The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

January 09, 2007 #2,785 Editor-Barry Block, DPM, JD

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NY Podiatrist Reaches Out to the Underserved

Dr. Richard L. Sawicki has helped healing the feet of the less fortunate for almost four years at Niagara Cerebral Palsy. He has his own office in Niagara Falls but also holds a foot care clinic on alternate Thursdays.

Dr. Richard Sawicki

Sawicki said he needed to open such a clinic because state regulations will not allow him to see patients receiving Medicaid in his office. And he stressed that he sees many, many patients, not just those diagnosed with cerebral palsy.

"We started the Podiatry Clinic in January of 2003 at Niagara Cerebral Palsy because there were people who were underserved in the community and needed foot care that didn't have access to it at a private office. It is handicapped-accessible there, so we started the clinic there. [It's] open to the public.", said Sawicki.

Source: Pam Kowalik, The Buffalo News, [1/7/07]

HS Basketball Twin Wants to be Podiatrist

The twin sisters are seniors at Gaston Day School, where they have helped create a state champion girls' basketball team. Gaston Day didn't have a varsity girls team until the girls were freshmen; the school had stopped the program three years earlier because of a lack of interest. But since the sisters and their coach/father Bob Long arrived, Gaston Day has won two state championships and is favored for a third.

Nisha Long said life without Kisha by her side would be a huge adjustment, but she isn't thinking about that. She's the focused, serious one of the pair who knows what she wants. Nisha wants to be a podiatrist and doesn't say a lot, but when she's on the basketball court, she's the player teammates count on.

Source: Kevin Cary, Charlotte Observer [1/7/07]

Getting Around the Physical Therapy Caps

Starting in January, Medicare placed a combined cap of $1,780 on physical therapy and speech-language pathology as well as a $1,780 cap on occupational therapy provided in non-hospital outpatient settings. To get around these caps for patients who have additional therapy needs, physicians can go through an exceptions process.

• A physician can secure an automatic exception by accurately diagnosing a patient with a condition or complexity approved by Medicare for extended therapy. The list of codes that trigger an automatic exception can be found online (www.cms.hhs.gov/transmittals/downloads/r1106cp.pdf).
• A physician whose patient isn't eligible for an automatic exception can apply for a "manual" one. This requires a written request by the doctor at least 10 business days before the provision of therapy exceeding the cap. The request must include documentation justifying the additional care.
• If the Medicare carrier doesn't respond to the request within 10 business days, the therapy is deemed medically necessary.
• If the carrier rejects either the automatic or manual exception, physicians may prescribe the therapy anyway and appeal the claims denial through the regular Medicare appeals process.
• Physicians can avoid the caps by referring the patient to a hospital rehab facility

Source: AM News [January 16, 2007]

Query: Billing Irregularities

I was recently approached by a patient with several questions as to the billing practices of another local podiatrist regarding a pair of orthotics. She presented her entire ledger from the provider and copies of EOBs from her major commercial insurance carrier, all from services performed 4-5 years ago. She has asked why she was forced to pay (in full) for orthotics, when they were paid by the insurer. I briefly scanned the ledger, and identified many, many more apparent unscrupulous billing practices. Billing over 14 office visits (99213) for what appear to be post operative visits, incorrectly coding DME items to get paid, etc, etc. I acknowledge a legal and ethical responsibility now rests on me to direct the patient, but where should I tell her to turn? I have asked her to obtain copies of her records, and will have her forward everything to the local state podiatric board, but should this be sent to the insurance carrier? The attorney general's office?

Name Withheld

Editor’s Comment: PM News does not provide legal advice. You undertook the correct of action by requesting that the patient request a copy of her medical records. To assume, merely on the basis of EOB’s that the podiatrist billed inappropriately is premature and unfair. Many times a patient is unaware or simple forgets services which wre legitimately performed.

If there are discrepancies after comparing the records to the billing, the patient can be directed to the state podiatric association for investigation. Unfortunately, statistics gathered by PM over the last decade show that while approximately 80% of DPMA are APMA members, 80% of those who have faced professional discipline are non-members.

If the practitioner in question is not an APMA member (easily verified at www.apma.org), the patient can lodge a case with the state medical licensing agency.

RE: Pediatric Hallux Valgus Bunion Splint (Nieuwenhuis, DPM)
From: Multiple Responses

I carry bunions splints in my school; they were donated by Raymond Ng, of Dr. Kong Footcare, Hong Kong. If anyone desires information on the pediatric products he has developed or his franchise of pediatric shoe stores, please let me know and I can put you in contact with him. He is an orthotist/prosthetist in Hong Kong and has 46 pediatric shoe stores.

