The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

February 06, 2010 #3,773 Publisher-Barry Block, DPM, JD

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TUSPM Podiatrist Provides Cold Weather Foot Care Advice

Winter sports participants can take steps to reduce their risk for cold-related injuries by dressing warmly and appropriately. When the body feels cold, blood is drawn away from the extremities to keep the internal organs warm, increasing the risk for frostnip and frostbite.

Dr. Howard Palamarchuk

Howard Palamarchuk, DPM, podiatrist with Temple University School of Podiatric Medicine in Philadelphia, says the toes and feet are very susceptible to cold injury. Many winter boots are made of rubber or some type of synthetic waterproof construction. If the feet sweat, or the socks get wet, the moisture can’t escape. The boots may not necessarily keep the cold away, so the socks (and toes and feet) can freeze. Palamarchuk recommends wearing socks that wick away moisture from the feet to keep them dry.

Source: WSOC-TV [2/5/10]

NV Podiatrist to Run for Ward Supervisor Seat

Sean Lehmann, a Carson City podiatrist and member of the Carson City Parks and Recreation Commission, has announced he will run for the Ward 1 supervisor seat being vacated by Robin Williamson. Lehmann believes his background as a small business owner will be beneficial to him as a supervisor. “I have run a successful medical practice for the last 10 years. I have a master's degree in administration. I know how to make a budget and stick to it,” he said.

Dr. Sean Lehmann

Lehmann said economic issues are among his top concerns. “Like many communities around the country, Carson City faces serious challenges due to the poor economy,” Lehmann said. “However, I believe the future looks promising for the city, and I look forward to debating the challenges and opportunities we face as a community in the upcoming campaign.”

Source: Sandi Hoover, Nevada Appeal [2/5/10]

Obama Admits That Health Plan May Die on Hill

No, maybe he can't. President Barack Obama, who insisted he would succeed where other presidents had failed to fix the nation's health care system, now concedes the effort may die in Congress.

The president's newly conflicting signals could frustrate Democratic lawmakers who are hungry for guidance from the White House as they try to salvage the effort to extend coverage to millions of uninsured Americans and hold down spiraling medical costs. Obama's comments Thursday night came hours after Republican Scott Brown was sworn in to replace the late Edward M. Kennedy, leaving Democrats without their filibuster-proof majority in the Senate, and Obama's signature health legislation with no clear path forward.

Source: Erica Werner, Associated Press [2/5/10]

Query: Billing and Coding Books Specifically for Podiatric Medicine & Surgery
 
Does anyone have a recommendation as to which set of books and or services are best for billing and coding specifically for podiatric medicine & surgery. I am familiar w/ the Ingenix and AMA's CPT & ICD-9 coding books.  Are there others that are better?  Someone mentioned  Dr. Martin Taubman's podiatry coding set... does anyone recommend it or know from whom I can purchase it?
 
Mark A. Lambert, DPM, Pensacola, FL

Editor’s Comment: Information on obtaining Dr. Taubman’s text can be obtained by clicking here.

Query: Routine Foot Care Bundling Denials

I am having problems with Medicare paying for CPT 11055 when I bill both CPT 11055 and CPT 11721-59. They will only pay for CPT 11721. This has not been a problem in the past, but now all of sudden, every time I bill these two codes together, they are denied the CPT 11055 with a "CO B15" (bundled; not paid separately) explanation.

I have contacted Medicare, but to no avail. I am also having problems with CPT 11040 billed with the above codes with anatomical modifiers and a "-59" modifier. Any suggestions?

A. Skelton, Office of James Rose, DPM, Anderson, SC

Response: You most likely need a "Q" qualifier for both codes.

If this does not work, it may be a system edit error, as we have had these with NGS. If that is the case, I suggest you contact your CAC rep through the APMA for more information.

Paul Kesselman, DPM, Woodside, NY

Codingline subscription information can be found at:
http://www.codingline.com/subscribe.htm

RE: Jones Fracture Healing (Bill Zaccardelli, DPM)
From: Lowell Scott Weil, Sr., DPM, Steven H. Goldstein, DPM

Jones Avulsion Fracture (Styloid process 5th met) in 13 Year Old

The "classic avulsion fracture of the styloid process of 5th metatarsal in a 13 year old" is very unusual in that age group. It may very well be a epiphysitis of a secondary growth plate of the 5th met base. Take an x-ray of the contra-lateral foot and see if it is there...Ooops, it’s an easy mistake to make so don't be embarrassed if you find it on the other foot.

