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06/01/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Robert Scott Steinberg, DPM
It should go without saying; you can't use CPT 29799 if you use shortcuts like foam boxes or scanners.
Robert S. Steinberg, DPM, Schaumburg, IL
Other messages in this thread:
12/21/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Philip J. Shapiro, DPM
Dr. Len Schwartz is offering poor advice. To ask a patient in the treatment room to give an unrehearsed video testimonial is nothing less than entrapment. Does this type of behavior promote a quality doctor-patient relationship based on trust? Does the patient have time to consider that their privacy as a patient is being compromised?
Having a negative review online is a fact of life in today’s world. Does the author of a negative review have a valid point? Does something need to be changed in your office? The idea of having a bank of positive comments posted online via entrapped patients is fraudulent. Grow a practice via sound and honest practice management, and that especially includes the staff and their attitudes, and the negative reviews won’t be as influential.
Philip J. Shapiro, DPM, Ormond Beach, FL
10/28/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Leonard A. Levy, DPM, MPH
John Mattiacci, DPM indicated that podiatric physicians will never have parity because we have a different degree. I have just completed 17 years as associate dean for research and innovation at an osteopathic medical school which also included frequently interviewing applicants for admission. DO graduates have parity with allopathic physicians, yet they each have separate degrees. DPMs within its specialty provide medical and surgical care no different than MDs and DOs.
While it is true that allopathic medical school students on average have higher GPA and MCAT scores, that has absolutely nothing to do with what their function is in the healthcare world. As Shakespeare said, “a rose by any other name is still a rose,” so we need to be more aggressive in letting members of our own profession as well as MDs and DOs know that we too are a “rose.” If just that message went out to applicants to our schools (and if we believed it too), it would be more likely that they would have higher GPAs and MCAT scores.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
10/20/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Robert D. Phillips, DPM
I am a little bit disturbed by the answer by Dr. Vogler as printed in PM News, in response to Dr. Ribotsky's question, "How are you applying podiatric biomechanics to advanced surgical procedures such as ankle fusions?" Unfortunately, Dr. Vogler did not really address any of the changes in the biomechanics of the lower extremity when one does an ankle fusion, and instead made a very generalized statement about ankle fusion changing the biomechanics of the lower extremity, referred to nondescript changes in orthotic technology, and finally recommended that an orthotist be consulted.
If this is the best answer that such a renowned surgeon as Dr. Vogler can give, it is indeed a sad commentary on the low state of knowledge of kinesiology, kinematics, and kinetics of the lower extremity that is sweeping our profession. It is very important that podiatrists not only fully understand how...
Editor's note: Dr. Phillips' extended-length letter can be read here.
06/08/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Chris Smith, DPM
A professional fee for capturing the morphology and alignment of the foot by a foot scan or plaster of Paris is certainly justified, assuming that the foot is properly positioned at the subtalar and midtarsal joints. Dr. Steinberg suggests that only a podiatrist has the skill and knowledge to properly position a foot. I counter this notion because I have seen a complete spectrum of properly and improperly positioned plaster of Paris casts taken by a litany of providers ranging from office staff, chiropractors, physical therapists, podiatrists, and other medical professionals. We cannot assume that only a podiatrist can take a true “neutral” cast. However, I firmly believe that generally, podiatrists do provide that service better than others, professional or non-professional. It is an ethical question whether a fee should be incurred if office staff performs the casting (or digitization, if applicable) that the APMA should address.
Digital scanning presents a similar question. Weight-bearing scanning/impression molding is inherently...
Editor's note: Dr. Smith's extended-length letter can be read here.
06/08/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1A
From: Richard Stess, DPM
As president of the STS Company, I have refrained from entering the discussion regarding casting with plaster, scanning, or casting with the STS casting socks, for obvious reasons. When my partner and I, who were in practice for thirty five plus years and attendings at the VA Medical Center in San Francisco, developed the idea of casting socks and slipper casts for obtaining negative models of the foot, it was done to provide practitioners a method that was not only clean and efficient but also accurate.
