The Voice of Podiatrists

Serving Over 13,500 Podiatrists Daily

February 15, 2012 #4,385 Publisher-Barry Block, DPM, JD

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Diabetics More Prine to Fungal or Bacterial Skin Infections: CA Podiatrist

When you have diabetes, you’re more prone to fungal or bacterial skin infections anywhere on the body. “Blood sugar coats the infection-fighting white blood cells, so they're not able to [get rid of] bacteria as well,” says podiatrist Lee C. Rogers, DPM, associate medical director at the Amputation Prevention Center at Valley Presbyterian Hospital in Van Nuys, CA.

Dr. Lee Rogers

“Fungal toenail and foot infections are common in diabetes,” Rogers says. “You need to have them treated before you get cracks in your skin and bacterial infections.”

Source: Peace FM [2/13/12]

MA Podiatrist Pens Diabetes Chapter in Surgical Text

Dr. John Giurini recently wrote a chapter entitled "The Diabetic Foot" in Fischer's Mastery of Surgery, 6th edition published by Lippincott-Williams/Wilkins.

Dr. John Giurini

Dr. Giurini is chief of podiatry at Beth Israel Deaconess Medical Center.

More Doctors Advising Patients to Exercise

The number of doctors in the U.S. telling patients to get physically active has increased in the past decade, new research shows.¹ In 2010 alone, one in three patients who visited a physician or other health professional had been told to start or maintain physical activity or exercise.

The data showed that physicians appear to be targeting obese and overweight patients. The most recent survey showed that 30.5% of overweight and 46.9% of obese patients were advised to exercise, percentages that were up from 21.9% and 34.8%, respectively, in 2000. In 2010, just 22.6% of adults at a healthy weight were advised to start an exercise program.

1. Barnes PM, Schoenborn CA. Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. NCHS Data Brief, 86, February 2012

Source: Michael O'Riordan, Medscape News [2/13/12]

Editor's Note: PM News is proud to present excerpts from Meet the Masters.

Bret Ribotsky: Doing a peg-in-hole hammertoe procedure is more involved than an end-to-end fusion. Can you bill the -22 modifier to receive a greater reimbursement?

Harry Goldsmith: CPT coding typically includes both comprehensive and component services and procedures. In the case of CPT 28285 – correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy) – the code value presumes you are doing whatever is necessary to correct a hammertoe deformity. The parenthetical example is there to guide you. A common question is, if the work performed to fuse the interphalangeal joint using a “peg-in-hole” technique is significantly greater than just removing the joint cartilage and using K-wires, why shouldn’t I add a “-22” (increased procedural service) modifier to CPT 28285 to be reimbursed more?  And the answer is, the technique used to accomplish the fusion is your choice. The reimbursement, however, is for the fusion. If you decide that your technique is significantly more challenging (to achieve the same result), and you append a “-22” modifier to the correction of the hammertoe code, maybe two things are guaranteed: 1) your claim will not process “cleanly”, but will need to be hand-reviewed (sometimes delaying payment 1-3 months), and 2) the “-22” modifier will be rejected, and the payment will revert to CPT 28285 allowances.

Dr. Harry Goldsmith

If you truly believe that the amount of work you performed (you personally rank it as “significant”) is not adequately reflected in the procedure code description (e.g., the clinical circumstances involve significantly more dissection, working around scar tissue, finding something you weren’t expecting, etc.), then you may want to weigh your coding/reimbursement options through the use of the “-22” modifier. Keep in mind, however, these circumstances are the exception, not the rule. Payers have a tendency to be very stingy in allowing “-22” modifier increased reimbursements. 

Dr. David Zuckerman

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). This week's guest is laser expert Dr. David Zuckerman. You can register for future events by clicking here

RE: Insurance Card Scanner?

Can someone recommend a good scanner to be used for patient insurance cards?

Marc S. Glovinsky, DPM, New Orleans, LA

Query: Checking the Status of Your Attestation

Is there a way to check the status of your attestation to 'meaningful use' once you have already done so?

Lori Weisenfeld, DPM, New York, NY

Response: Click on this webpage:

Login at bottom of page with your username and password.
[Welcome Screen] displays
At bottom of page click on (Status)
[Registrations] for your NPI will display.
(Select) your account.
Click on {Status} tab across top.

