adult braces and oral implants. And of course, the orthopedic surgeons have become the Cinderella surgeons of pain-free joints for life. You can see where I’m going here, and I ask you to think about what we may be creating, be it good or bad for the profession. I am the first to espouse...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
11/04/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: eRX Phone Apps
From: Brent Rubin, DPM
There are several free eRX phone apps. These enable you to prescribe electronically without requiring you to have an EMR system. These allow you to prescribe directly on your phone and you don’t have to call the pharmacy.
I use the app called Prescriber on my iPhone, but you can also use iprescribe on any android phone.
Brent Rubin, DPM, Lakewood Ranch, FL
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: David Laurino, DPM
Dr. Khoury, I'd be happy to share my experiences. Like Dr. Vargas, I co-own a virtual assistant company which offers virtual front and back office support specifically tailored to the needs of medical practices. Our VAs, primarily based in the Philippines, are college-educated, and many are nurses or have advanced educational backgrounds, which brings an added layer of understanding to medical administrative tasks.
We've found that by leveraging virtual assistants, our clients experience a reduction in both overhead and turnover, which can ease the workload on remaining staff significantly. Our VAs are trained in handling phone calls, scheduling, insurance verification, prescribing, and prior authorizations. Additionally, they become a stable extension of your team, helping to reduce the disruption that often accompanies staff changes.
David Laurino, DPM, Chandler/Gilbert, AZ
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Howard Bonenberger, DPM
Everything is related to the perceived value brought to the table. In their minds, a degree which is universally recognized by the public, VC firms, or other businesses, the MD (DO) can author research on the entire body. The DPM has limited scope which can be covered by orthopedic research, at least in their minds.
Perhaps submit research that is blind as to the authors' names and degrees. It would not be for actual publication but to have it read by someone who is curious. If of high enough quality and the publication inquired, then it would be revealed that the author(s) were DPMs. I may be way off base, I'd appreciate thoughts on this idea.
Howard Bonenberger, DPM (Retired), Nashua, NH
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Paul Kesselman, DPM
I have to partially disagree with Dr. Tomczak. There is no question that the MD degree may get doors open that another doctorate degree may not. I also know at least 2 MDs who either decided not to pursue residency programs or who quit their surgical residency in midstream to pursue other areas of interest, such as medical IT, etc. This area is growing by the day as physicians with clinical experience and those in medical school see how difficult clinical practice is.
However I know many DPMs who, for one reason or another, pursued work outside the clinical arena in the pharmaceutical industry, orthopedic equipment or orthotics and prosthetics industries, and some even the teaching profession, at one level or another. Other DPMs are working for insurance companies as investigators, others as...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/29/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: No DPMs Need Apply
From: Rod Tomczak, DPM, MD, EdD
I recently received a notice on Linkedin from a young lady who gave up a lucrative career with a pharmaceutical company to attend medical school in Curacao. The notice simply stated there was a change in her status. I remember asking her in the interview why she wanted to give up her position to pursue an MD degree from the Caribbean. She said there was a glass ceiling for folks in the medical business industry who were not doing the bench research and did not possess an MD degree.
I followed up the other day on Linkedin and saw she is presently teaching at Columbia University in New York City. When I talked with her, she told me she got a great offer to teach, not in Columbia’s College of Physicians and Surgeons but in the business sector, at least partly because of her MD degree, so she took it. She mentioned there was even a ‘go to’ site for MDs who did not want to practice medicine, and this website even advertised jobs. I was curious about what she said, and I...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Marco A Vargas, DPM
It seems that after the pandemic, it has been very difficult to find and retain staff. Salaries have increased dramatically and there is a significant amount of staff turnover which creates disruption and is very costly for the practice. Therefore, after limited success with two virtual assistant companies for my own practice, I decided to start my own podiatry-specific virtual assistant company based in Medellin, Colombia.
We specialize in training podiatry virtual assistants in-office duties such as answering phones, appointment scheduling, insurance verification, and prior authorizations among other tasks. We also provide in-room translation services for Spanish speaking patients. All virtual assistants are bilingual, college graduates with podiatry experience, and cost less than half of what an on-site employee does and with less turnover.
Marco A Vargas, DPM, Sugar Land, TX
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Source for Cantharone
From: Paul Betschart, DPM
I was surprised to see on the Dormer Laboratories' website in bold red that Cantharone and Cantharone Plus are not permitted for sale or use in the United States. It is a shame as they make a quality product that is very effective for treating plantar warts. People may be scrambling to find alternatives as their supplies dwindle. Practitioners should contact their preferred compounding pharmacy to see if they can have a compound made with the same ingredients.
I have gotten compounds with the same exact ingredients as Cantharone Plus from Bayview Compunding Pharmacy in Warwick, RI in the past when Cantharone plus was in short supply. It costs a little more per mL than Cantharone but the effectiveness was similar to the original formula.
Disclosure: I have no financial interest in Bayview Compunding Pharmacy
Paul Betschart, DPM, Danbury, CT
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Kathleen Neuhoff, DPM
When I was in veterinary school, I remember my instructors telling us that the difference between a trade and a profession was research, I believe this to be true. We have some amazing researchers in podiatry but they are rare. The value of contributing research should be part of the mindset of us all and as Dr. Secord pointed out, it is not.