Your treatment is basically the same as with any other injury. I would just have the patient wear a running shoe and keep off gym and sports for a few weeks, and treat it based on symptoms. Let us know what you find!

Lowell Scott Weil, Sr., DPM, Des Plaines, IL, weil4feet@aol.com

I recommend an Exogen bone stimulator which is approved for fresh fractures. I still believe that even with a CAM walker, the peroneal tendon still has some pull on the base of the 5th metatarsal when weight-bearing is allowed, so non-weight-bearing seems like it should fit into the equation as well.

Steven H. Goldstein, DPM, Royal Palm Beach, FL, stevefootdr1@yahoo.com

RE: Poor Surgical Result (Tip Sullivan, DPM)
From: Jeffrey Kass, DPM

1) It would have been helpful in the posting if Dr. Sullivan stated specifically where the pain was on the 5th toe. Oftentimes, I use a circular lesion marker, and place it directly over the region of pain. This may help identify the etiology.
2) The 5th toe appears to be in an adducto varus attitude based on the shadow of the film. I usually perform a lateral middle hemi-phalangectomy anytime I do a 5th digit hammertoe in addition to the arthroplasty of the head of the proximal phalanx.
3) Have you tried anything yet in terms of treatment? Maybe, a local injection....it is not absurd to still have some post-op irritation from December.
4) Is the patient  wearing proper size shoes?

I agree that the deformity is mainly a met adductus - hence, when the question is asked for the best way to treat the transverse plane deformity, I assume the question was rhetorical. Correct the met adductus. Attempts were made to correct a bony etiology via soft tissue correction. Hindsight is always 20/20. One broken smart toe and migrated K-wire later, the 5th toe problem should be the easiest to fix.

In a prior posting, Dr. Jonathan Haber (for a different case) recommended a syndactly of the 4th and 5th toes. Again, depending on where the pain is and if all conservative measures fail, this may be an option in this case as well. 
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

RE: Dwight Freeney Ankle Injury
From: R.D. Teitelbaum, DPM

I'm sure that most podiatrists are looking on in possible amazement that Dwight Freeney will be sent out to play in the Super Bowl with a Grade-3 ankle ligament rupture/sprain.-- a condition that would require O.R.I.F. for a professional player. That it can be done is not the issue.  A local anesthetic block can be performed, ankle taped, then fitted with an in-shoe hinged, lightweight brace a la Donjoy or Ossur. 

Of course, several questions arise: 1) With the loss of proprioceptive input, how can a fast lineman know what he is doing with that ankle?  2) Isn't the risk of rupturing the remaining ligaments greatly increased? 3) Isn't his career in jeopardy if he plays at his usual high level of play? A whole host of medical ethics questions will dog the doctors, players, and coaches involved in this case if it goes the wrong way. To paraphrase what was said in Rome--"For those about to play, we salute you." We shall see how it plays out.
 
R.D. Teitelbaum, DPM, Naples, FL, mfvandange@aol.com

RE: EMR Change-Over (Harry Cotler, DPM)
From: Multiple Respondents

Dr. Cotler is in a unique situation. He has used an EMR program and is familiar with EMR software. At this point in time, he is much more educated about EMR than when he first selected Medinotes. In order to use a program that meets federal requirements for "Meaningful Use,"  he must now switch to another EMR program. No matter how you look at it, he will now need to go through the process of learning to use another EMR program.

Take the experience and knowledge of what you like about Medinotes, and what you did not like about Medinotes and review all of the available software offerings. You may find that Peak Practice is best for you, and you may find that another product is a better choice. I have a preference for products that have been developed specific to podiatry. They usually have tools and features that are specific to our profession that aid us in charting and billing to a much greater degree than products that have been built with the primary care physician in mind. 

For an idea of which products are built with tools that are specific to podiatry, I suggest looking at the advertisements in PM Magazine, or here in PM News. These are the software vendors who know our profession best. After evaluating your options, you may or may not end up with Peak Practice, but you will be confident that the decision you made was an informed decision and the best decision for your practice.

Michael L. Brody, DPM, Commack, NY, mbrody@tldsystems.com

I have been using EMR for over four years now along with a built-in practice management system. I have been using what has formerly been known as PodMed by Leum Software. The company was bought out by Biomedix, the makers of PADnet in the second half of last year and is now known as TRAKnet DPM. The program was written by a podiatrist for podiatrists and will be compliant with the standards for “meaningful use” set down by the government. The program combines EMR, billing, scheduling, and inventory management for items in your office. The one advantage that Dr. Cotler would have is that TRAKnet DPM works with Gateway as their clearinghouse so he would not need to switch over to a new clearinghouse.

