The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

January 20, 2010 #3,758 Publisher-Barry Block, DPM, JD

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NY Podiatrist Headed to Haiti

Haitian born Dr. Patricia Nicholas, who practices in Wading River, NY is on her way to Haiti to assist with relief efforts.  Dr. Nicholas, who came to the U.S. from Haiti at the age of fourteen, is a member of the New York State Podiatric Medical Association (NYSPMA) and on the board of The Caribbean Medical & Scientific Association (CAMSA).  

Dr. Patricia Nicholas

“I could not see those images on the television and not go to Haiti,” said Dr. Nicholas. “The need is so great, and the time for action is now.” Because Dr. Nicholas, the mother of three children, is fluent in the French dialect commonly spoken in Haiti, she hopes to be an asset to the medical teams who are working around-the-clock delivering medical supplies and care to the thousands affected by last week’s devastating earthquake. 

Dr. Nicholas is reaching out to her fellows podiatrists for donations of medical supplies. Funds are being collected via the CAMSA website at www.camsa.org.

Ultrasound Guiding Means Fewer Injections: MO Podiatrists

When patients don't respond to more conservative measures, podiatrists Jody McAleer and Bill Duke use a combination of a numbing agent and a steroid. But the key to making the treatment work is the way it's now delivered, the doctors said.

(L-R) Drs. Jody McAleer and William Duke

An ultrasound machine helps the doctors see the inflamed ligament and place the injection where it can do the most good. McAleer and Duke said the approach has paid off with patients requiring fewer injections. "We're seeing more and more patients coming in after one singular injection saying, 'I'm 70 to 90 percent better. I'm fine now and I feel much, much better,'" McAleer and Duke said.

McAleer and Duke compare that to the traditional "blind" method of placing injections, where doctors feel their way to the right spot. They said that previous patients required two and three injections and might also need additional treatments. They recommend the injections along with stretching exercises. They said that if one shot doesn't work, a second injection may be needed. Then they look at adding orthotic devices in the shoe, physical therapy, platelet injections, and surgery.

Source: Teresa Snow, KRCG, [1/18/10]

Editor's Note: PM News is proud to present excerpts from Meet the Masters.

Bret Ribotsky: What method do you advise podiatrists to use to document patient care?  

Richard Boone, Esq.

Richard Boone: I don’t care whether the doctor chisels his notes on a stone tablet, scribbles them on the back of a grocery bag, or what have you, as long as the notes are complete, consistent, and they tell a story that justifies what s/he was doing and the outcome s/he received. I probably have seen every kind of record you can imagine. If they are complete, consistent, and they explain what happened, then I can live with them. Would I prefer something that is nice and neat and tight? Sure, it makes it easier for me to read.

Dr. Adam Landsman

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). This week's show features famed researcher Adam Landsman, DPM, PhD. of Harvard Medical School. You can register for this event  by clicking here

Query: Hallux Limitus/Rigidus Implants

Approximately 6 months ago, I inserted an Arthrex- "Anatoemic Proximal Phalanx Hemiprosthesis" into a healthy and active 58 year old woman. The indications were moderately painful hallux limitus with degeneration of the proximal phalangeal articular surface and the dorsal fourth of the articular surface of the first metatarsal head - with DJD surrounding the periphery of the met head articular surface. Intra-operative ROM and correction were good. Presently, she complains of limited range of motion of the joint with pain (4/10), and discomfort in any shoe with more than a very slight heel raise. She now has 30 degrees active dorsiflexion/ 16 degrees plantarflexion of the MPJ.

Hallux Limitus Implant

After physical therapy, shoe modification, orthotics, topical and oral NSAIDs, and exhausting conservative treatment, I referred the patient to an orthopedist for a second opinion. He suggested several surgical options - preferring a fusion of the MPJ. What specific hemi or total first MPJ implant will gain the maximum range of motion in the MPJ? Would removing more of the proximal phalanx base and re-inserting the same implant create better ROM? 
 
Craig Aaronson, DPM, Fresno, CA

Query: Practice Websites

We're interested in positive or negative experiences by podiatric physicians in setting up and maintaining a practice website in terms of cost, efficiency, and visibility on search engines, etc.