We knew it would save money because of the reduced time required to cast and clean up but soon learned that there are other factors to make a successful cast for each foot orthotic device and AFOs besides...
Editor's note: Dr. Stess' extended-length letter can be read here.
06/07/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Jeff Root
While the subject of casting originally began as a billing question, it has turned into a much broader and more complex discussion. Although it may seem rudimentary, let’s review the objectives when casting the foot for the manufacture of custom, functional type foot orthoses. The purpose of casting is to create a three-dimensional representation of the foot. While that sounds simple enough, we must ask what areas or surfaces of the foot need to be captured in the cast and what position should the various joints of the foot be placed in during the casting process?
When casting for a functional type foot orthosis, ideally we want the cast to be an accurate anatomical model of the...
Editor's note: Jeff Root's extended-length letter can be read here.
06/07/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1A
From: Paul R. Scherer, DPM
I must also comment on Dr. Kesselman's post about a "high quality scan" from an I-Pad or I-Phone. Several orthotic manufacturers who accept these images do not possess software that allows correction of the image or positive and simply use the image to select a predetermined shape and size orthotic. Actually no work is done on the orthotic other than adding a heel post and top cover. If it seems too good to be true...
Paul R. Scherer, DPM, ProLab Orthotics, Napa, CA
06/06/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
RE: When capturing casting for orthotics, should you bill a casting fee? (Robert Steinberg, DPM)
From: Dennis Shavelson, DPM
I am not sure when the American Prosthetic and Orthotic Association (APOA) and the Pedorthic Footcare Association (PFA) became trusted authorities alongside podiatry when it comes to biomechanics. I echo Dr. Ritchie’s comments on scanners, as they are only capable of producing foot orthotics that have never been proven to be custom or fix anything.
The “modern day practices of manufacturers” referred to by Dr. Kesselman involve using libraries of orthotics that marry a scan to the best orthotics matches they have on file (let’s say 100) and are not custom. They include the use of algorithms (A finite set of unambiguous instructions that can be performed in a prescribed sequence [by a computer] to achieve a certain goal that has a recognizable set of end conditions). These algorithms are labyrinthine cheats which marry a positive cast to a piece of thermoplastic with the intention of creating a foot orthotic that can posture the foot more optimally, and make muscle engines more trainable, therefore having corrective properties.
The APMA advises patients to “seek a podiatrist with an interest in biomechanics or sports medicine.” It is the future of the goals and outcomes of foot orthotics and the importance of the DPM in biomechanics that is messy, and not the plaster we are giving up.
Dennis Shavelson, DPM, NY, NY
06/06/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1A
RE: When capturing casting for orthotics, should you bill a casting fee? (Robert Steinberg, DPM)
From: Paul Kesselman, DPM
Historically, the HCPCS impression casting code S0395 was developed in order to provide a method by which the practitioner taking the impression could recoup their expenses associated with the materials used during this process. This was obviously in the good old days when plaster was "king" and the only real way to obtain an impression. It may have been even prior to the development of foam impression materials. I welcome comments on the history of that as well.
I also agree that the many errors associated with any orthotic fabrication (this is not just limited to foot orthotics) starts with the impression. Having the foot in the wrong or intolerable position should be avoided at all costs. And certainly Dr. Steinberg's remarks about having personnel who don't place the foot properly are well heeded and this is true regardless of what technique is used to capture the foot impression (plaster, STS, etc.). However, that is...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
06/03/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) -PART 1A
From: Doug Richie, DPM
There is no evidence that an I-Phone App can provide a high quality scan of the foot. Only a few scanners can adequately capture the posterior aspect of the calcaneus relative to the reference plane of the weight-bearing surface of the metatarsals, while the foot is held in a neutral postion, all essential for the fabrication of a true functional foot orthosis. This suggestion by Dr. Kesselman regarding the availability of a "high quality scan" from an I-Phone is entirely incorrect.
