The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

January 24, 2007 #2,792 Editor-Barry Block, DPM, JD

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V.A.C. Study Suggests Real Benefit For Diabetic Wound Healing: Armstrong

The following is excerpted from an Interview of David Armstrong, DPM, PhD, Director of the Center for Lower Extremity Ambulatory Research at Rosalind Franklin University of Medicine and Science.

Ivanhoe: Can you tell me about your research on the V.A.C. device?

Dr. Armstrong: In the study, we compared severe diabetic foot wounds in people who needed part of their foot amputated. These were very large wounds. Some patients got very high quality standard of care, and others got the V.A.C. device. People who got the V.A.C. device were more likely to heal than those who did not get the V.A.C. device. It was a 16-week study, so relatively short.

Dr. David Armstrong

Interestingly, when we exercised the suggestion, fewer people there actually lost their legs. In fact, all high-level amputations were conducted on the control group, not the people who got the V.A.C.. In other words, the V.A.C. did seem to suggest a real benefit. I think future trials will have to confirm or refute that. I think it's very promising.

Source: Ivanhoe Broadcast News [1/22/07]

Salsa Dancing Good for Feet: CT Podiatrist

Salsa consists of a mixture of African rhythms and European music that first appeared in the United States in the 1950s. While Puerto Rico is considered the salsa capital, salsa continues to be popular throughout the world. Dr. Jeffrey Gross, a Stamford podiatrist, feels the lessons are beneficial, not just for himself, but for his patients as well.

"Regular salsa dancing gives your muscles, joints, and bones a really good workout," said Gross, who lives in Danbury. "It can help delay the onset of osteoporosis and arthritis by keeping the joints mobile."

Source: Sandra Diamond Fox, The News-Times [1/20/07]

New Medicare Commission Proposed

Sens. Pete Domenici (R-NM) and Dianne Feinstein (D-CA) unveiled a plan to establish a permanent, independent commission called the National Commission on Entitlement Solvency to shape legislation aimed at preserving Medicare and Social Security. The 15-member commission would make recommendations to Congress about the programs one year after the law’s enactment and then every five years.

The proposal would set mandatory timelines for Congress to introduce legislation based on the commission’s recommendations, take committee action and schedule debate. “The solvency of Medicare and Social Security rank among the highest and most significant problems that face our nation down the line,” Domenici said. In 2006, 52.3% of federal spending, or $1.42 trillion, went to Social Security and Medicare, Feinstein said. That number is expected to climb to 60.4%, or $2.54 trillion, by 2016. Projected deficits will exhaust Medicare in 2018 and Social Security in 2040, according to the Social Security and Medicare trustees.

Source: Matthew DoBias, Modern Healthcare 1/22/07

Query: Hyaluronic Acid Injections 1st MTPJ for Hallux Rigidus

I would like to know if anyone has any experience in using hyaluronan injections (i.e., Synvisc, Supartz) off-label for hallux rigidus. If so, how many injections, how long between injections, and how many cc's do you inject?

Robert Fridman, DPM, New York, NY

Query: Subtalar Arthroresis

A 10 y/o little girl with bilateral flexible pes planus (PTTD) that was treated for two years with physical therapy, orthotics, an alteration in footwear, as well as rest. Her parents noted that in spite of the orthotics, it seemed that her feet were looking worse and she was complaining of more discomfort. Last November, I performed a subtalar joint arthroreis. The surgery went well and she and her parents are quite pleased with the appearance as compared to the non-operative foot. The pre-operative pain has completely resolved and she has returned to all activities. At her post-operative visit (60 day) I noted that she has a mild but flexible hammered hallux on the operative side. There is no limitation in STJ motion (i.e., normal ROM without the pathologic pronation). She can stand on her toes, and walk on her heels. I have started her in some physical therapy. Any thoughts?

Andrew H. Cohen, DPM, Saginaw, MI

Query: Removing Granulation Tissue

A patient presented with a bleeding second toenail without signs of infection. After debriding the nail back a little bit, there was a small granulation tissue "bud." I "nipped" (sterile tissue nipper) it out, dressing the digit, followed with advising the patient on soaks at home.

Is there a procedure code that could be billed for this, or is this included in the E/M service?

