The Voice of Podiatrists

Serving Over 13,500 Podiatrists Daily

January 09, 2012 #4,353 Publisher-Barry Block, DPM, JD

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NY Podiatrist Discusses Non-Surgical Treatment of Heel Pain

Dr. Suzanne Levine often treats heel pain with a non-surgical anti-inflammatory shot. (A cheaper at-home alternative to the injection can be had by mixing kosher salt, a dab of mineral oil and one teaspoon of ground coffee. “Use that exfoliate judiciously and it will help alleviate the buildup,” Levine says. 

Dr. Suzanne Levine

Levine recommends that patients increase their daily vitamin K intake –– “Most heel discoloration comes from bruising, which that can heal” –– and to start generously applying tea tree oil to the trouble spots. “If you take care of your feet, you can wear any type of shoe,” she says, but warned that part of the problem is that women don’t anticipate problems: “When you’re in your 20s, your feet don’t hurt and you can wear huge stilettos. It’s when you’re in your 30s that the deformities begin to show.”

Source: Adapted from Chelsea Zalopany, New York Times [1/5/12]

UK Podiatrist Discusses Treatment of Verruca

Verrucas – small hard lumps – are warts on the foot. They are caused by a virus known as the human papillomavirus (HPV). "They are usually picked up at swimming pools as the humid environment is ideal for the virus, which can survive for months on floors without a host," says podiatrist Emma Supple. "If you have any scratch or abrasion on your foot, the virus can enter the skin."

Emma Supple, UK Podiatrist

Treatments are based on either destroying the infected tissue, or bringing about an immune response. "My first suggestion is to apply a mixture of tea tree oil and lemon daily. It’s mildly antiviral," says Supple. "If you can bear the pain, some people use a sterile needle to poke it, which effectively kick-starts the immune system – if you suffer a wound, white blood cells will flock to the area in order to heal it, killing the lesion," says Supple.

Source: Daily Mail [1/7/12]

eRx Penalty Revealed in Fine Print of Medicare Remittances

Physicians who wonder whether they received a hardship exemption from Medicare's 1% penalty in 2012 for failing to e-prescribe in 2011 will have to find out by reading the fine print on their payment remittance statements. The Centers for Medicare and Medicaid Services (CMS) had intended to inform physicians and other prescribers whether they would be subject to the penalty through a feedback report that they could access online. However, on December 29, the agency announced that "due to the high volume of significant hardship exemption requests, it is no longer technically feasible for CMS to provide a...feedback report."

Instead, CMS encouraged prescribers to check their remittance statements for claims submitted for services rendered since January 1, 2012. If they were hit with the 1% penalty (a "payment adjustment" in CMS parlance), they would see the letters "LE" on the statement and 2 different codes. The first is Claim Adjustment Reason Code (CARC[I1]) 237, indicating a "legislated/regulatory penalty." The second is Remittance Advice Remark Code (RARC) N545, which explains that the provider was an "unsuccessful e-prescriber" in 2010 as defined by Medicare's e-prescribing incentive program.

Source: Robert Lowes, Medscape News [1/5/12]

Query: Alcohol Sclerosing Injection Complication
 
I recently treated a 38 year old healthy female patient without known allergies and with neuroma-like symptoms. I completed a series of 7 injections using 4% alcohol sclerosing solution. There was minimal improvement in pain from the injections. The patient reported some burning and itching with the first injection and there was a light discoloration of skin in the injection site.  

Alcohol Sclerosing Injection Complication

The other injections were unremarkable except for the last injection when the patient reported more severe burning and itching to the area with "bubbling" of the skin and darker discoloration of the skin.  The burning, itching, and "bubbling" has subsided since then, but the skin is still discolored. Has anyone else had a similar experience to this? 

Charles Baik, DPM, Tustin, CA

Query: Starting a Solo Private Practice

I would like the opinion of PM News readers as to whether or not they feel a young podiatrist can still start a private practice and be successful? Is there going to continue to be a place for stand-alone podiatrists among the larger hospital-based groups? If so, what would the readers consider the minimal dollar amount needed to start and keep the practice afloat until its collections allowed it to be self-sustainable?

Name Withheld, Chicago, IL

RE: Doppler Study for Diabetics (Ron Werter, DPM)
From: Lee C. Rogers, DPM 

Trauma with subsequent edema can cause a compartment syndrome-like condition, especially if there is already reduced arterial pressure.  Even if just the venous side is compressed, the backup of pressure through the capillary system can lead to impaired perfusion and cause gangrene. Yes, pedal pulses are a poor indicator of good flow.

Every diabetic with an ulcer deserves at least a non-invasive test to uncover silent ischemia. But the problem with your endocrinologist's rationale is that they're suggesting NIVS as screening for all diabetics. The tests are not reimbursed for screening and would not likely be cost-effective until there is a trauma, ulcer, or otherwise.