Disclaimer: I am a consultant for Biomedix, manufacturers of TRAKnet.

Alan L. Bass, DPM, Manalapan, NJ, abassdpm@optonline.net

I have been using Medinotes for 18 months and chose it in part because it was CCHIT-certified. They are trying to sell me on the Eclipsys, but I haven't felt the need to change over yet since I have a very new practice. I was not aware that Medinotes was NOT going to be considered "compliant." Does this mean that I need to get a different EMR to qualify for the $44K? If so, this is bogus! What was the CCHIT for? What makes Medinotes non-compliant? Can we have a list of the EMR's that are compliant?

David R. Sullivan, DPM, Westfield, IN, drs@westfieldfoot.com

RE: From Evidence-based Medicine to Marketing-based Medicine (Michael Turlik, DPM)
From: Elliot Udell, DPM

Acknowledgments are well deserved for Dr. Turkik for bringing up this very important issue. I know the editors of our journals well, and I doubt whether any of them can be manipulated by anyone, however, significant other parts of our profession are manipulated by corporate interests. I lecture at many conventions, and only rarely do I get subsidized by pharmaceutical firms. Many seminars, however, will not allow me to speak because I don't get subsidized, and being subsidized means that the pharmaceutical company gives the seminar twenty five thousand dollars for an unrestricted grant. Even though the grant is supposed to be unrestricted, representatives of the sponsoring firms sit and listen, and woe to the speaker who takes part of that money and does not push the sponsor's product during the presentation.
 
I am proud to say that every conference I have lectured at, has had mixtures of subsidized speakers, as well as speakers who are totally unsubsidized by any corporation. This makes such conventions fair and just. Those conferences that only choose speakers who are subsidized by pharmaceutical firms are, in essence, exposing its patrons to three days of a collection of thinly disguised infomercials. Our patients deserve that we educate ourselves in better ways. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Liability for Recommending Barefoot Running (Kevin A. Kirby, DPM)
From: Multiple Respondents

I am as vehemently opposed to my patients running and even walking barefoot as dentists are against their patients chewing gum and eating candy. In the summer, I dread having to search for foreign bodies in people's feet or do incisions and drainages of infections caused by puncture wounds or spicules of dirty glass embedded in their feet. Many of these patients have gotten those foreign bodies in their feet from walking barefoot inside their homes. Invariably, when I remove a chunk of glass from the foot of a woman who likes to walk around her kitchen without shoes and socks, she sheepishly says that she thought she had cleaned up the pieces of glass from a wine glass that shattered a month earlier. Hello!
 
Beach walking is another source of aggravation. Needles seem to find their way onto sandy beaches, and punctures can lead to pseudomonas infections, tetanus,  and  osteomyelitis. Even if some legitimate investigator proves that barefoot running is biomechanically fine, the risks of walking barefoot in our environment outweigh any gains. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

I have two thoughts regarding barefoot liability. The first is we can minimize this with a minimalist shoe. The second is that there is an assumed liability when you undertake certain activities i.e., going to the beach, skiing, etc. I agree that there is a slippery slope regarding making anthropological statements based on a set of assumptions. One of my favorite scenes in "The Planet of the Apes" was when the good Dr. Zaius concluded that humans could not talk when they found a human doll at an archeological dig because his daughter played with one only to be shown evidence to the contrary when the doll dropped and cried out mama.

Ben Pearl, DPM, Arlington, VA, abenpearl@netscape.net

I ask of my profession: Would you recommend sending kids out barefoot running? 10,000 years ago, the human race decided to become civilized.  We carved hard roads into the landscape, eventually paving them. We developed foot coverings to protect, support, and shock absorb our feet that couldn’t tolerate civilized ground and elements. We built homes attached to each other in order to develop large communities and common societies, and our feet have had to absorb being the foundations of our civilized life ever since. Enter podiatry!

Podiatry is a civilized profession. That is why our greatest numbers, our research and our advances live in big city locations around the world.  We exist to benefit civilized society. Nudist colonies, Earth Shoes and barefoot running are a wonderful break from civilized life, but like the Earth Shoe, the popularity of barefoot running will fade and should not be high on the list of podiatry recommended “to do” lists.

We should be driving media stories about biomechanics, foot orthotics, and other civilized podiatric advances and niches that are a long term benefit to mankind and our civilized quality of life, and leave recreational fads to the tabloids realizing that the liability of barefoot running for podiatry is making it a high priority subject when rendering expert opinions. 