Charles Perry DPM, Cambridge OH

Response: When you state that you clipped the "nail back a little bit" and "nipped" out the granulation tissue, it appears, at least to me, that simple "procedure" would be included in the work-up and management of the presenting problem. Clipping back the nail, at least for the payers I am familiar with, would be routine foot care or expected to be included under a more comprehensive service/code. In this case, there wasn't since the use of a nipper to resect granulation tissue would involve minimal work. Personally, I would just bill an E/M service taking the work-up and management of the problem into account.

If the work is more than just "cleaning up" or resecting granulation tissue, you could consider debridement (CPT 1104x, if the tissue was truly debrided) or chemical cauterization of granulation tissue codes (CPT 17250, if chemical cauterizaton was used) or partial nail avulsion (CPT 11730, if the digit was anesthetized and more than just a clipping back of the nail was done).

Tony Poggio, DPM, Alameda, CA

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RE: NY Clinical Conference
From: Dennis Shavelson, DPM

I attended the New York Conference and give credit to Dr. Joseph Sciandra. As Chairman, he has turned the conference into "The" major event by making it fresh.

Dennis Shavelson, DPM NY, NY

RE: Discharging an Employee (Name Withheld)
From: Jon Purdy, DPM, Bob Levoy

It is imperative that direct and timely action take place in cases of employee non-performance, failure to correct addressed issues and all other unacceptable behavior. It is also imperative that you as an employer have performed to certain standards. To start with, every employer should have an employee handbook that contains detailed job descriptions and duties. Have your employees read, understand and sign onto this document. If you do not have one, there is no better time to address that task than now.

We find it best to leave disciplinary actions up to the office manager that do not fall into the category of infractions with serious implications. If I directly observe problem issues, they are addressed on the spot and may prompt further action such as a formal write up from the office manager. Your employee manual should be the office manager’s guide in what is considered a disciplinary action, and what constitutes grounds for termination. It should be just as clear to the employee committing the action or inaction.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

As I have written in my newest book, "222 Secrets of Hiring, Managing and Retaining Great Employees in Healthcare Practices, "the initial step in hiring an employee who is right for your practice is to prepare a written job description of the duties and responsibilities that the position entails. Such profiles will help simplify the hiring process, ensure that employees know what is expected of them, and provide supervisors with a guideline during performance reviews."

If your decision to fire someone is based on performance issues as you indicated, you'd best have a clear and reasonable documented record that the person knew what was expected, that the employee had the tools and opportunity to succeed, and that he or she was given reasonable notice and a chance to improve. In other words: Make sure there are no surprises.

Bob Levoy, Great Neck, NY, b.levoy@att.net

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 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

ASSOCIATE WANTED - NORTH CAROLINA, CHARLOTTE AREA

Incredible opportunity to join a busy, well-established group practice. Looking for a self-motivated, hard-working individual seeking to become a partner. Hospital and surgery center privileges. Salary plus percentage, 401k and real estate opportunities. Send CV to universityoffice@ bellsouth.net

EXCELLENT ASSOCIATE OPPORTUNITY – SOUTHERN CALIFORNIA

Established 25 year well-rounded biomechanical and surgical practice seeking energetic, enthusiastic, personable and proficiently-trained PSR-24 or PSR-36 foot and ankle surgeon for associate with ultimate partnership opportunity in LA area. Excellent position for an individual interested in all aspects of podiatric medicine with emphasis on reconstructive foot and ankle surgery. Only 8% Medicare with No HMO. Email CV to dr4feet@sbcglobal.net

OFFICE SPACE TO SHARE – MANHATTAN / PLAINVIEW, NY

East 60th and or East 22nd in Manhattan and on South Oyster Bay Road Plainview. Turnkey operation, all equipment needed is available as well as an extremity MRI, fluoroscopy, x-ray and surgical equipment. Each office has an operating room with anesthesiologist available for iv sedation. Call 516 476-1815 or email to
podo2345@aol.com include a phone #

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

POSITION AVAILABLE – SOUTHERN CALIFORNIA

Los Angeles and/or San Fernando Valley. House Call Practice, Doctor on maternity leave needs Podiatrist to assist with housecalls in San Fernando Valley and Los Angeles (310, 323 and 818 area codes). Must have own car and malpractice insurance. E-mail responses to Docrandi@sbcglobal.net

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 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 - 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- 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

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