Kathleen Neuhoff, DPM, South Bend, IN
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Lawrence Rubin, DPM
A recent post in PM News pertaining to insurance reimbursement compliance said, "Any abnormal findings on the LEAP Vitals Exam, i.e. dry and xerotic skin (L85.3) caused by sudomotor dysfunction, is a significant risk to a patient with diabetes. It therefore warrants a care plan." To prevent confusion of business names, this is not a stated opinion of the 501(c)3 not-for-profit LEAP Alliance.
Lawrence Rubin, DPM, Las Vegas, NV
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Paul Kesselman, DPM
I stand by my partner Alan Bass, DPM, whose opinion is absolutely correct. Each patient encounter should have at a minimum an appropriate history and physical with components of lower extremity systems including but not limited to dermatology and must also include neurovascular and a MSK examination. Any changes in patient history or PE should be well documented and incorporated into the note.
But the change in history is not what will get you paid for a separate E/M nor is documenting a change in the physical examination. It is that last part, the management, what exactly did you do? If all you did was document a change in history, nope. If all you did was document a change in the PE, again, no dice. You must document all 3 issues, ...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) PART 2
From: Michael J. Schneider, DPM
I would like to add my congratulations to SuEllen and David on their retirement. I had used their products throughout my career. When I retired and began volunteering at the Denver Rescue Mission, SuEllen and David donated Gordon Labs products for my patients. Good Luck on your retirement!
Michael J. Schneider, DPM, Denver, CO
10/24/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Shawna Shapero
Like Dr. Arnold Signer, I am saddened to see the recent announcement of the closure of Gordon Laboratories yet happy for SuEllen and Dave on their decision to retire. In their 60 years of service to the podiatric medical community, Gordon Labs has generously given back to the profession in ways too numerous to be mentioned in one place. Thank you for setting the standard for everyone involved on the commercial side; truly the end of an era.
Congratulations on your retirement, SuEllen and Dave. Gordon Labs will be missed.
Shawna Shapero, VP Corporate Relations, Bako Diagnostics
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Paul Kesselman, DPM
I must admit that those promoting this are either a mentor and friend of the last twenty years (Doran Edwards, MD) or Lawrence Rubin, DPM, a longtime mentor, friend and former teacher of mine at ICPM in the late '70s and '80s. So it pains me to have to offer some criticism of each of their posts. And I will have attempted to speak with or have already spoken with both of them prior to this post being printed.
For one, Dr. Edwards and I have worked together numerous times to improve the therapeutic shoe bill, met with DME MAC medical directors and CMS to improve the accessibility to beneficiaries by removing some of the...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Doran Edwards, MD
I appreciate Dr. Bass's post and his enthusiasm for the Arche LEAP Vitals exam for patients with diabetes. There is one point of clarification that needs to be provided. Dr. Bass wrote, “if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression, and this patient may need a prescription based upon the findings of the LEAP tests, the patient will then meet the requirements for an E/M service.”
The quick and efficient LEAP Vitals tests are all about skin integrity in this high risk population. We understand that “chronic illness” as well as “chronic illness with exacerbation” helps determine, in part, the level associated with the E/M service through medical decision-making (i.e. 99212 versus 99213). By no means does the patient need to exhibit exacerbation or progression of their diabetes to qualify for the LEAP Vitals tests, nor the ability to meet the medical necessity associated with an E/M billing. A prescription is also not required.
Any abnormal findings on the LEAP Vitals Exam, i.e dry and xerotic skin (L85.3) caused by sudomotor dysfunction, is a significant risk to a patient with diabetes. It therefore warrants a care plan, either an initial care plan or a change to a previous care plan that’s not working well. This change in medical condition alone provides the medical necessity for an evaluation and management service through the counseling of the patient on their risks associated with dry skin, and changing their treatment, even if only an over-the-counter skin care recommendation.
Doran Edwards, MD, Former DME MAC and PDAC Medical Director
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: David Secord, DPM
Although it pains me to say so, I agree with Dr. Tomczak on the issue of research. In 2013, I practiced in Riyadh, Saudi Arabia, at the King Abdulaziz Medical City, Central Region hospital. At that time, the Chief of the Section, Dr. Abdulaziz al Gannass, was doing Charcot reconstructions (as indicated) as ankle fusions, either with or without talectomy. Instead of using an intermedullary rod, he repurposed the Synthes VA-LCP Condylar Plate (normally used to fixate femoral fractures) to connect the tibia to the calcaneus. The butterfly shape of the condylar plate worked amazingly well at the calcaneus and after removing the distal fibula, laying the plate at the lateral aspect of the tibia to the calcaneus made for a robust structure, as it is a locking screw and plate system with variable angle abilities. The majority of the patients walked on it post-op (although informed that they were to be non-weight-bearing) and none of these patient failed to fuse.
In the case of a talectomy, allograft bone stock was used to...
Editor's note: Dr. Secord's extended-length letter can be read here.
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Lawrence Rubin, DPM
In a recent post, Dr. Freireich said, "If APMA promotes an Annual Comprehensive Diabetes Prevention Foot Examination, I hope they also promote that the exam is not covered by insurance, unless things have changed since this issue was also brought up."
Actually, there has been some progress in gaining covered podiatric Medicare diabetes amputation prevention examination coverage. Although we have not yet succeeded in gaining coverage for a comprehensive diabetic foot examination (CDFE) to screen for many potentially hazardous lower extremity problems, podiatrists can now be well reimbursed when providing...
Editor's note: Dr. Rubin's extended-length letter can be read here.
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