The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

January 06, 2007 #2,783 Editor-Barry Block, DPM, JD

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PM's 25th Anniversary Issue Mailed

We’ve just mailed the Special 25th Anniversary Issue. At 244 pages, it’s our largest January issue ever. We mark this milestone with a look back at the last quarter century of podiatry. We’ve also printed many congratulatory letters from notable podiatry leaders and friends.

You’ll also want to read the dozens of interesting and informative articles, columns, and features that you’ve come to expect from PM, as well as our latest CPME-approved CME.

Loss of Fat Pad Becomes Problematic With Aging: Caselli

"Even if you get fatter and heavier, the fat pads still get thinner," says Dr. Mark Caselli, an adjunct professor at the New York College of Podiatric Medicine and staff podiatrist at the VA Hudson Valley Health Care System. When this happens, they can absorb less shock, which can make feet sore and painful after time.

Dr. Mark Caselli

The loss of padding can also cause corns and calluses on your balls and heels, Caselli says, "which for athletes can cause problems when performing activities." Caselli says there's no need for people to retire from an athletic life. "You shouldn't cut activities out. Just decrease how much you do, to compensate for the wear and tear on your body," he says.

Shoes should have good cushioning in the heel to make up for the loss of natural padding, and the widest part of the foot — usually the front — should fit the widest part of the shoe. "Some people think, 'Just get a bigger shoe size,' " Caselli says, "but if the shoes are too long, they will pinch the toes."

Source: Mary Beckman,, Los Angeles Times, [1/1/07]

NJ Podiatrist Joins NY Health Law Firm

David S. Ivill, a former partner at McDermott, Will & Emery, has joined Mintz Levin's Health Law Section. Dr. Ivill is an accomplished attorney with expertise in many areas of health law, including the representation of not-for-profit and tax-exempt organizations in numerous types of transactions, and providing counseling to health care institutions on corporate, transactional and regulatory matters. He also has a broad physician-based practice, representing physicians and medical groups in joint ventures and other transactions, as well as fraud and abuse, and other regulatory matters.

Dr. David Ivill

Dr. Ivill graduated from the Pennsylvania College of Podiatric Medicine and practiced podiatric surgery for more than ten years. He thereafter obtained his law degree from New York University School of Law, where he served as Articles Editor for the Review of Law and Social Change. He is a member of the bars of the States of New York and Connecticut.

Source: Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C

No Region III (Atlantic City) Meeting For 2007

There will be no Region III Meeting for 2007. This seminar, traditionally held in May has been cancelled this year because of the time and location proximity are too close to the APMA Scientific Meeting to be held in nearby Philadelphia.

Podiatrists who normally obtain CME credits and purchase supplies and equipment are reminded that the Region II New York Clinical Conference will be held January 19-21, 2007. Information is available at www.nyspma.org

Query: Lost Soft Tissue Mass

I recently resected a suspicious looking soft tissue mass from under a patients big toe. The mass was deep beneath the subcutanous layer. It was dark, well-circumscribed and about 2 cm. in diameter. The patient was a 28 year old female who recently gave birth. The mass appeared during pregancy.

Can you identify this mass?

We sent the sample out to pathology and somehow the sample was lost by UPS on the way. At this point I have a frustrated patient and would like opinions on what to do next. The area has totally healed and the patient is now pain-free. Any thoughts on this matter would be greatly appreciated.

Andrew Glass, DPM
New York, Ny

Query: STJ Arthroeresis vs Evans

Does anyone have any comments, pearls, etc. on making a decision to use an arthroeresis implant verses doing some sort of calcaneal osteotomy (Evans), given the calcaneous does not need medial transposition. When performing them, they both seem to be very effective at stabilizing the lateral column. Clinically after recovery from the other procedures that I often use in conjunction, I haven’t seen a big difference.

Tip Sullivan DPM, Jackson, MS

Medicare: Treatment of Porokeratoma

I have recently started treating porokeratotic lesions (post enucleation) with 40% ureacin cream, and additional debridement every two weeks for two or three additional treatments. I have had measurable success in eliminating the lesion using this treatment.

With Medicare patients, would this be a billable visit, and, if so, which code would I use? Or does this fall into the 60 day rule for which it is considered a frequency issue? If so, would an advanced beneficiary notification (ABN) stating that is it not covered enable me to bill my patient instead?

Stuart Steinberg, DPM, Burbank, CA

Response: There are several issues here.

First, 40% ureacin, while a keratolytic agent, *may* not meet the "destruction of benign lesion" definition (CPT 17000 series codes pre-January 1, 2007; CPT 17110 series codes post-December 31, 2006).

Second, I am not aware of studies that have validated its efficacy in the treatment of porokeratosis. If you have published studies validating the treatment, you should line them up in case you need to appeal a denied claim based on the use of the medication.