Doug Richie, DPM, Seal Beach, CA
06/03/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Robert Scott Steinberg, DPM
Nearly 100% of the orthotics created from scanners that patients show me are the result of the foot being improperly scanned in a true subtalar position, and failed to capture forefoot misalignment. Maybe it's because they were not imaged by a podiatrist, but instead done by office staff, a chiropractor, or a physical therapist. At a minimum, the use of CPT 29799 or CPT S0395 should be reserved for when the scan is being done by the physician.
While there are some DPMs who have been using scanners, it is my feeling that the only reason scanners are being promoted by the orthotic industry is to make it easier for improperly trained people to get into the orthotic despensing business. Adding scanning to the definition of CPT 29799 and CPT S0395 is a huge mistake. Using L3000 for a device created from a scanner is also problematic. If scanners are being provided at no charge by the orthotic laboratory, in exchange for a minimum number of orthotic orders per month, I believe that to be unethical.
Robert S. Steinberg, DPM, Schaumberg, IL
06/02/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) -PART 1A
From: Paul Kesselman, DPM
Actually, the issue of using scanners has come up in a joint meeting among APMA, AOPA, and PFA which I recently chaired, and it was then discussed at the APMA Health Policy and Practice Committee. The issue will also be discussed at the APMA Coding Committee later this week. Representatives of the AOPA, APMA ,and PFA all agreed that the use of scanners (if they provide a true 3-dimensional Image) should be incorporated into the interpretation for S0395. This incorporation is certainly in line with modern day practices of both orthotic providers and manufacturers.
The cost of scanners is now well below $500, and there are some which use an I-Phone App and provide high quality scans. Given the costs and high quality imaging, along with modern manufacturing technologies, the days of messy plaster are coming to a close.
Paul Kesselman, DPM, Woodside, NY
06/02/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Ron Werter, DPM
The non-specific casting code CPT29799 is generally meant for applying a cast. There is no mention in the definition of applying a removable slipper cast for taking an impression for a foot orthotic.
I do take issue with Dr. Steinberg's comments about not billing for taking the impression if one is using a scanner or foam box. I think he misunderstands the purpose of technology. Any new technology, in this case the scanner, is used to...
Editor's note: Dr. Werter's extended-length letter can be read here.
04/08/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Tip Sullivan, DPM
I believe that Dr. Boudreau may have a great idea! If we continue to want parity, then we should prove that we deserve it. Why don’t we give the same test to our graduates (USMLE step 1, 2, and 3) and see if we are as well educated as we feel we are? It would be well worth any expense incurred by our profession to gain this information. At least, then we will know where we stand in the realm of general medical knowledge.
Tip Sullivan, DPM, Jackson, MS
04/07/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Robert Boudreau, DPM
I dont get it. It seems that there is a segment of our profession that continually harps on the "We've got to get the MD degree" and the "parity" theme, but then I read this and think that the same segment wants to "get it the easiest way possible." No offense, Dr. Wan, but I don't want someone who is just "adequate" when I have a medical problem, and I don't think the general public does either. It should be all or none; quit trying to cut corners.
Robert Boudreau, DPM, Tyler TX
Editor's note: Dr. Boudreau, we hope that you never have to go to an emergency room at a hospital. If so, there's a good chance that you will be treated by a foreign medical doctor.
03/23/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Neil H Hecht, DPM
I have been reading with interest the latest postings regarding MD parity. Although I didn’t really want to chime in on the various opinions, I thought I would relate my experience with a website this morning. I was searching the Internet to see any general news regarding my “home hospital” next door and came across U.S. News and World Report Health website. I tried to search “doctors” for my name and was unsuccessful. I tried to search for “podiatry,” or any variation thereof, and was unsuccessful. Same for surgery, orthopedics, etc.: “we” just aren’t there.