Lee C. Rogers, DPM, Los Angeles, CA, lee.c.rogers@gmail.com

RE: Nursing's New "Doctors"
From: W. David Herbert, DPM, JD

My wife has been a nurse educator for nearly twenty years. I have followed with interest the evolution of nursing education and its latest titles and certifications. A few years ago, the Doctor Of Nursing Practice (DNP) degree was introduced, I believe, at Columbia University. I understand that there are 120 of these programs today, including several on-line.

These individuals are now "Doctors." I believe it is wise for podiatrists to firmly establish themselves as physicians and surgeons of the foot or as licensed medical specialists. I believe this is more important than worrying about the actual scope of practice at this point in time.

W. David Herbert, DPM, JD, Billings, MT, herbert.dpm.rn@gmail.com

RE: Bone Mineral Density Testing (Sloan Gordon, DPM)
From: Elliot Udell, DPM
 
Dr. Gordon cites the use of a peripheral bone density test, which studies the calcaneous instead of the gold standard which studies the hip and spine to determine if a patient has osteoporosis and may warrant systemic treatment. Devices which use the calcaneus have been around for a while, but should we be sending our patients for this test in lieu of the gold standard? In the paper, he quotes from "Precision and Discriminatory Ability of Calcaneal Bone Assessment Technologies" by Greenspan, et al. They studied a fairly small number of patients and concluded that the calcaneal devices compared well with the hip and spine tests; however, the authors state at the end of the paper the following: "...future studies are needed to determine whether these techniques can be used to monitor disease progression or response to therapeutic intervention."
 
Other papers published reached similar conclusions and also call for more studies to determine if the calcaneal studies are as good a test as the gold standard, hip and spine test. Osteoporosis is a serious disease with systemic clinical ramifications. In our practice, we send patients to radiologists for the gold standard test which studies the hip and spine and, if the results are positive, the patients are referred to appropriate specialists for follow-up.
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Insurance Company Controls
From: Seth J Steber, DPM

The problem is that biomechanics has become an inexact science for most practitioners. Evaluations are subjective, and goniometers are rarely used as our profession has become more surgically oriented. We need to maintain our status as the biomechanics experts and stop losing ground to physical therapists, chiropractors, and shoe store scanners. In this era of evidence-based medicine, podiatrists should be providing objective gait analysis as a regular part of their practices. 

I agree that the schools seem to have been lacking in this department, and we cannot rely on them for the research. Affordable video and computerized gait analysis systems such as the Optogait can be used in the private office setting to objectively evaluate dynamic motion in gait, orthotic/bracing efficacy, and propensity for falls. We can and should provide evidence to insurance companies validating the positive effects of what we do every day.

Disclaimer: I own Incedo Orthopedics, LLC, the podiatric distributor for Optogait.

Seth J Steber, DPM, Lehighton, PA, contactus@incedoorthopedics.com

RE: Medicaid Change of Orthotics in NY (Barry Mullen, DPM)
From: Dennis Shavelson, DPM

Dr. Mullen is accurate about being in-network and being bound by contracts. When confronted with this exact situation, I successfully defended my evaluation, casting, prescription, and the eventual device I was representing.
 
My fee is based upon my custom diagnosis, treatment plan, the custom orthotic I generate, my ancillary program, and its monitoring. My analogy would be that whether I use wet films or digital ones, my fee is for my reading of an x-ray. We have allowed biomechanics to become a DME code and not a CPT code. In my analogy, when we bill 73620, we are getting paid for our expertise and not the film or developing process. Perhaps someday our code will be a technical component to biomechanical cases (L3000-TC) with an appropriate fee. Let the lab bill L3000 for our Rx.

Dennis Shavelson, DPM, NY, NY, drsha@foothelpers.com

RE: Doctors Feel Helpless Over Patients' Online Slams
From: Steven J. Kaniadakis, DPM

It's a harsh reality. However, the time is now for business practices to change. Hire an IT team, including an intern with a job title that includes "social networking" (under public relations in your business plan). It's better than having a community in your face "chatting" about you and your medical or business practices.

Steven J. Kaniadakis, DPM, St. Petersburg, FL, stevenkdpm@yahoo.com

SPACE AVAILABLE - NYC & LI

WANTED TO BUY - EQUIPMENT (MICROCASSETTE TRANSCRIBERS)

Want to buy Panasonic microcassette transcribers model RR-930 or other brands of microcassette transcribers. Please reply to paulajn@cox.net

ASSOCIATE POSITION - MARYLAND

Looking for 3rd associate. Must be personable, well trained and highly motivated. Great locations in Southern Maryland, including an Ambulatory Surgical Center. We currently have EHR, digital radiography, dispensing center and PADNet. Looking for immediate hire! Please send CV to: myfeetfeet@aol.com

ASSOCIATE POSITION - LONG ISLAND, NY

Full time associate position available with well rounded multi-office group on Long Island. Ideal position for July 2012 graduating third year resident who wants to practice and live on Long Island. Candidates must be board qualified or board certified, and well trained in all phases of podiatry including surgery, biomechanics, wound care and palliative care. Compensation includes salary,malpractice insurance, paid vacations and surgical incentives, with a future partnership opportunity available for the right candidate. Interested doctors are encouraged to submit their CV's in response to: mets724@gmail.com.