Third, the package insert (example from Carmol-40) states, "INDICATIONS AND USES: For debridement and promotion of normal healing of hyperkeratotic surface lesions, particularly where healing is retarded by local infection, necrotic tissue, fibrinous or prurient debris or eschar. Urea is useful for the treatment of hyperkeratotic conditions such as dry, rough skin, dermatitis, psoriasis, xerosis, ichthyosis, eczema, keratosis, keratoderma, corns and calluses, as well as damaged, ingrown and devitalized nails." Using a ureacin-40 cream as a defnitive treatment of porokeratosis may result in the procedure reimbursement denial (e.g., investigational) without studies or FDA indications.

From your post, I would presume that the application of ureacin-40 cream (patients could, with a prescription, apply the medication at home) is adjunct to the primary procedure, the repeated debridements. Past California Medicare (NHIC) local carrier determination (LCD) policy on the debridement of keratotic skin lesions excluded payment for the debridement of the porokeratotic lesion. The revised LCD on the debridement of intractable plantar keratosis will also exclude payment for the debridement of the porokeratotic lesion as routine foot care (unqualified).

I would let the patient know this (and have them sign an agreement to the pay for the treatments with an advance beneficiary-like notice of reimbursement exclusion which you would keep in the office for your files), and bill the patient directly. Since it is a non-covered service, the claim would only be submitted if the patient insists or you are contracted to the patient's secondary payer. If you do have to submit the claim for the debridement, append a "GY" modifier to the debridement code. The ICD-9 code would be ICD-9 757.39 (other specified anomalies of skin).

While you would bill an E/M service for the initial encounter needed to make the diagnosis and explain the treatment, you would not bill E/M services with each returning visits with (or instead of) the debridements because the primary purpose of the returns-to-the-office is procedural, not E/M.

Harry Goldsmith, DPM , Cerritos, CA

[Dr. Goldsmith is a featured speaker at the Codingline Oakland *Strictly Coding*" Seminar and the New York *Strictly Coding*" Seminar (www.codingline.com/events-ca.htm & www.codingline.com/events-ny.htm)]

Codingline subscription information can be found at
http://www.codingline.com/subscribe.htm

RE: Gold Standard for Osteomyelitis (James Breedlove, DPM)
From: Multiple Respondents

The gold standard for diagnosing osteomyelitis is an open bone biopsy. An MRI will demonstrate increased hydrogen content within fluid, however it cannot differentiate what type of fluid qualitatively. Gadolinium will help with binding to white cells, but it certainly is not a definitive diagnosis. An example is a Charcot fracture where there are phagocytes in the bone during the remodeling phase that give a false + with both gadolinium and on a bone scan with gallium or indium. They can be helpful but I would not want to contemplate an amputation for destructive bone changes without a + bone culture

James Fagan, DPM, Oakland, CA, James.Fagan@kp.org

Actually if one wants to be technical, a bone biopsy is the "gold standard" for diagnosing osteomyelitis. However, since I'm assuming you're talking about non-invasive techniques, an MRI w/ contrast (w/o contrast if the patient has renal compromise) is actually more specific than a bone scan. There are many articles that you can find online that point to the fact that the sensitivity and specificity of an MRI for O.M. is actually higher than that of a 3-phase bone scan especially in diabetics. MRI's are inherently more specific and sensitive for bone marrow edema (which is why they're also more useful for stress fractures) vs bone scans. Don't forget a lot of patients who do ultimately develop O.M. are usually diabetic and have some sort of renal compromise - you don't really want to be injecting dye into a patient who has CRF do you?

Rahul Patel, DPM, Flushing, NY, docrahulpatel@gmail.com

In my medical community, MRI is the Gold Standard. This is what the radiologists and infectious disease physicians believe as well. Keep in mind that the standard of care may differ from one community to the next.

There is much greater anatomic information and a higher degree of certainty, especially when using contrast with an MRI. If there is a decreased T1 marrow signal with a well defined fluid area and postcontrast signal abnormality on fat suppressed T1 &T2 weighted images, you can be pretty sure there is osteo. There is not this certainty with bone scans even when using combined triphasic and indium scans.

I have found that when an MRI is positive and I do surgery, the pathology is positive for osteo 99% of the time. I have not found that to be the case with bone scans.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

As far as a "gold standard", bone biopsy and culture is your classic board answer. Personally, I use MRI because of speed in obtaining results however false positives can be caused by rheumatoid pannus, Charcot, etc..
.
As far as radiolabeled scans go, Indium is best for acute OM, poor for chronic OM. HMPAO (Ceretec) is excellent for acute and chronic OM but can give false negatives in the digits. All-WBC labeled scans can have false negatives if not enough WBC's are obtained due to human error or antibiosis, not injected in a timely fashion, and some literature states that corticosteroids can obscure results.