Now, my home hospital website does have options for “podiatry”, but my feeling was re-inforced by the U.S. News website: “We” DPMs aren’t “real doctors” and not perceived as such by most folks.
Podiatry will NOT achieve parity in any real sense until we get the coveted “MD” degree after our name. It just has to be that way. Our revered professional protectionism will yield eventual obsolescence unless this happens. I know what we do on a comprehensive basis is rarely duplicated by any other specialty. Maybe the term “podiatry” itself needs to be re-invented?
Neil H Hecht, DPM, Tarzana, CA
03/21/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Simon Young, DPM
Truly sad to say, I am in full agreement with Dr. Markinson. The residents must realize the difference in their post-graduate education from allopathic education. I can only speak from my experiences, but there is a vast difference. Yes, they do rotations in various disciplines, but do they learn? Many are capable, but are they interested enough? Is there a desire? Yes, training by podiatrists is important, but it should not be the main source of their education. Surgery should be a focus, but not the priority.
My positions on podiatric education still haven't changed from previous posts. Sad to say, Markinson's crystal ball might very well be accurate. Change must come from within. The future residents must work much harder, and utilize their training years to indoctrinate the medical residents who will be instrumental in patient referrals. The future path will be difficult for many, me included.
Simon Young, DPM, NY, NY
03/18/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Bryan C. Markinson, DPM
I am in complete agreement that a license (differentiated from degree) in podiatric medicine should be the same full license as MD/DO. As was correctly stated, the institutional re-credentialing process controls what any specialty can and cannot do; ensuring that no podiatrist or orthopedist or dermatologist or vascular surgeon does brain surgery. However, in support of full licensure, the statement of Dr. Hultman and many others that “The reality is that the end product of our education and training is indistinguishable; thus the license a DPM gets should be the same as the license an MD gets," is simply a fantasy (at least the part about the end product).
There is no question that podiatric medical education is a million light years ahead of what it was thirty-five years ago. But as a faculty member in a medical school for...
Editor's note: Dr. Markinson's extended-length letter can be read here.
03/17/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Jeff Kittay, DPM
"The reality is that the end product of our education and training is indistinguishable; thus the license a DPM gets should be the same as the license an MD gets." Really Dr. Hultman? This endless discussion about parity is pointless and will remain so until every medical school graduate receives the same degree (MD/DO) and then a similar residency experience. Podiatrists do NOT have parity and never will until our education, training, and professional degree are equivalent.
Those podiatry schools unwilling to convert their curricula to meet allopathic standards should close. Why is this so difficult to understand? It has been debated ad nauseum in this forum and others for more than thirty years. DPM does not equal MD/DO in any meaningful way, especially in insurance parlance, and that is where it will really count if you plan on eating after your last residency check clears. Change the programs, change the degree, or prepare for obsolescence.
Jeff Kittay, DPM (retired), San Isidro, Costa Rica
03/17/2016
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1A
From: William Deutsch, DPM
Wishing and hoping and wanting parity isn't going to achieve it. Dr. Hultman states that podiatry schools aren't interested in joining medical schools to incorporate the foot care specialist into a specialty with a full MD license. Of course not, it's against self-interest.
It's a short-sighted truism. Podiatry isn't what it was 50 years ago. The name change from chiropodist signaled a change in education, scope, and practice. It was accepted by patients but not by the MDs or insurers. Now we flaunt 3-year residency programs and burgeoning forays into rearfoot and ankle surgery. Our craft is undifferentiated from that of the orthopedist specializing in the foot and ankle. But the profession clings to old ways and fails to acknowledge new realities.
The new reality is slapping us in the face. Insurers and government rule the roost. All doctors are afterthoughts. Why should foot care specialists be the underbelly of the afterthought? Podiatrists practice medicine which affects all systems through prescribing, administering anesthetics, and performing surgery. It should be our professional goal to ensure our continued success and proficiency and service to our patients, and that can only be achieved by full medical licensure as foot care specialists.
