The Voice of Podiatrists

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February 07, 2007 #2,804 Editor-Barry Block, DPM, JD

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We’ve just mailed the February 2007 issue of Podiatry Management. At 222 pages, it’s our largest February edition ever. In it you’ll find our much anticipated Annual Practice Survey, along with dozens of information-packed articles and features, including our newest CPME-Approved CME.

FL Podiatrists (and Podorthist) Offer 1-Stop Orthotic Center

Spotting problems in a patient's gait using video motion analysis is one of the ways the specialists at Footcare Express diagnose and treat foot, leg and muscular-skeletal problems. Charles Mutschler, who is the medical director at Footcare Express, watches a lot of patients' leg and feet videos. Besides video analysis, Footcare Express podiatrists also use X-rays and ultrasound to diagnose and treat problems. Footcare Express places under one roof a retail store, a center for podiatry consultations, and a manufacturing site for orthotics. The company is owned by Harold Reinhartz, a podiatrist, and his son Jarett Reinhartz, who is a pedorthist -- a specialist who fits and makes correctional inserts or specially fitted shoes.

Jarrett Reinharz (L) Dr. Charles Mutschler, Dr. Harold Reinharz (R)

The vertically integrated company was the brainchild of Jarett Reinhartz, who established it six years ago after working in his father's office and with another set of partners. His father had podiatry practices in Kissimmee and Winter Park that he sold before moving to South Florida. Reinhartz said the company's revenue rose after major insurance companies began to accept claims. 'We managed to get on all the major plans and that was a huge, huge plus,' Reinhartz said. The company doubled its revenue last year to about $1 million in annual sales.

'This year we expect to do a lot more than that,' Reinhartz said, adding that a growing part of the company's business -- about 40 percent of revenue -- comes from working with sports teams such as the Miami Heat, Florida Marlins and Miami Dolphins on diagnosis, rehabilitation and orthotics.

Source: Jane Bussey, The Miami Herald [2/5/07]

Diagnostic “Divining Rod” For Diagnosing Limb-Threatening Bone Infection Not Reliable: Study

An often-used tool to diagnose very common and sometimes limb-threatening bone infections in persons with diabetes may not be as reliable as many once believed, based on a recent study by a transatlantic team of researchers. The study, published to the Web ahead of print in February’s edition of the journal Diabetes Care, longitudinally evaluated a large sample of persons with diabetes with wounds, and tested the commonly performed “probe to bone” test. The test, which uses a sterile instrument to feel for bone inside a wound, has been thought by many to be highly predictive of bone infection.

Dr. David Armstrong

“It certainly makes sense that if you can feel bone, then it must be infected,” noted David G. Armstrong, DPM, PhD, Professor of Surgery at Scholl’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science, and a co-investigator on the study. “Unfortunately, though, this doesn’t always seem to be the case. The test, if used by itself in a normal clinical setting, isn’t much better than flipping a coin. We therefore recommend it be used with other aids, such as biopsy or appropriate imaging tools.”

The two-year longitudinal study was the result of partnerships from Texas A&M University, Rosalind Franklin University of Medicine and Science, the Leiden University Medical Center (Netherlands) and the University of Washington School of Medicine.

Patients Can Also Help Reduce Medical Errors: Experts

Patients Should Take Steps to Prevent Mistakes USA Today on Monday examined the prevalence of medical errors in the U.S. and steps patients can take to prevent them. About 34% of U.S. residents in a recent Harvard School of Public Health survey said that they or a family member have experienced medical errors, and the Institute of Medicine has said that hospitalized patients should expect to experience at least one mistake daily.

Hospitals have begun to take steps to reduce medical errors, but many experts maintain that "patients and their families also need to take a larger role in ensuring their safety," USA Today reports. According to experts, patients should ask physicians questions about their medical care and should voice concerns about potential errors. Patients also should ask family members to serve as advocates when they cannot make medical decisions to help prevent errors, experts said.

Source: USA Today via American Health Line [2/5/07]

Query: Radiographs for Nail Pathology

I am curious as to how frequently PM readers obtain radiographs in association with nail pathology. We obtain elevated lateral, oblique, and DP radiographs on any patient with an infection greater than 10 days by history, and have found 15% to have underlying radiographic bone changes, confirmed by biopsy as osteitis/osteomyelitis.

Similarly, we have found a 30% incidence of distal or proximal metaphyseal exostosis in association with incurvated toenails, which we address at surgery.

Allen Jacobs, DPM, St. Louis, MO

Query: ICD-9 & CPT Coding for a Painful IPK

What is the best diagnosis code and the procedure code used when debriding a painful nucleated intractable plantar keratosis (IPK)? I document the location of the lesion, the diameter, the symptoms, limitations to the patient, and the debridement (enucleation of the core with application of sal acid to soften the lesion margins) in the medical records.

Peter Wilusz, DPM, Warren, MI

Response: Coding in this matter has shifted somewhat over recent years, as carriers try to differentiate routine foot care (which may or may not be a covered service depending upon qualifying at-risk factors), and palliative treatment of the symptomatic lesion.

For Noridian Medicare states, ICD-9 701.1 (keratoderma), or, perhaps, ICD-9 700 (hyperkeratosis), is to be used. I prefer to only use ICD-9 700 for the asymptomatic lesions and ICD-9 701.1 for symptomatic IPKs; it makes differentiation of intent clearer. You might add a secondary diagnosis of ICD-9 729.5 when the presentation is a symptomatic/painful lesion.

