The Voice of Podiatrists

Serving Over 10,600 Podiatrists Daily

January 23, 2008 #3,148 Editor-Barry Block, DPM, JD

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"Every wound doesn't fit every algorithm” FL Podiatrist

For Tamara Fishman, DPM, when it comes to treating wounds, the best way is the old-fashioned way. A podiatrist, Fishman sees patients with ulcers on their feet and legs, and, as one might expect, about 75% of her cases are diabetes-related. .

Dr. Tamara Fishman

Rather than follow evidence-based protocol, Fishman prefers to rely, first and foremost, on her own judgment. "There are multiple options in dealing with wounds. First, of course, you look at it. Does it appear infected? Is it red, hot, odorous or draining? Does it need debridement? What about systemic factors—does the patient have nausea, chills, or shakes?" Fishman notes.

Although Fishman is not one to strictly adhere to evidence-based protocol—"I never followed a pathway"—she does give it credence for providing guidelines."I do attend to the basics that are always part of an evidence-based approach, such as checking for infection, circulation problems, debridement, and so on." But that's where it ends for Fishman, because "every wound doesn't fit every algorithm. There's a person attached to the wound who has lifestyle issues, financial issues, social and behavioral issues, and, of course, physical issues. One plus one doesn't always equal two," she says.

Source: Alan Ruskin, Rehab Management [January/February 2008]

Biggest Show on Feet to Draw “Standing Room Only” Crowd!

It’ll be standing room only for the country’s biggest show on feet from January 25 to 27, 2008 at New York’s Broadway Marriott Marquis. Bringing Down the House, the Foundation for Podiatric Medicine’s three-day conference and exhibition has more exhibitors and more sponsors than any show in the organization’s history. According to Dr. Edward A. Buro, president of the Foundation for Podiatric Medicine, one of the hottest topics this year is a Podopediatric and Biomechanics Track to help podiatrists better assist young people with an assortment of foot abnormalities and conditions.

Dr. Edward A. Buro

But that’s not all that’s in store. “The prevalence of diabetes in our culture continues to dominate the media and Bringing Down the House is packed with valuable information to help podiatrists diagnose and treat this nationwide epidemic,” says Dr. Buro.

The American Academy of Sports Medicine Track is designed to get podiatrists in shape for the increased demand for foot-related services. Young Members are an important part of NYSPMA and their issues will be attended to at an American Podiatric Medical Association ( APMA)-sponsored special session.

Physician Gifts Removed by Health System as Part of New Policy

SMDC Health System, which operates four hospitals and 17 clinics in Minnesota and Wisconsin, recently removed all promotional gifts from pharmaceutical companies from the facilities -- a move that "underscored SMDC's decision to join the growing movement to ban gifts to doctors from drug companies," the AP/Washington Times reports. SMDC -- which collected 18,718 gifts, such as pens, notepads, coffee mugs and other items with logos for medications -- plans to send the items to a health system in Cameroon. In addition, SMDC implemented a comprehensive conflict-of-interest policy that bans gifts from pharmaceutical companies and limits access to physicians and other health care professionals by company sales representatives.

Kenneth Irons, chief of community clinics for SMDC, said, "We just decided for a lot of reasons we didn't want to do that any longer." According to a study published in the Journal of the American Medical Association in 2006, gifts from the pharmaceutical industry to physicians can influence medical decisions. Marcia Hams, assistant director of the project, said that she hopes other health systems follow the example of SMDC. Hams said, "This seems like a pretty aggressive way to kick off a policy," adding, "It sends an important message, I think, for how a strict policy can be implemented in an effective way." Ken Johnson, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said, "I've never seen nor heard of a systematic roundup of pens and coffee mugs before," adding, "It's a bit draconian."

Source: AP/Washington Times, [1/20/08] via American Health Line [1/22/08]

Query: Painful Erythematous Toes

I have a 33 y/o female patient that c/o pain, redness, and swelling on the distal tips of her b/l 2nd toes x 8 months. Pain only occurs in the morning and gradually lessens as the day goes on. She denies any tight-fitting shoes or Raynaud's type symptoms. PMH-none, PSH-b/l carpal tunnel release, meds and allergies-none. No ETOH or tobacco. Her grandfather has a hx of gout.

On exam there is mild erythema and edema to the distal 2nd toes b/l. Pulses +1/4 DP b/l, +0/4 PT b/l. CFT is immediate.There is no hammering of the toes. There is minimal tenderness to palpate the affected toe tips. X-rays are normal, as are ABIs and toe pressures. Her shoe length is adequate. I have placed her on an aspirin qday in the event this may be a mild/early erythromelagia. Any other thoughts would be appreciated.