Madison Brawner, DPM, Savannah, GA

Codingline subscription information can be found here
APMA Members: Click here for your free Codingline Silver subscription

RE: Hyperhidrosis (Mark Birmingham, DPM)
From: Barry Mullen, DPM

Hyperhydrosis is usually idiopathic, can be hereditary (check family history), or secondary to an underlying systemic process that stimulates the sweat glands. Two systemic etiologies that immediately come to mind and should be ruled out are hyperthyroidism and hypoglycemia. The main conservative treatment option is the use of topical astringents. When unresponsive to topicals, anti-cholingerics such as Robinul may be tried. If one does not have a familiarity or comfort level with this medication and its side-effects, a referral to an endocrinologist is appropriate.

Botox has been tried by some clinicians with sporadic success. Finally, a last resort surgical option exists designed to eliminate the sweat gland's nerve innervation (endoscopic thoracic sympathectomy). I'm unsure if this procedure is performed anywhere in Illinois, but I believe the Mayo Clinic provides this treatment option for recalcitrant cases.
 
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

RE: Gouty Tophi, 3rd Digit (Charles Baik, DPM)
From: Elliot Udell, DPM

Addressing gouty tophi from a surgical perspective without addressing hyperuricemia is not doing the patient any favors. Unlike localized osteomyelitis, which some of us choose to address surgically, gout might be a local, pedal condition today, but if the hyperuricemia is not properly managed, it can affect other joints tomorrow. The patient's eating habits also need to be addressed. We have all had patients who we have seen in the emergency room who are willing to take uric acid lowering drugs but are also willing to walk into a restaurant and eat a red juicy steak. 

The two oral drugs most commonly used to lower serum urate levels are allopurinol and Uloric (feboxustat). Renal status will affect if and how much allopurinol you can give. Many diabetic patients have renal problems. Uloric, on the other hand, is not affected by renal status but is not FDA-approved for the treatment of tophi even though it may prove to be effective. One drug which might be a choice is called Pegloticase which is administered IV for refractory cases of gout. It is highly effective, but I would caution anyone contemplating its use to work with a good physician who has experience with this drug.  
 
Since the patient described has multiple medical conditions, it is highly advisable that you co-manage this patient with a good internist or rheumatologist. If the patient is resistant to diet modification, referral to a mental health professional trained to work with food addictions should also be considered.
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Gouty Tophi, 3rd Digit (Charles Baik, DPM)
From: Stephen Pirotta, DPM, Keith Gurnick, DPM

I have dealt with a few of these and think the best, most effective, least expensive, and long lasting resolution is amputation of the digit. I do them in my office. It's a 15 minute good solution that best serves the patient. Managing future episodes is then the next goal for their PCP.

Stephen Pirotta, DPM, Bentonville, AR, iwillctrnow@yahoo.com

Since the toe does not appear to be infected, you could leave it be and suggest shoe modifications or open sandals (when appropriate) so that there is less pressure against the toe. I would caution you to be very careful administering additional cortisone shots into the toes of elderly diabetics.

A peripheral vascular study to assess small vessel circulation would be prudent to help guide your surgical decision. If you choose to open the toe and remove the gouty deposits, be aware that the chalky material will be invested all over the area, including the dorsal tendon and all the surrounding tissues and you will be scraping, dissecting and curetting that small area for 30 minutes. Removing this gouty material may further devascularize a toe that could be already somewhat compromised, and if the toe does go on to heal, the gout and tophi deposits could return in the future.

Obviously, it goes without saying that you should also...

Editor's Note: Dr. Gurnick's extended-length letter can be read here.

RE: Nail Dystrophy (Tip Sullivan, DPM)
From: David Zuckerman, DPM

Looking at the structure of the foot could well reveal the cause of these greenish toe nails. There may be a Pseudomonas infection (clincial odor as well as culture may be needed). It appears from the photo that the hallux toes are elongated compared to the 2nd toes. I would do a gait analysis as well as a range of motion of the first MPJs to evaluate hallux function.  

I would debride the nails as far back as possible. If there are areas that won't debride, I would have the patient apply 40% urea to the toe and toe nail bed and return for weekly debridements. Then, I would use a laser to treat the nail, skin, and nail bed. Results should be good, however without a higher toe box and an evaluation of the first ray function, these results might be short-term.