Pam Haig, C. Ped., The Robert M. Palmer, MD - Institute Of Biomechanics, Inc. rmpinst@aol.com

Since the current gold standard Root-type orthotics have failed in this situation, I would suggest a look out of the box. I have had clinical success (although labor intense) with my Neoteric Biomechanical approach. The family is either type 3, rigid-flexible or type 8 flexible-flexible, and using casting tenets and in Root terms, the medial arch must be supported in an exaggerated arch position (foot centring) so that posterior tibial, peroneus longus and flexor hallucis longus can leverage, tighten and strengthen so as to lock the medial column in function.

A heel lift should be considered temporarily to negate equinus influence and the device even though rearfoot and forefoot corrected should contain very deep extended counter cupping. The patient should be evaluated q3-4 months for additional posting modifications as their flexibility begins to be casted out (like met adductus). If this fails, subtalar stenting in type 3 and/or lapidus procedure in type 8 should be considered when age appropriate with post-op foot centering.

Dennis Shavelson, DPM, New York, NY, drsha@lifestyelpodiatry.com

A comprehensive biomechanical examination may reveal a common etiology in all of the children. This common denominator might be the presence of a structural condition that produces functional hallux limitus, such as a congenital metatarsus primus elevatus, a congenital long 1st metatarsal, an osseous equinus, etc. or a functional condition such a midtarsal or subtalar joint axis anomaly, a soft tissue equinus, or a combination of factors that may be associated with hallux valgus. An accurate diagnosis is important for both current and future treatment decisions.

Since this condition appears to have a familial tendency, take a close look at family history. If there is a family history of severe, symptomatic HAV verses a history of asymptomatic, minor HAV, you can consider this in developing your prognosis and in helping you judge how aggressive your treatment should be for these young children. Examining the parent’s feet might be an important factor in providing quality treatment for their children.

If you can identify the etiology of the HAV, then it may be possible to tailor your orthotic prescription to treat the condition more effectively than that which occurred with the previous orthoses for the older siblings. For example, if you find that these children have a midtarsal joint anomaly such as excessive transverse plane motion at the midtarsal joint (i.e,. a high-pitched MTJ axis or MTJ hypermobility), then the use of a very deep heel cup and a medial heel skive or perhaps the use of a Blake type functional orthosis can achieve better functional control and improve the position of the hallux. While treating children can create an ethical dilemma, using a true, prescription orthosis which is based on the patient’s specific pathomechanics is an appropriate option to consider.

Jeffrey A. Root, jroot@root-lab.com

RE: STJ Arthroeresis vs Evans (Tip Sullivan DPM)
From: Tim Vogler, DPM

I do not perform arthroeresis procedures but I have performed (and continue to do so regularly) Evans procedures since 1991, when I learned the procedure from J. Barry Johnson, DPM (who has most likely performed more than anyone in the USA). I firmly believe the Evans, when combined with a gastroc release or TAL (whichever is indicated) to be a far superior procedure for the following reasons:

1) Lateral column lengthening can be tailored to the precise length necessary to correct MTJ abduction.
2) Extra-articular (without risk of damage to subtalar joints).
3) Upon incorporation into the calcaneus, permanent correction is achieved.
4) No need for second surgery to remove device.

Please note that rarely will the Evans (or for that matter a STJ implant) correct the sagittal plane deformity (medial column) that I see in most equino-valgus deformities. I almost always incorporate a Cotton procedure with the other two procedures for complete correction. Additionally, like Dr. Johnson, I do not regularly fixate either graft and I almost always can “walk” these patients in a specially applied walking cast.

Tim Vogler, DPM, High Point, NC, Timothy.Vogler@cornerstonehealthcare.com

RE: Lost Soft Tissue Mass (Andrew Glass, DPM)
From: Bryan C. Markinson, DPM

Never do a soft tissue mass in the office. NEVER. You rob the patient of the possibility of a frozen section diagnosis. What if the specimen of Dr. Glass was not lost and he got a malignant diagnosis back three days later? He then would have a new mother with a malignancy with unidentifiable margins, forcing a much wider secondary surgery than would have been had he just done an open incisional biopsy. Where is the pre-op MRI with contrast that would have identified this as a vascular lesion? Plain film? Open incisional biopsy with frozen section after obtaining plain films and MRI with contrast is a standard. Even if you only do the incisional biopsy, close and wait for the pathology, it is much better than what was done.

I suspect that Dr. Glass' patient should be referred to a musculoskeletal oncologist, who will observe the patient, possibly get an MRI with contrast to see if there may be any remaining tumor, and possibly re-explore the area, to get some sort of tissue specimen, or evidence of proximal sites free of any kind of tumor.

Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@msnyuhealth.org

POSITION AVAILABLE-SOUTH FLORIDA/BROWARD COUNTY

Needs 2 or 3-year post surgical training in forefoot and rearfoot
Salary plus incentives Email responses to office email: advfoot@bellsouth.net

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

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.

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