Judd Davis, DPM, Colorado Springs, CO

Query: Reimbursement for Topaz Procedure

I was intrigued by the statement in the article “Topaz Procedure More Successful Than Open Heel Surgery” that the radiofrequency ablation procedure on the plantar fascia was "covered by most insurance plans." Since a radiofrequency ablation procedure on the plantar fascia would be billed as CPT 28899, unlisted foot/toe procedure, I was wondering what doctors are doing to convince "most payers" to reimburse the procedure? Do you send a letter of explanation with the claim and op report? Do you send in published studies documenting its effectiveness? Do you get denials, but win on appeals? For those performing radiofrequency ablation procedure on the plantar fascia, are you also finding most payers are reimbursing the procedure (CPT 28899)?

Harry Goldsmith, DPM, Cerritos, CA

Query: Amerigel Coding

What is the proper modifier to an Amerigel pad covering an ulcer or any 1st layer covering? I know this is billed to Medicare DMERC, but am not sure of the appropriate modifier.

Harry E. Confer, DPM, West Covina, CA

Response: A6231 (gauze, impregnated, hydrogel, for direct wound contact, pad size 16 sq. in. or less, each dressing) is the correct code for Amerigel Wound Pad. If there is only one wound, then use the "A1" modifier; if there are two wounds, then use the "A2" modifier; if there are three wounds, then use the "A3" modifier; etc. You must also document that the ulcer is at least full-thickness or greater (Wagner II or higher), or the supply will not be covered.

Bear in mind that each HCPCS code and the amount to be dispensed is covered in the local coverage determination (LCD). If you expect that a patient may only have the medical necessity for the surgical dressing for one month, you may only dispense one month's supply.

The reimbursement does vary minimally from state to state, and is $4.66 in NY and $4.68 in California.

Paul Kesselman, DPM, Woodside, NY

Editor's Note: Dr. Kesselman is a featured speaker at Codingline's New York Strictly Coding Meeting. Click on www.codingline.com/events-ny.htm for details and registration information.

RE: Bromidrosis (Melissa Gaffney, DPM)
From: Mike Boxer, DPM, Robert D.Teitelbaum, DPM

The odor in bromidrosis does not come from the foot. The odor is caused by bacterial action on the shoe leather. The moisture from the foot wets the leather and that starts the bacterial action. As soon as the foot is placed in the shoe it picks up the odor from the leather. To rid the shoe of the odor try Bromi-Talc Plus (Gordon Laboratories). Bromi-Talc Plus (not Bromi-Talc) contains Abscents, a potent deodorizing agent. If it does not get rid of the odor in the shoe, the footwear needs to be discarded. Keep the feet dry with new shoes and the problem will be solved.

Mike Boxer, DPM, Woodmere, NY, MCBDPM@aol.com

About fifteen years ago one of my daughters developed a bromhidrosis that was quite startling. On car trips, if she took her shoes off for a minute, everyone else knew what was going on and was yelling to her to put her shoes back on. She never had any tinea, eczema, pruritus, allergic reactions, etc. The skin and interspaces of her feet were completely normal. We tried several OTC antifungals to no avail. I figured that with up to 30 different microorganisms inhabiting some people's feet, I developed this treatment: I filled a basin up with a five to one water to bleach solution where she soaked her feet for five minutes only. This "flat-lined" the flora to a point where the regrowth that was expected resulted in a combination of bacteria/fungi that simply did not produce that odor.

A few months later the problem reoccurred, and she repeated the process. We haven't yelled at her for the past fifteen years.

Robert D.Teitelbaum, DPM, Naples, FL, mfvandange@aol.com

RE: Resistant Verruca (Richard Burnell, DPM)
From: Multiple Respondents

I like to use a combination of what was stated. I do not feel any method of wart treatment is effective with a foot that has hyperhidrosis present. I will first use Drysol solution or any of the other methods mentioned. I then use an air injector with Bleomycin. I cannot remember a patient that did not respond to this method.

Barry A. Wertheimer, DPM, Redondo Beach, CA, feetfixer@cox.net

Try using Catharidin(in collodion) applied to the area. If 1 lesion then in addition to the Cantharidin apply a donut hole 1/8" felt pad and fill with Salinocaine. The hole in the felt should be the same size as the lesion. Cover with tape. Have the patient remove the dressing after 48 hours and start soaking in concentrated tea solution 15 mins. twice daily. This will help to dry out the blister. See the patient in 2 weeks and if necessary I & D the blister. If any residual wart, repeat process. You may need to medicate for any pain. I have used this method successfully over and over!! (P.S. if there is any callus over the wart shave the callus till pin point bleeding observed, cauterize with Styptocain)

Dan Klein, DPM, Fort Smith, AR, TOEFIXER@aol.com

I have used autoimmunization in resistant cases. This is a procedure where you harvest a piece of the verruca, make a small incision near the abductor hallucis muscle, then re-implant the verruca into the muscle belly. The body then responds against the verruca and...voila...the warts go away. I do have an article that explains the procedure step-by-step if you are interested. It is a very straight-forward procedure that seems to work well.