David Zuckerman, DPM, Cherry Hill, NJ, footcare@comcast.net

RE: Podiatric Physicians Practice Podiatric Medicine: RIP Podiatry (Alan Sherman, DPM)
From: Robert Scott Steinberg, DPM

We are foot and ankle surgeons, and that is no lie! Within the year, our podiatry section became the Department of Podiatric Medicine and Surgery. Members of the Department of Surgery tried to stop the designation, but that is the name adopted, and then approved by the hospital's board of trustees.

Codingline & PM News
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The Greenbrier Coding & Practice Management Workshop - August 20-22
(Following the 2012 APMA Annual Scientific Meeting in Washington, DC)  

The Greenbrier, White Sulphur Springs, WV

Speakers: Harry Goldsmith, John Guiliana, Barry Block, Michael Brody, Paul Kesselman, Jonathan Moore, Rem Jackson, Chad Schwarz, and other nationally-known authorities. 

Earlybird Bonus Until March 1 - Save $50 

Click Here for information or to Register

SPACE AVAILABLE - NYC & LI

Office to sublet and share - East 60th Manhattan, and Plainview, Long Island. access to an MRI, Joint Commission certified operating rooms, digital x-ray, diagnostic ultrasound, and access to a multi-specialty ambulatory surgical center. Also availability E 22nd between 2nd and 3rd and E 70th off 3rd. Turn-key operation - no investment needed 516 476-1815 PODO2345@AOL.COM

ASSOCIATE POSITION - SOUTHERN CALIFORNIA

Full-Time Associate needed for busy multi-office locations in LA, Orange, San Bernardino and Riverside counties. SIX FIGURE SALARY PLUS BENEFITS!! Knowledge of Spanish is helpful. Good mix of office patients, house calls, some surgery, etc. NO NURSING HOMES!! Needed in July, 2012 or sooner. If interested, please send contact information and CV to scpodgroup@yahoo.com

ASSOCIATE POSITION - MIAMI, FLORIDA  

well established modern practice all phases of podiatric medicine/surgery needs associate. Respond with CV and cover letter. podistristinsouthflorida@aol.com 

ASSOCIATE WANTED - MANHATTAN

Park Avenue office seeks personable, capable and experienced podiatrist, part-time. Office needs coverage March 21 until May 2, possibly longer, with one day a week position available after May 2 .Growth potential. Please fax CV to 212-889-6150 or email info@healthyfeetny.net

ASSOCIATE POSITION - UPSTATE NEW YORK

Outstanding Opportunity. Our medical surgical group is recruiting a well-trained licensed podiatric physician. Located in Beautiful upstate NY. Full hospital privileges, as well as working with two residency programs. Must be highly motivated and great with patients. Opportunity for growth. Competitive salary and benefit package. Please send CV to associateinfoot@yahoo.com

SOUTHEAST GEORGIA- SAVANNAH & SURROUNDING AREAS

Beautiful weather year round & near the Coast. Opportunity for Early Buy-in. Seeking podiatrist looking to build a career & long-term relationship. Either established practicing physician or new residency graduate. Must be PSR-24/36 trained. Multiple locations. Full range of services with new facilities. E-mail cover letter & CV to melissafoot@pol.net

ASSOCIATE POSITION - SOUTHERN KENTUCKY

Available in beautiful southern Kentucky in progressive, multi-office practice with 6 providers. Excellent base salary, malpractice, full benefit package with 2-year track to partnership. Looking for someone that wants to grow with our practice, work hard and develop relationships with local hospitals and surrounding communities. Strong communication skills, bedside manner and willingness to learn a must. Narrow window for interviews: email CV and letter of interest before March 1: footdocky@gmail.com

ASSOCIATE POSITION - KANSAS CITY, MISSOURI

I'm not just looking for an associate. I am looking for a doctor who wants to build a highly successful career with a doctor who is as committed to their success as he is to his own. Go towww.YourFutureInPodiatry.com to find out about this opportunity.