Dennis Shavelson, DPM, NYC, NY, drsha@lifestylepodiatry.com

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-INLAND EMPIRE, SOUTHERN CALIFORNIA

Associate needed full or part-time for multi office practice. Must be ABPS BC/BQ. Hard working, ethical individual who is looking to a possible partnership opportunity. Looking for current licensed or resident completing program this spring. Email CV to bkatzman2@earthlink.net

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

ASSOCIATE POSITION - MARYLAND

Associate needed to join a multi-office podiatry practice in the Baltimore MD Region. Desired candidate should be surgically trained with Board Eligible / Certification. You must be hard-working, ethical, compassionate and confident in your abilities to deal with pathology, patients, staff and fellow physicians. Patient base is already established. Excellent income and growth potential for the right associate. Please forward a cover letter and resume and availability to FootDocMaryland@Gmail.com

EQUIPMENT FOR SALE – MICROVAS

Microvas Unit for sale in good condition, 1 year old. Works well for various conditions we treat.Joining multispecialty group and unable to bring unit. Best offer. Please e-mail inquiries to footdoctor@verizon.net

ASSOCIATE  POSITION - MONTANA

Great opportunity for a PSR 24 or 36 residency trained individual to join a dynamic two doctor group with physical therapy.  Needs good FF surgical skills, RF a bonus.  Beautiful office and great area of the country for outdoor recreation-minded individuals. Opportunity for partnership after employment. Please reply to: jclough@bridgemail.com

PRACTICE FOR SALE – WASHINGTON STATE 

Kent (20 miles South of Seattle) 15 year part time practice. Share office with two MD’s. Midmark 417, ExCel X-ray and processor Ritter M9 autoclave, instruments. Owner retiring. VERY REASONABLE PRICE. Call Martin Lynn @ 206.355.3701 Leave Message; or Email at mlynn@wport.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 – 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 - MASSACHUSSETTS

Full-time/Part-time podiatrist needed for a busy nursing home practice. Please send inquiries to debbierobertsm4@hotmail.com

ASSOCIATE POSITION – MISSOURI

Expanding multi-location practice seeks motivated individual to contribute to growth. Practice enjoys strong reputation and name recognition. Prefer candidates with interest in partnership opportunity. Established locations available for PSR 24+ and includes incentive comp with benefits/coverage. Please send CV to jmurray@foothealers.com or call John Murray at 314.842.3875

OFFICE SPACE TO SHARE - NYC

Wanted- Licensed podiatrist to share space in a State-Of-The-Art medical office in the midtown area. Please call Dr. Robert Singer (212) 921-5775 or e-mail dr.roberth.singer62@netzero.net

ASSOCIATE POSITION - SAN FRANCISCO, CALIFORNIA

We’re seeking an energetic and enthusiastic Associate to help our thriving non-surgical practice grow. Located in the heart of San Francisco, we provide state-of-the-art sports medicine, trauma and lower extremity care. Excellent compensation package. Submit CV with cover letter to: sfsportsmed@yahoo.com

ASSOCIATE POSITION - MARYLAND/D.C AREA

We are looking for an energetic and well-trained podiatrist to join our rapidly growing group; we have offices in Maryland and D.C and are in need of someone who is hard-working and growth-oriented. This candidate must be a graduate of a PM&S 36 residency program or have the equivalent in practice experience. We are looking for the person that wants to make this area their home and become an integral part of our group. If interested, e-mail your CV and cover letter to washingtonpod@aol.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

PRACTICE FOR SALE - NORTHWEST CHICAGO SUBURBS

17 year-old surgical practice for sale. Practice sees a wide variety of foot and ankle pathology and is largely referral especially regarding surgical patients. Two offices fully equipped. Lease or purchase of office condo also possible. Doctor willing to stay Please email inquiries to crystallakefootandankle@live.com

ASSOCIATE POSITION - W FLORIDA, BEACHES

Well established podiatry pPractice with excellent mix office/surgery seeking full time associate PSR 12-36. Excellent salary & benefits for the right hardworking, personable candidate. Email resume to capecoralpodiatry@live.com or fax to 239-573-9201

ASSOCIATE POSITION - VICTORIA, B.C.

Beautiful Victoria, B.C. Canada on the ocean, fast growing area, Associate for multi-office full scope practice. Interviews in Orlando, February 20th and 21st, Reply by email to orthotic4D@shaw.ca

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.

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