David B. Williams, DPM, El Paso, TX, drdave@elpasofootcare.com

ASSOCIATE POSITION - VIRGINIA (SOUTHERN)

Immediate full-time and part-time associate position 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 dcarrone@cox.net fax to 757-397-5889

PARTNER WANTED FOR GROUP PRACTICE LOCATED 1 1/4 HOURS NORTH OF NYC

We can interview prospective partners at the NY Clinical Conference this coming Friday, Sat & Sunday. Feel free to call Dr. Hudes cell at 845-807-8864 to set up a meeting or respond to: mhudes@footcaregroup.com

ASSOCIATE POSITION - ILLINOIS

Excellent opportunity for ethical & personable hard-working individuals to join a busy multi-office two physician practice. Looking for one podiatrist with interest in conservative care, including sports medicine and one podiatrist trained in rearfoot surgery. Rearfoot surgeon must be board eligible and working toward board certification. Competitive salaries, 401-K, health insurance, paid vacation and more. Please forward CV with references to nrussell@neondsl.com

PRACTICE FOR SALE - SOUTH CAROLINA

Step into a high volume, high grossing practice. 60% routine foot care, 40% surgery. Several nursing homes. Plenty of opportunity for growth. Hospital and Surgery Center privileges. Financials available upon request. Serious inquiries only! Beautiful area. Contact: Carolinafootdoctor@yahoo.com

ASSOCIATE POSITION – NEW JERSEY

Established practice in Ocean County seeks hardworking, ethical, energetic and well-trained (PSR 24/36) individual. Practice provides EMR, digital x-rays, ultra-sound and NCV’s. Must be willing to do all aspects of podiatry! Competitive salary and benefits package. E-mail CV to NJFeet@aol.com

ASSOCIATE POSITION - NEW YORK CITY

Excellent opportunity for foot/ankle surgeon, Manhattan and Brooklyn Associate position leading to possible partnership. Requirements: Two years enrollment in a surgical residency program Qualities of self-motivation and impeccable skills in forefoot and rear-foot surgery. Package Includes: Malpractice insurance, Health Insurance plus salary, Incentives. Terms negotiable Email CV to Manfootcare@aol.com 212-349-7676

SEEKING ASSOCIATE WITH POTENTIAL TO FULL PARTNER

Busy multi-physician podiatric group with 2 locations seeking BQ/BC surgically trained doctor. Applicant should be well-trained in all aspects of surgical and conservative care. Seeking ethical, hard working and outgoing physician to join our 4-physician group. Excellent quality of life in suburban Houston, near NASA and the Gulf of Mexico. Email CV and cover letter to Dr. M. Rockett at Mrockettman@comcast.net.

INTERVIEWING AT NEW YORK CONFERENCE: JAN 25-26TH

Looking for well-trained (PSR- 24/36) personable, energetic practitioner to join multi-office practice in the beautiful Hudson Valley. Well-rounded practice including general podiatry, high volume orthotics, and reconstructive surgery. Outstanding opportunity to work into partnership. Competitive starting salary, bonus incentives, benefits, and pension. Submit: CV, letter of intent and references to: footassociate@yahoo.com

Unique & rare opportunity for a Japanese-bilingual podiatrist. Seeking motivated, conscientious, and ethical individual with excellent people skills for associate leading to ownership or a buyer for immediate purchase. No nursing homes & well-established referral base. Serious inquiries only. E-mail letter of introduction, photo and CV to: socaldpm@gmail.com

ASSOCIATE POSITION- CONNECTICUT

Established Practice looking for PSR 24/36 trained surgeon. Must have experience and be responsible for all surgical cases for the
practice. EMR and digital x-ray in new 6-treatment room office.
Hospital privileges available. Connecticut has a new ankle law for the
Properly-trained DPM. Competitive salary, benefits, and bonus. Great area to raise a family. Fax resume to 860 243-5790

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com -- www.homephysicians.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

PRACTICE FOR SALE - SOUTH CAROLINA

Upstate SC practice of 25 years. Retiring. High volume, high grossing. 60% routine foot care, 40% surgery. Several nursing homes. Plenty of opportunity for growth. Hospital and Surgery Center privileges. Financials available upon request. Serious inquiries only! Beautiful area. Contact: Carolinafootdoctor@yahoo.com

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 – VIRGINIA

Must have Virginia license. Requires 24 to 36 month Residency. Permanent position with potential buy in. Includes all phases of Practice excluding nursing homes. Competitive Salary and Benefit package. Please send Resume including salary requirements and availability date to needpodjob@yahoo.com

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