ASSOCIATE POSITION - SOUTHWEST FLORIDA

Immediate position for associate to partnership for a surgeon that is BQ/BC by ABPS. Must be PSR-24 or PM&S-36 trained. Excellent salary w bonus. Must be ethical, self-starter, hard worker. Willingness to learn/work as part of a team. Surgery Block time. Must be proficient in rearfoot/ankle surgery. Email CV, photo, LOI to: susmitad86@yahoo.com

ASSOCIATE POSITION - LAS VEGAS/HENDERSON, NV

Well-established 22 year practice in   Las Vegas/Henderson, Nevada seeking full-time associate. General podiatric care with moderate amount of surgery to be done in local hospital or surgery center. Competitive salary and benefits. Modern office in new area. Please respond by email to: lvfootandankle@gmail.com

ASSOCIATE POSITION - TAMPA BAY
 
Well-established, dynamic multi-doctor practice in the Tampa Bay, high-tech with EMR and digital x-rays. Sports medicine, surgery and potential partnership. No NH/ HMOs. Excellent hospital privileges. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle second to none. C.V. to  flpodiatrist@tampabay.rr.com

ASSOCIATE NEEDED - NORTHERN CINCINNATI, OHIO (FAIRFIELD)

Lead to partnership &/or buy practice. Well-established, reputable & successful (700K collection annual) 25+ year practice. Newer 2k sq.ft office condo & w/5 tx rooms, Aver.80 new patients monthly, full hospital privileges, DME, Padnet, digital x-rays. Inquires to email: gsherwood1@cinci.rr.com

ASSOCIATE POSITION - ALBANY/CAPITAL DISTRICT AREA

Immediate position available with generous salary, fringe benefits and percentage. All phases of Podiatry. For more information please contact Dawn at (518) 828-6516 or fax your resume to(518) 828-9510.

ASSOCIATE POSITION - EAST TENNESSEE

30 year old practice with 5 offices in greater Knoxville area seeking ethical, personable, hardworking, team player. $160,000 base salary with bonus incentives and benefits. Post-residency experience a plus. Please send resume to ddavidphawk@yahoo.com
 

ASSOCIATE POSITION - NAPLES, FLORIDA

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills to join multi-office practice. Hospital privileges available at 648 bed hospital system, 200 bed hospital system and multiple surgical centers. Candidate should have the skills and desire to perform rearfoot/ankle surgery. Florida has a great scope of practice law and we rotate for ER call. Candidate needs to be ethical and motivated. Established practitioner or new practitioner. In a cover letter tell me why you should be selected for the team. Email cover letter and CV with subject line "I am your new team member." to:  Drgordon@gulfcoastfootcare.com

ASSOCIATE POSITION - CENTRAL VALLEY/SOUTHERN CA

Seeking associate with partnership availability. Must be highly motivated and have good patient skills and personality. Salary excellent with all paid benefits/incentives including malpractice/401k and profit sharing. Compassionate and well-trained for immediate position. Surgery Center and hospital-based with no HMOs/no rest homes. Bilingual in English and Spanish preferred. Offering a permanent position/partnership in a multi-million dollar hi-tech practice with Partnership also in Surgery center. Please e-mail CV and short bio to: Tonya@wetreatyourfeet.com

ASSOCIATE POSITION - HAWAII (OAHU)

Full-time position available. Join this fantastic practice in paradise. Diagnostic ultrasound, Digital X-Ray, EHR, Surgical Privileges, Competitive Salary plus benefits package. Send CV to:  yoleven316@yahoo.com.

ASSOCIATE POSITION - NAPLES, FLORIDA

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills to join multi-office practice. Hospital privileges available at 648 bed hospital system, 200 bed hospital system and multiple surgical centers. Candidate should have the skills and desire to perform rearfoot/ankle surgery. Florida has a great scope of practice law and we rotate for ER call. Candidate needs to be ethical and motivated. Established practitioner or new practitioner. In a cover letter tell me why you should be selected for the team. Email cover letter and CV with subject line "I am your new team member." to   Drgordon@gulfcoastfootcare.com

PART-TIME PODIATRIST NEEDED - LOS ANGELES, CALIFORNIA 

ASSOCIATE POSITION - CENTRAL VALLEY/SOUTHERN CA

Seeking associate with partnership availability. Must be highly motivated and have good patient skills and personality. Salary excellent with all paid benefits/incentives including malpractice/401k and profit sharing. Compassionate and well-trained for immediate position. Surgery Center and hospital-based with no HMOs/no rest homes. Bilingual in English and Spanish preferred. Offering a permanent position/partnership in a multi-million dollar hi-tech practice with Partnership also in Surgery center. Please e-mail CV and short bio to: Tonya@wetreatyourfeet.com

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