Procedural coding USED to be billed as CPT 11040 (debridement, partial thickness skin). With Noridian, that code is only used when debriding "true ulcerations."

For debridement of IPKs, trimming of hyperkeratosis, the current coding would be CPT 11055 or CPT 11056 or CPT 11057 (paring/cutting of hyperkeratosis).

Rick Horsman, DPM, Olympia, WA

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

Editor’s Request: PM is planning a story on the use of I-Pods in podiatric medicine. If you would like to share your experiences as part of this article, please write Laura Gater at lsgater@earthlink.net. Thank you

RE: PowerPoint Presentations (Nicholas Varveris, DPM)
From: Betsy Herman, David M. Davidson, DPM

The APMA offers a number of pre-made and customizable PowerPoint presentations to their members. There are currently presentations on General Podiatric Medicine, Diabetes and Sports Medicine on the website available to be downloaded at any time. In addition, there are several presentations on Careers in Podiatric Medicine available by request. APMA’s latest presentation on Arthritis can also be made available upon request. APMA members interested in receiving these can either log onto the website at www.apma.org in the Marketing section of the Member Center, or by requesting a copy at apmaorder@apma.org

Betsy Herman, APMA Marketing & Career Development Specialist, BHerman@apma.org

The American Academy of Podiatric Sports Medicine has several PowerPoint presentations available to their membership. You may want to call or e-mail or visit www.aappm.org AAPSM for information.

David M. Davidson, DPM, Buffalo, NY, ddavidson7@verizon.net

RE: Achilles Rupture and Posterior Spur (Loren Miller, DPM)
From: Randall Brower, DPM, Michael M. Rosenblatt, DPM

The longer you wait to repair the Achilles, the more likely you'll face two major problems. First, either the gap will be so large that you will not be able to perform an end-to end repair and require a flap-down procedure, or allograft. Secondly, the more likely you'll have to debride the ends leaving you with a large gap. Her posterior spur is likely a result of a long-standing moderate/severe equinus I have to assume. Expose the entire length of the Achilles, remove the spur and anchor the attachment if necessary, hold the ankle at 85-90 degrees and assess your gap. Repair the gap at that position so you don't recreate an equinus that caused her problems to begin with. I think the biggest mistake we make in posterior spur resection is not correcting the equinus that is almost universally present.

Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

No matter what choice is used, surgery now or later, the patient with the ruptured, calcific Achilles tendon probably has gastrocnemius equinus, or short Achilles tendon caused by age or genetic makeup. Unless the chronic short Achilles tendon is dealt with, the patient is apt to re-rupture the repair or have a poor result with the surgery. This may manifest itself in slow recovery time, considerable pain, and inability to use physical therapy successfully.

One of the advantages of surgical repair of Achilles tendon rupture is that many techniques actually "lengthen" the gastrocnemius aponneurosis during the process. Choosing the right procedure that accomplishes this is essential.

Waiting to repair the tendon is fine. But unless the length problem is "dealt with," the patient will probably have a very rough road and not do well, no matter what else you do.

Michael M. Rosenblatt, DPM, San Jose, CA, rosey1@prodigy.net

I have seen several cases of this type. I prefer not to repair the tendon. Considering the patient's age, often gravity equinus casting, followed by serial casting to neutral is extremely effective. In patients of this age, often casting followed by aggressive therapy leads to a very satisfactory outcome. I am hard-pressed to repair an asymptomatic Achilles tendon in a non-athlete. Additionally, because of the idiopathic lengthening of the heel cord, often times the retro-calcaneal pain will resolve.

Treat with a heel lift for three months and activities to tolerance following two months of aggressive rehab.

John S. Levin, DPM, Atlantis, FL, John.Levin@OCPBC.com

ASSOCIATE POSITION – NEW YORK & CONNECTICUT

Opportunity to be a part of a prestigious and well-established large Orthopaedic and Rehabilitation practice, with locations in Stamford, CT and West Harrison, NY. Looking for a podiatrist to join an already busy practice with opportunity to build. We have state-of-the-art offices with MRI, digital x-ray, paperless charts, physical and occupational therapy. Applicants should be Board Certified or Board Eligible. Competitive salary and benefits. For further information on the practice, log onto WWW.NYCONNORTHO.COM Interested candidates should forward their C.V. to: Cliff Katz, Executive Director ckatz@nyconnortho.com

ASSOCIATE POSITION- WEST CENTRAL FLORIDA

Position available for PSR 24/36 trained DPM to join the Podiatry Service of the largest multi-specialty Rural Health Group Practice in Florida. Good salary/incentive compensation and excellent fringe benefits plan, which includes paid vacation days, CME dollars and much more. EOE/DFWP Send CV and letter of interest to: MCRHS, P.O. Box 499, Parrish, FL 34219 or fax to (941) 776-4013.

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 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

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 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

ASSOCIATE POSITION -MINNESOTA – PRIME MINNEAPOLIS SUBURB

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with potential partnership opportunity. Looking for PSR 24+ individual. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

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

PRACTICE FOR SALE -BOSTON SUBURBS

Established practice for sale. Practice averages 18 – 22 patients per day. Currently all surgery is referred out. Opportunity to transition patient base to full service. Priced for sale. Contact dpminboston@comcast.net

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 – CENTRAL NEW JERSEY

Associate Wanted....For well established Central Jersey practice, diversified in all aspects of podiatric medicine and surgery. I am looking for a highly motivated, conscientious, individual with strong work ethhics. My practice may offer great potential for the right person. Minimum PSR 24. Please reply to Jerseypod@gmail.com

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