Mark K. Johnson DPM, West Plains, MO

Query: Billing Unrelated Care in Post-Op Period

I treated a Medicare patient for a 3rd metatarsal fracture left foot and casted her. Two weeks later, she came back to the office with a very swollen right foot. It was not painful or infected. My assessment was edema secondary to the compensation for the left-sided fracture.

I billed Medicare for the office visit - CPT 99212-25, thinking they might bundle it with the fracture. That is what they did anyway. So I resubmitted it as CPT 99212-79. It was again rejected. They told my office manager that it needs a "major" modifier. Any suggestions?

Bob Kornfeld, DPM, Manhasset, NY

Response: Presuming you billed for fracture care, you would be in the global period for post-op care related to that treatment. The "-25" modifier would be appended to an E/M code if you had a "minor" procedure on the day that patient came in for the problem on the other foot. That wasn't the case, though.

The patient came in with an unrelated problem that required a work-up. The E/M service would be payable with a "-24" modifier.

You would not append a "-79" modifier to an E/M code.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found at:
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RE: Corticosteroids (Michael Forman, DPM)
From: Stanton C. Southward, DPM

I've been using Celestone Soluspan for many years and have had no problems. I can count on getting positive results with its rapid and long-lasting effects. My only difficulty with Celestone is when I review the invoice from the supplier; but this expense has to be covered in the injection fee.

Stanton C. Southward, DPM, Colorado Springs, CO, sbsouthie@comcast.net

RE: Custom Orthoses vs OTC Study (Dan Preece, DPM)
From: Allen Mark Jacobs, DPM

The Cochrane database of systematic reviews had examined studies on the utilization and efficacy of othotics. This is available at the Cochrane database of systematic reviews, Hawke, et al.;(online) (3) pp CD006801. There is evidence from appropriate studies that orthotics are useful for the management of pes cavus, plantar fasciitis, hallux valgus, and foot pain.
 
In addition, the use of orthotics for the management for plantar fasciitis (as well as other modalities) has been reviewed by Crawford and Thompson, Cochrane database of systematic reviews (online) (3) CD000416.
 
Allen Mark Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net

RE: Limitation of Privileges (James Breedlove, DPM)
From: Multiple Respondents

Ask your medical staff liaison for a copy of the credentialing requirements for the ortho department.  You may be shocked if it doesn't have 3 (or fewer) boxes for equivalent surgical credentialing: ankle surgery, foot surgery and digital surgery (which may be included in foot), whereas it is not uncommon for podiatrists' credentialing forms to have multiple pages of procedures to check off.  This adds up to having to do more procedures to remain competent if you have to show competence in EVERY category on your delineation request. I would ask to be credentialed in a similar manner that all foot and ankle surgeons at your facility are credentialed.    
 
Jeffrey M. Dull, DPM Bay Minette, AL, premierfoot3991@bellsouth.net

I had the same problem in CA. Apparently, with JCAHO now, board certification means nothing. If you haven't operated on the appropriate number of neuromas (or whatever) in the last few years, you become neuroma incompetent. Is this new rule based on JCAHO research proving surgeons brains go blank after a few years, or is this just a new make work project for JCAHO? If not based on research to prove physician incompetence, JCAHO needs to be sued for capricious trade restriction. I had to perform a number of surgeries in the office to prove competence to the hospital to get privileges, which proves I don't need a hospital for many of the procedures I perform.
 
Paul Kruper DPM, Kingsburg, CA, prkruper@yahoo.com 

It is standard protocol for a hospital to ask how many of a particular procedure you performed, when granting privileges. I am sure it originated from some type of lawsuit, but is, in my opinion, a very reasonable request. If you haven't done a case in over 8 years, they probably wouldn't deny you privileges, but may require someone to scrub in or observe you.
 
If you haven't done a case in over 8 years, I wonder how often it will even be a factor. After 8 years, it seems like a good idea to have someone more familiar with the procedure be with you anyway. Just playing devil's advocate, I wouldn't want someone operating on me who hasn't done my procedure for 8 years either!  As everyone else is, in today's times, your hospital is just covering itself. I have never heard of someone being denied hospital privileges because of one particular procedure not being done frequently.
 
