The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

January 31, 2007 #2,798 Editor-Barry Block, DPM, JD

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PA Podiatrist Uses Voice Dictation & The Internet to Save Time

Podiatrist Dr. Gregory Spain takes the keyboard out of the loop with a program called Dragon Naturally Speaking, by Nuance. Instead of tapping out his notes, Spain talks to his computer. "You train the speech engine to recognize your voice, and when you speak into the engine, the program will type the words for you," he said. "You can ask the program to bold or underline a word, and you can ask it to call up information on standard procedures or surgeries to input into your patient's chart."

Dr. Gregory Spain

The MediNotes system lets the doctors set guidelines and choose from a list of symptoms to place in each patient's record. The program then checks the information and provides details to the medical billing staff. "This prevents overcharging Medicare or the insurance agency," Spain explained.

Using a wireless Internet connection, doctors and staff at Laurel Podiatry can download the results of lab tests done at the hospital. All software used in the office complies with federal privacy regulations, so patient information is secure, they said. "First-time patients who call our office can go to our Website and fill in their information online. The staff in the office can then download that information and have it ready when the patient comes in for their appointment," Spain said. "This saves a lot of time for the patients and our staff."

Source: Marjorie Wertz, Pittsburgh Tribune-Review [1/29/07]

NY Podiatrists Say Honor Your Feet…Not Just Your Heart…This Valentine’s Day!

If New York State’s podiatrists have their way, you’ll be giving chocolate soles…rather than hearts…to your sweetheart this Valentine’s Day. The organization is making a stand for the feet this year. “The beloved heart is recognized for its tireless efforts, but what about the work that goes into pumping blood back up to your heart?” asks Manhattan-based Dr. Scott Altman, president of the New York State Podiatric Medical Association.

Dr. Scott Altman

According to Altman, the vessels, muscles and arteries of the lower extremities are the body’s unsung hero. Every day they fight an uphill battle to keep the circulation going. “If people stopped and thought about what their feet accomplish, the feet…not just the heart… would be appreciated.

To honor your feet this Valentine’s Day, podiatrists from the New York State Podiatric Medical Association suggest partnering-up for a romantic “Soleful” foot massage.

Barry Student Takes Part in Minority Center Groundbreaking

Jeffrey Schnell came to Barry University on a recent Thursday morning wearing a suit and a tie, and he also wore a smile despite spending more than an hour in the Florida sun. The heat failed to faze him because the occasion was a groundbreaking for the first phase of Barry's new Center for Community Health and Minority Medicine.

Jeffrey Schnell

“This makes us feel integrated in the campus community,” said Schnell, who is president of the Florida Podiatric Medical Student Association. “It feels like we have someplace we belong, our own facility, a home.”The third-year podiatric medicine student and native of Bowling Green, KY, spoke eagerly about his plans to return and serve his hometown with a wide range of medical knowledge.

The $5 million first phase will contain two 80-seat classrooms, faculty offices, student research facilities and a space for patient simulation where students practice making diagnoses. It's scheduled to open in the fall of 2008. The second phase would be a 300- to 400-seat amphitheater, which could double as a large lecture hall, Evans said. The third phase would encompass anatomy and biochemistry laboratories for classes that make up the first two years of medical education.

Source: Emily Stevens, Miami Herald [1/28/07]

Query: 10 Year Old Toe-Walker

I have a patient that is 10 years old and has autism. Essentially his exam is normal otherwise. He is a toe-walker, but does not have equinus. When his mother tells him to assume a natural plantar-grade gait, he does so immediately, only to go back to his extreme toe-walk status seconds later. He has had Botox injection into the gastrocnemius muscle belly, physical therapy, serial casting, and has tried walking AFO devices as well. His mother states he toe-walks in AFO’s, no matter how there were fabricated.

I am going to put him in AFO night braces at 90 degrees to keep him supple and stretched while sleeping, however, I don't know of any device or technique that would be constant feedback to make him assume a normal plantar-grade gait. His condition is a cognitive one which makes this a perplexing problem. Has anyone encountered this before? Any suggestions would be helpful.

Charles T. Martin, DPM, Milford, OH

Query: Proper Coding For a Night Splint

What is the proper code for a night splint: L1930, L4398 or L4396?

Anthony Lombardo, DPM, Bridgeton, MO

Response: The definitions of the codes you listed are

L1930 - Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment

L4398 - Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment

L4396 - Static ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment

Medicare and most payers that I am familiar with have designated L4396 as the code for a night splint (L1930 which is a dynamic AFO would absolutely be the wrong code to describe a “night splint”).

Keep in mind that having the code (L4396) does not guarantee payment. Night splints are increasingly being reviewed for efficacy and realistic compliance. You may wish to check with your non-Medicare payers regarding reimbursement for “night splint” use under their plan benefits. See if they have any “medical necessity” criteria (e.g., non-first line treatment for plantar fasciitis) or fee schedule caps associated with night splint use.

Harry Goldsmith, DPM, Cerritos, CA

Codingline subscription information can be found at
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RE: Pale Cell Acanthoma (Edward Orman, DPM)
From: Bryan Markinson, DPM

Pale cell acanthoma, also called clear cell acanthoma is a rare lesion, but it almost always occurs on the lower extremities in middle age to elderly patients as a solitary lesion. It is completely benign and easily excised. They are usually very red and may bleed if prodded. I have only seen one case. The histology is very straightforward. The process is in the epidermis, and seems to be related to glycogen accumulation in keratinocytes.

