The Voice of Podiatrists

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February 14, 2007 #2,809 Editor-Barry Block, DPM, JD

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Small Cuts Can Lead to Infections in Diabetics: NM Podiatrist

A simple infection in the foot can result in a deep bone infection called osteomyelitis. 2.4 million diabetes patients will develop a serious foot ulcer during their lifetime and one in four diabetic ulcers will result in loss or amputation of a foot. Studies show that half of diabetic patients who have had a leg amputated will lose the other leg in three to five years.

Dr. Roya Mirmiran

“Patients often fail to check their feet for small cuts or punctures that may become infected,” says Dr. Roya Mirmiran, a foot and ankle surgeon in Albuquerque. “If you have diabetes and see anything suspicious on your feet, consult a foot and ankle surgeon for diagnosis and treatment as soon as possible. If not detected early, a small break in the skin of the foot can result in an infection and subsequent loss of all or part of the foot and in severe cases the entire leg,” says Dr. Mirmiran.

Source: New Mexico Woman

Senators to Reintroduce Physician Payment Alternatives

Sen. Debbie Stabenow (D-MI) announced plans at the American Medical Association’s National Advocacy Conference today to reintroduce legislation that would seek alternatives to the way Medicare pays physicians, and to reward them for investing in health information technology.

Proposing cuts to Medicare and Medicaid, and a 10% reduction in Medicare physician reimbursement in 2008 have been the administration’s strategy to bring down healthcare costs, “But that strategy has not worked,” she said. Her bill would establish an all-physician Medicare payment commission that would come up with an alternative to repeal the sustainable growth-rate formula, which ties payments to the health of the economy.

The formula is “a flawed, inequitable mechanism that needs to be repealed,” Stabenow said. In addition, she and Sen. Olympia Snowe (R-ME) plan on reintroducing a health IT bill that would offer a tax credit for physicians who invest in IT equipment. Cutting down on forms through health IT could save as much as $80 billion to $100 billion per year, she said, citing previous estimates.

Jennifer Lubell, Modern Healthcare [2/13/07}

Project Targets Doc-Pharma Influence

A consumer-advocacy group has launched a national campaign to try to reduce conflicts of interest between doctors and the pharmaceutical companies that ply their physician-customers with everything from boxfuls of drug samples to free lunches and generous lecture fees. The Community Catalyst, a Boston-based not-for-profit group, said the two-year long Prescription Project, funded by a $6 million grant from the Pew Charitable Trusts, will attempt to raise awareness of these conflicts and encourage physicians to use evidenced-based systems when they prescribe drugs to patients.

Community Catalyst will work with the Institute on Medicine as a Profession, a think tank at the Columbia University College of Physicians and Surgeons in New York, to demonstrate how these close financial connections affect quality and costs in healthcare. Drug companies spend about $12 billion a year on marketing efforts to doctors, and national spending on prescription drugs—rising at a rate double that of other health services—is nearing $200 billion a year.

The kick-off of the project comes one year after a hard-hitting report in the Journal of the American Medical Association concluded that marketing incentives such as cash, gifts and free samples pose “extraordinary challenges to the principles of medical professionalism.”

Source: Michael Romano, Modern Healthcare [2/13/07]

Query: Refractory Hyperhidrosis

I have a patient with refractory hyperhidrosis. She has failed Drysol, Certain Dry and foot powder treatments, and wears appropriate wicking socks and breathable footgear. Does anyone have any further suggestions regarding effective treatment? Her hands do not sweat.

Evan F. Meltzer, DPM, Browning, MT

Query: Punch Biospy Billing

What is the proper coding for punch biopsies (not lesion shaving or complete lesional excisions)? I have billed CPT 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion) and CPT 11101 (...each separate/additional lesion) with ICD-9 238.2 (neoplasm of uncertain behavior of other and unspecified skin) for tumors, ICD-9 692.2 (contact dermatitis and other eczema; due to solvents) for derm. I keep getting denials from downstate Medicare.

Michael Farrell, DPM, Sidney, NY

Response: Empire Medicare (the Medicare carrier for downstate New York) does not have a local carrier determination (LCD) for CPT 11100, CPT 11101 (biopsy) coding.

There is no apparent reason why the claims should have been automatically denied. Look at the denial code and explanation on the explanation of benefits. What reason was given as to why the claim was denied? If it was because the procedure was deemed medically unnecessary, appeal.

Mark Schilansky, DPM, Catskill, NY

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RE: Anterior Compartment Syndrome After Ankle Tourniquet Use (Greg Mowen DPM)
From: Richard Bouche, DPM, Barry Mullen, DPM

From Dr. Mowen’s description, it is unlikely this patient had a traumatic anterior compartment syndrome. The symptoms you related are “persistent tingling of the superficial and deep peroneal nerve” after use of an ankle tourniquet. If these are the only symptoms, your patient likely has a neuropraxia of the involved nerves from constriction of the tourniquet.

To establish a diagnosis of compartment syndrome, be it acute (traumatic) or chronic (exercise-induced), four requisites must be present: 1) limited anatomical envelope, 2) increased intracompartmental pressure, 3) ischemia, and 4) neuromuscular compromise. Your patient has a localized problem to the anterior leg with persistent tingling. For a diagnosis of compartment syndrome, your patient must have evidence of increased pressure- patients will complain of severe tightness and on your exam, palpation will reveal induration of the anterior compartment (this is usually validated with intracompartment measurements initially).

Also the patient would have evidence of localized ischemia characterized by subjective complaint of severe pain out or proportion and on exam, pain on passive stretch (in this case plantar-flexion). In addition to neurological symptoms the patient would have muscular weakness as well characterized by weakness on dorsi-flexion. The gait classically would be a steppage gait with a foot drop.

After 6 months, if an acute compartment syndrome had occurred your patient would have evidence of extensor contracture of some or all of the anterior compartment musculature representative of Volkmann’s ischemic contracture.

Richard Bouche, DPM, Seattle, WA, spmrtb@earthlink.net

Do you have documented elevated anterior compartment pressures to substantiate your presumptive compartment syndrome diagnosis? In light of the history provided, direct tourniquet compression to the deep and/or superficial peroneal nerve branches seems like a more plausible etiology for your patient's neuritic symptoms than compartment syndrome. Also, how long was the tourniquet inflated for? Prolonged ischemia from over extended tourniquet time may also cause peripheral nerve damage.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

RE: Retrocalcaneal Pain and ESWT (Jeffrey Miller, DPM, Christopher L. Hendrix, DPM)
From: David Zuckerman DPM

Dr. Hendrix makes the comment that high impact ESWT shouldn't be used for this specific Achilles tendon problem. I do agree with him but not for his reasons. Using energy levels below 0.28mj/mm2 is safe and effective for insert ional tendinosis. This isn't a high impact energy level. Studies have shown there is no impacting the bone, causing breaking or stress risers. ESWT at the energy level that podiatry used doesn't break or scatter bone. The ESWT treatment goal is to induce neovascularization and not to treatment any boney pathology.

When metal hardware is in the ESWT treatment field you need to use an alterative treatment and avoid ESWT.

David Zuckerman DPM, Woodbury, NJ, footcare@comcast.net

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