Brian Kashan, DPM, Baltimore, MD,  drbkas@worldnet.att.net

RE: Surgery and Podiatry (Peter Bregman, DPM)
From: Kenneth Meisler, DPM, Barry Drossner, DPM

I too understand why residents often want to have a surgical practice. Most truly enjoy being a podiatric surgeon. I too enjoy surgery. When one of my patients presents a few years after surgery with an excellent surgical result, I still get as excited as I did when I started practice more than 30 years ago. However, almost as enjoyable is that patient who comes back a few weeks or months after their first visit saying that the metatarsal pads I gave them have totally relieved their neuroma pain without even an injection. Or the patient who expressed a sigh of relief when I told them they didn't "need" the bunion surgery another doctor told them they should get. How about the runner with severe plantar fasciitis who is running again without pain from just stretching, taping, heel cushions and a night splint?  These patients are thrilled to have avoided surgery or unnecessary injections.

I frequently have students, residents, or practicing podiatrists visit my office at which time I show off my excellent conservative treatment with as much pride as I do my great Lapidus results. I think excellent conservative care is a part of practice that residents do not always see or appreciate.

Kenneth Meisler, DPM, New York, NY, kenmeisler@aol.com

You should practice what you enjoy doing and what gives your patients the greatest benefit. It is quite unfortunate that surgical reimbursements are not higher, but this is a global issue affecting all surgical specialists. If we claim that podiatrists are the most qualified foot care experts, it would be counterproductive to our profession to limit our surgical treatments because the payments are not what we expect. Podiatrists should continue, when appropriate, to showcase their skills in the operating room to all of the ancillary medical personnel and other specialists who observe and assist us. This is how we will continually elevate the status of our profession. The reimbursement issue is a political one that all surgical specialists should address with Congress via their national organizations.

If we only look at the bottom line to determine what treatments to perform, we will allow other non-DPM surgical specialists to claim to be the "real foot surgeons." We have come too far to allow this to happen. We are a small profession which is to our disadvantage. Money talks and everything else walks! This is why we must collectively increase our donations to APMAPAC. The entire medical profession must push hard for fair and just compensation for both surgical and non-surgical procedures. Admittedly, this will be a challenging task.

Barry Drossner, DPM, Aventura, FL, bdroz50@aol.com

RE: New Balance TV Ads (Allen Mark Jacobs, DPM)
From: Doug Milch, DPM, Howard J. Bonenberger, DPM

In general, I hate regulations and certifications. But it now seems like the orthotics industry needs to be regulated. Differentiation between custom-made orthotics and off-the-shelf products needs to be clear to the public. Good Feet inserts are OTC inserts sold at custom prices and consumers are getting ripped off because they think an orthotic is an orthotic and don't know the difference.

Anyone can make an orthotic and call it a custom orthotic. Without proper training, people who make orthotics can actually hurt people with improperly made devices. They can just take advantage and rip off a patient.

I needed to pass several tests to become a podiatrist. I needed to pass a test to get a driver's license. But anyone can make orthotics. I don't know how regulation of orthotics will occur, but it seems that there should be some type of proof of proficiency before "practitioners" are let loose to make orthotics for the general public. Something just isn't right.

Doug Milch, DPM, Asheville, NC, ldmilch@charter.net

PRACTICE FOR SALE - NEW JERSEY

Part-time practice for sale. Located in Bloomfield, NJ. Great location in professional building. All modern equipment including digital x-ray. Please contact doccapo@yahoo.com

PRACTICE FOR SALE - CENTRAL FL

Practice and medical building for sale, in beautiful, high quality of life, growing area, Central Fl.; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion & investment; good insurance climate. 352-223-2713 / E-mail: windnwave@earthlink.net

ASSOCIATE POSITION FULL-TIME - SUBURBS OF CHICAGO

PSR 36 - month-trained podiatrist needed for busy suburban Chicago practice. Full benefit package included. If interested, please email your curriculum vitae to foot1st@yahoo.com

ASSOCIATE POSITION - MARYLAND (Kensington/Rockville/Silver Spring) 

If you are a graduating resident in July, or an esablished practitioner, and you are enthusiastic, personable, motivated and well-trained, we would be delighted to discuss an associate position, in our group, with you. Established practitioner relocating. 5-doctor, 3-office practice with significant patient flow already in place to keep you busy from the start! All the bells and whistles-EMR, digital x-rays, ultrasound, computerized scheduling, certified ambulatory surgical centers, hospital and physician referral base. Please send cover letter and resume to mddpmassociate@comcast.net We look forward to hearing from you.