Bryan Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org

RE: Practicing Without Hospital Privileges (Name Withheld)
From: Multiple Respondents

If it was impossible to have a practice without hospital privileges, the non-surgical podiatrist would be a thing of the past. Although I do not practice in New York , most hospitals that I am affiliated with will allow you to continue to be on Courtesy or Consulting staff without being a surgeon. You need so many “patient contacts.” That can be nail care or palliative consultations for wound care. Talk to your administrator and see what the hospital bylaws say. Usually there is a minimum patient contact number for courtesy staff which is easily met by having the hospitalist or primary care docs consult you for nails and heel ulcers….Not everyone is a surgeon….

Marybeth Crane, DPM, MS, Grapevine, TX, crane@faant.com

I've been [practicing without hospital privileges] for nearly thirty years. The insurance companies ask what arrangements I have in place in the event that a patient does need hospitalization and it's always been sufficient to give them the name of a hospital affiliated local colleague who has agreed to admit for me. Thus far, I have never been turned down by an insurance company.

Paul Busman, DPM, Troy, NY, BREWERPAUL@aol.com

I encountered a similar situation with a colleague friend of mine. He had no hospital privileges and unfortunately did not have the qualifications to apply for hospital privileges. What he ended up doing is stating through his attorney to the insurance entity that if any situation arises whereby his patients would need hospital facilities he will refer them to someone who has these hospital privileges. In this instance, this satisfied the insurance entity and he was allowed to continue as a participating podiatrist.

Notwithstanding, this might not be a feasible solution for all insurance entities but is one scenario that can work. If possible, the editor’s response is the ideal solution, especially if you are in the correct area where you can slowly transition your patients from network to out-of-network status.

Simon Young, DPM, New York, NY, simonyoung@juno.com

RE: What Bugs Drs. About Patients
From: Arthur Gudeon, DPM

I'm surprised they didn't list patients not showing for appointments, and not bothering to call, coming in very late for appointments, and not even apologizing, arguing about paying for co-pays/deductibles and/or arguing amount of fee for services rendered.
These bug me, anyway.

Arthur Gudeon, DPM, Rego Park, NY, afootdoc@ix.netcom.com

RE: IN Podiatrist Diagnosis RSD (Kove Schwartz, DPM, JD)
From: Elliot Udell, DPM

Dr Kove Schwartz asks whether our colleagues feel that RSD is a mystical condition. I treat many patients with RSD. I have lectured and written about it. The reason why some doctors might feel that RSD or more widely called chronic regional pain syndrome is mysterious is that the etiology is really unknown. Yes there are theories ranging from a short circuiting of the neurological system, an idiosyncratic reaction of hot or cold and several others. Dr. Hooshmand in his text elaborates on some of these theories.

None have been proved. Part of the mystery is why some patients can endure trauma from bad accidents or excessive surgical procedures and never develop the syndrome while others will have a single hammer toe operation and two years later they are in a wheel chair with atrophy, crippling pain and a condition that is rapidly spreading all of their bodies. Yes I have seen such cases.

What we do know is that early intervention with physical medical modalities such as the Dynatronics STS, which I helped clinically evaluate before it was approved, can often reverse the condition and prevent deterioration of muscle and nerves. There are other modalities such as implantable spinal cord stimulators that are sometimes effective. Another problem is that very often CRPS (RSD) is misdiagnosed by doctors who have not properly evaluated the patient or seen cases of CRPS. Some of these faulty diagnoses made by small town family practitioners and internists are so glaring that any doctor reading PM online without exception would gasp and scream incompetence.

I recently evaluated a patient who was told she had the syndrome but after undergoing the tests I ordered it was found she had spinal cord trauma caused by faulty spinal surgery. The surgeon told her she had RSD to cover over his negligence.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

ASSOCIATE POSITION - SOUTH CENTRAL PENNSYLVANIA-PM & S 36

Large, busy podiatry group looking for associate interested in future partnership. Practice facilities and technologies include: Surgical Center, Physical Therapy Department, six appointment locations, EMR, MRI and Digital X-ray. Full compensation and benefit package offered. Mail CV to Martin Foot and Ankle, 1203 S. Queen St. York, PA 17403 or email business administrator, johnreitzel@comcast.net

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 – 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 LEADING TO PARTNERSHIP - TAMPA BAY AREA-FLORIDA

Immediate position available in growing multi-office/multi-physician practice. Looking for a highly motivated psr24/36 trained podiatrist. Must be board qualified/board certified ABPS physician and be highly enthusiastic, motivated, with excellent patient/ social skills. Excellent benefit package including salary/bonus, health ins, paid time off, paid CME, and much more. Please e-mail CV to drdad94@aol.com or contact (727) 944-2522 for more information.

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.

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

PRACTICE FOR SALE -NORTHERN CALIFORNIA

Great opportunity to own a well-established turn-key podiatry practice located in modern medical office building in East Bay; Electronic billing, good payor base, no HMO contracts; biomechanics, general podiatry with great potential for surgery. Please send CV and letter of interest to: norcalpod@hotmail.com

PEDALIGN SCANNER, COMPUTER, MONITOR, AND KIOSK FOR SALE

Considerable savings on 1 year old system. Lease may be assumed. Contact Jeffrie Leibovitz, D.P.M. Office 317-545-0505 ftbenpod@sbcgloabal.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 -WASHINGTON - SEATTLE AREA

Two-location practice looking for long-term commitment leading to partnership. Medicare certified surgicenter each location. Must be highly motivated, ethical & have good patient skills. Competitive salary & benefits package available. Excellent opportunity for the right candidate. Send CV to fax 425-775-9078, e-mail to nwfootandankle@yahoo.com or call 425-775-1505.

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