William Deutsch, DPM, Valley Stream, NY
12/16/2015
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1B
From: Michael L. Rosenblatt, DPM
I appreciated Dr. Richard Derner's comments about the "necessity that podiatrists be inclusive of both non-surgical and surgical DPMs." Since Dr. Derner writes for ACFAS, that comment had meaning. But I was disappointed in his using the word "deserve" when he suggests that not all DPMs "deserve" to be surgeons. This word suggests lack of respect. As DPMs, we already work under a shadow of hierarchy. Why add more among ourselves?
By way of example: When I had my pacemaker installed, it was done by an MD surgeon. Yet, there is a real need for physicians to treat cardiac conditions conservatively, as well as manage them after the surgery is completed. Some patients are better treated without...
Editor's note: Dr. Rosenblatt's extended-length letter can be read here.
12/16/2015
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS) - PART 1A
From: Brian Kiel, DPM
Dr. Rich Derner made perhaps the most important statement about podiatry that I have ever seen that contradicts the common thought among all of us and should lead the way to a dramatic change in our profession. He said, "Just because you graduate podiatry school, doesn't mean you deserve to be a surgeon." How very true.
When you graduate from general medical school, you are a doctor, not a neurosurgeon or gastroenterologist. We need to have a track to practice non-surgical podiatry, without the nonsense of a 3-year surgical program. Everyone cannot and should not do surgery, but many can practice great podiatry and serve the public without spending three unnecessary years learning something they will not or cannot use.
Brian Kiel, DPM, Memphis, TN
02/19/2015
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Jon Hultman, DPM, MBA
Keith Greer is not the only one with that opinion. On November 8, 2014, J. Kevin West, an attorney who defends DPM coding and billing audits, spoke on that same topic at the APMA CAC/PIAC meeting in Washington DC. One of his opening slides read as follows: “KEY FACT: Podiatry has been, and continues to be, a highly audited medical specialty.” Since legal action is not a viable option, a strategy the California Podiatric Medical Association is considering is the building of a more representative podiatric database.
Payers claim they compare physicians’ billing practices with peers of the same specialty, but there is a huge variation amongst DPMs in terms of practice focus. This makes the comparison of any individual DPM with the “average” subject to a wide margin of statistical error – errors that can lead payers to incorrect conclusions.
Jon Hultman, DPM, MBA, Los Angeles, CA
02/18/2015
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Jeffrey Kass, DPM
"Bret Ribotsky: DPMs are audited at a higher frequency than other physicians. Is there something that each of us should add to our notes that may help assist us if we get audited?"
This is a quote taken from PM News. I was wondering if Dr. Ribotsky's quote was based on fact or opinion. If fact, would that not be discriminatory?
Jeffrey Kass, DPM, Forest Hills, NY
Editor's comment: PM News does not provide legal advice. According to the transcript of Meet the Masters, this statement appears to be the opinion of attorney Keith Greer, which was shared by host Bret Ribotsky. Even if the statement is true, it is doubtful that podiatrists would have much legal recourse as podiatrists are not considered a "protected class." This is particularly true because podiatrists have a degree which differs from any other medical specialty.
06/12/2014
RESPONSES/COMMENTS (SUCCESS TIPS FROM THE MASTERS)
From: Seth Rubenstein, DPM
APMA has listened to the concerns regarding our eAdvocacy system and has responded by creating a brand new site for our members. The new site is currently in testing and will be ready for member use in July. Best of all, the site will be mobile ready, so you can advocate from your iPad, smartphone, or any other device at any time and from anywhere.
Advocating for podiatric medicine has never been easier. Simply click on your topic and you are taken to a page that displays all the...
Editor's note: Dr. Rubinstein's extended-length letter can be read here.
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