Bone biopsy is still best. Pathologists look for osteoblasts and necrosis in the specimen and not necessarily organisms. Antibiosis will not affect osteoblasts so no need to stop prior to obtaining specimen. I have only had one instance where the bone was so devitalized that no osteoblasts and necrosis were present and the pathologist would not call it OM. Instead they called it dead bone and to refer to culture.

Clinical correlation is always prudent in these instances. I would never limit myself to one modality, but rather based on the entire clinical picture, determine which scan or combination of scan and biopsy to use.

Eugene A. Batelli, DPM, Naples, FL, ebatelli2001@yahoo.com

ASSOCIATE POSITION - NORTHERN VIRGINIA

Well-established, busy, diversified, multioffice/multidoctor practice seeking associate with opportunity for partnership. Must be highly motivated and ethical with strong interpersonal and patient skills. Excellent opportunity for PSR 24 or higher trained individual to complement a full-scope podiatric medical and surgical practice. Competitive salary and benefits package. Please send CV and references to saglag2@aol.com or fax to (703) 368-5103.

ASSOCIATE POSITION – ST. LOUIS, MISSOURI

Immediate Opening. Busy practice in prime suburban St. Louis location looking for a surgically trained associate, possible partner. Must be honest, ethical and hardworking. ABPS preferred, but not required. Please reply with CV and requirements to mdwrtw@aol.com

ASSOCIATE POSITION- PALM BEACH COUNTY, FLORIDA )

Excellent opportunity for a hard working, motivated podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Partnership opportunity available. Seeking a board eligible/certified trained foot and ankle surgeon for a well rounded podiatric practice. Position is available immediately. Competitive salary. Please respond to springwm41@aol.com

ASSOCIATE POSITION—NORTH COASTAL CALIFORNIA

Two fully staffed rural offices with continually growing patient load. We take care of all aspects of podiatry: assisted-living centers, palliative care, wound care, biomechanics, surgery, diabetic care. Hospital privileges are available to those properly qualified. If you are interested in challenging and hard work leading to partnership, send your CV to jimf@humboldt1.com

ASSOCIATE WANTED FOR SOUTH MIAMI AREA

Large group, busy, multi-office, partner potential. Motivated applicants only. Mail resumes and letters of intent to 999 N. Krome Avenue, Homestead, FL 33030. July start time OK, sooner preferable. E-mail lianadpm2@aol.com. I can also be reached at 305-331-4501.

ASSOCIATE POSITION - NORTHEASTERN PA, POCONO REGION

Looking for an enthusiastic, personable, well-trained foot and ankle surgeon to join busy practice. Candidate must have completed a minimum two-year surgical residency program, demonstrate qualities of self-motivation, high morality and good surgical skills. Package includes malpractice ins. health ins. and competitive compensation. Terms negotiable. Email LT1525@aol.com Or fax CV with cover letter to 570-476-6839.

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901

ASSOCIATE POSITION--PHOENIX SUBURB

Attractive opportunity for enthusiastic, proficient, and personable associate. Well-established modern practice with multiple newer spacious offices, technology and equipment. Solid referral base, close to hospitals, knowledgeable certified staff. 22% MCR. Practice and surgical center partnership potential opportunity. Prefer 24-36+ PSR. Send CV: AZpodassociate@aol.com

ASSOCIATE POSITIONS - VIRGINIA

Immediate/July full time associate positions available. Unlimited income potential. Busy, diverse, 40+yr Hampton Roads practice. Must be compassionate; energetic; and motivated; PSR24/36. Looking for long term arrangement. Please send letter and CV to fixafoot@cox.net or fax to 757-397-5889; www.podiatryltd.com

ASSOCIATE POSITION - MISSISSIPPI

Well established, busy, 3-doctor practice seeks PSR 12 or 24 trained podiatrist for associate position to fill vacancy of retiring member. East central location is a great area to raise a family and is a prime location for accessibility to several major cities. Competitive salary, benefits, and incentives. Partnership possible in 2 years to right individual. June - July start date. Applicant must be ethical, personable, and motivated. Please E-mail CV and letter of intent to shanegan@bellsouth.net

ASSOCIATE POSITION - LOS ANGELES/SOUTH BAY AREA

Multi-office, multi-doctor, well-established practice near the beach cities. Seeking a board eligible/certified PSR-24 or PSR-36 trained foot and ankle surgeon. Well-rounded practice requiring knowledge in biomechanics, pediatrics, sports medicine, diabetic wound care, trauma, and reconstructive foot and ankle surgery. Full-time position available immediately with generous compensation and benefits, including malpractice, and health insurance. Two-year commitment required with partnership opportunity. Send CV to akemfoot@sbcglobal.net or fax to (310) 838-0227.

POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multi-location practice looking for PSR-36 associate leading to partnership. PSR-36 trained podiatrist with great opportunity for reconstructive surgical practice. Practice has Medicare-approved surgery center. Must have excellent interpersonal skills. Excellent salary and incentive. Respond to: westsidefoot@yahoo.com

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