PRACTICE FOR SALE – MAINE

20+ years, full scope, turn-key practice in the same medical building location. Podiatrist-friendly hospitals just down the street, wonderful, appreciative and cooperative patients await. Excellent expansion potential. Maine offers an enjoyable life style, recreation abounds, reasonable housing costs, excellent school systems, low crime rates. Colleges and universities nearby as are cultural opportunities. Retiring seller will stay for transition. Please contact: mainefootdoc@yahoo.com

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes. Top hospitals. Fax CV with references to 703-491-9994

ASSOCIATE POSITION – ILLINOIS

Quality Podiatry Group provides quality services to residents at long term care facilities. We are currently offering full-time or part-time positions for motivated ethical podiatrists. Immediate openings are available. If interested, fax curriculum vitae to 847-674-2113 or e-mail to feetwork@aol.com

ASSOCIATE POSITION - MASSACHUSETTS

PSR-24 trained podiatrist for busy multi location practice, high volume and high-tech. Seeking energetic individual for high volume of patients with multiple needs. Orthopedic, sports medicine, wound care, pediatric orthopedics and surgery skills required. Looking for immediate hire for the right candidate with possibilities for partnership. Contact Debbie Roberts debbierobertsm4@hotmail.com

ASSOCIATE POSITION – NORTH AND CENTRAL FLORIDA

Quality Podiatry Group of Florida provides quality services to residents at long term care facilities. We are currently offering full-time or part-time positions for motivated ethical podiatrists. Immediate openings are available. If interested, fax curriculum vitae to 847-674-2113 or e-mail to feetwork@aol.com

ASSOCIATE POSITION - SOUTH FLORIDA

Ft. Lauderdale/Miami office locations seeking associate leading to partnership for the right person. Active modern busy practice needs help. Competitive salary + benefits + incentives. Send resume to podiatrydoctor@aol.com

ASSOCIATE POSITION – TEXAS

Dynamic, growing practice in Dallas/Fort Worth area, seeking surgically trained, Board Certified/Board Qualified Podiatrist. Excellent salary and benefits compensation package, for the right candidate, with partnership/buyout opportunity. Contact/Send resume to: jmh6122@yahoo.com

ASSOCIATE POSITION IN WESTERN NORTH CAROLINA
Well diversified growing podiatry practice with good mix of office, surgery center and hospital procedures seeking a full-time associate. Must have NC license or taking state exam this year. Candidates should have excellent bedside manner equal to their medical skills. E-mail a cover letter and CV to DPMCAREER@AOL.COM

PRACTICE FOR SALE - ALABAMA, GULF COAST

26 year old practice for sale. Owner desires to sell. Practice operated 25 hours per week. Surgery and general podiatry. MD referrals. Surgery center and hospitals in close proximity. Highly profitable. Priced to sell. Seller will lease office to buyer. Contact Mike Crosby at 1-888-776-2430 or mcrosby@providerresources.com

ASSOCIATE POSITION – CINCINNATI, OHIO

This is your once in a lifetime opportunity to join one of the most successful practices in the United States. We do not have a seniority system. If you are motivated and have completed a PSR 24-36 residency, your income is limited only by your enthusiasm and desire to achieve. Email resume to khart@cincinnatifootcare.com

PRACTICE FOR SALE - TENNESSEE

Well established practice for sale. Full scope medical and surgical practice including DME. Exceptional practice with a high volume of new patients. Excellent hospital and surgical center privileges with investment opportunity. Great area for a family and the outdoorsman. 731-446-7285/E-mail nraines@charter.net

ASSOCIATE POSITION - MINEOLA, NEW YORK

Full-time associate position with future partnership potential available with busy multi-office practices on Long Island. Must be proficient in all phases of podiatry with emphasis on surgery, biomechanics and RFC. Minimum standards include either a three-year PSR, or board qualified/certified status with ABPS. Existing hospital privileges with a NY based facility helpful. Interested doctors are encouraged to e-mail their CV to mets724@gmail.com

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

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