ASSOCIATE POSITION - NEW YORK

WORK SMARTER NOT HARDER. Join a modern, well-established 42-year-old podiatric medical/surgical practice within a multi-specialty office. Located just 20 minutes from NYC. Must be responsible, compassionate, driven, and self-starter. Enjoy cross-referrals from other specialists and support of medical assistants, office managers, and medical billers with over 50 years combined experience. Utilize modern technology: state-of-the-art diagnostic ultrasonography, fluoroscopy, ESWT (machine is owned by practice), physical therapy, x-ray, circulation testing, NCV, and in-office operatory suite. Very strong and effective advertising/marketing program. No nursing homes, No HMOs, No Medicaid, No Medicare. Must be licensed for podiatry in New York. Send cover letter/CV to: linchpindpm@yahoo.com 

ASSOCIATE POSITION - CENTRAL NJ

Looking for a three-year surgically-trained associate who has entrepreneurial spirit. Partnership guaranteed within three years for the right person. Must be very outgoing and personable. Great opportunity for a person who is confident and a go getter. drwfoot@verizon.net

ASSOCIATE POSITIONS - MULTIPLE STATES

Podiatrist Needed in Missouri, Nebraska, Iowa, Minnesota, North Dakota, South Dakota, Ohio, Texas, Colorado, Oregon, Washington, Arizona, Massachusetts, Rhode Island, Wisconsin, Indiana, Oklahoma, Connecticut and Vermont. Expanding multi-state medical practice seeking podiatrists to service long-term care community residing in nursing homes and assisted living facilities. We offer an established patient base, scheduling, equipment allowance and cover travel expenses. Provide generous compensation, bonus opportunities, disability, health insurance benefits, malpractice coverage and flexible scheduling. Looking for a Podiatrist with excellent skills, able to provide expert and compassionate care to patients. Email CV to: careers@aggeus.org or call 773-770-0140 x300/x305. www.aggeus.org

ASSOCIATE POSITION - MARYLAND

Looking for 3rd associate. Must be personable, well trained and highly motivated. Great locations in Southern Maryland, including an Ambulatory Surgical Center. We currently have EHR, digital radiography, dispensing center and PADNet. Looking for immediate hire! Please send CV to: myfeetfeet@aol.com

ASSOCIATE POSITION – FLORIDA

Emerald Coast on the North Shore of the Gulf of Mexico, a well-established group practice with multi-offices, seeking an associate with opportunity for partnership for a PSR-24/36 Doctor well-trained in foot/ankle/diabetic problems/wound care/surgical and medical podiatric care, covering 3 area hospitals, NO nursing homes. e-mail letter of interest, CV, and references to basewedge@yahoo.com

PART-TIME PODIATRIST NEEDED - LOS ANGELES, CALIFORNIA

Busy podiatrist looking for assistance with patients located in facilities, homes, office, etc. Flexible hours, independence, and great compensation. If interested email CV to or call Terri at 323-353-8103.homefootcare@hotmail.com

ASSOCIATE POSITION – F/T MARYLAND

Looking for a bright, hard-working, personality plus, extremely well trained podiatrist with both top notch surgical and non-surgical skills. Remarkable opportunity with our busy practice. Excellent salary and benefits. Email CV and salary requirements to Marylandpodiatrist@live.com

ASSOCIATE POSITION - ARIZONA

Podiatrist to joint established practice in the Phoenix, Arizona area. Modern office utilizing EMR, Digital X-Ray, ultrasound, full DME, seeking entrepreneurial, ambitious individual who can provide excellent care and expand already existing patient base. Send CV to ArizonaFeet@gmail.com

PRACTICE FOR SALE - BALTIMORE, MARYLAND

Established 40+ year old well-rounded practice of both surgical and non-surgical care with special emphasis on sports medicine. Medicare and BS/private insurance base, no Medical assistance. Needs to transition to a confident well trained individual. Purchase can include building. Contact:podiatrypracticesale@gmail.com

EQUIPMENT FOR SALE 

Koven Doppler, Synthes Titanium Mini Frag screw set, Zimmer & Hall Micro 100 set (all 5 heads including wire driver), Two full major surgical instrument sets, miscellaneous surgical tools including osteotome set (curved & straight). All German stainless steel. Best offer. Retired due to illness. Call 586-675-4311 or 440-285-2827. Dr. Gary Docks.

EQUIPMENT FOR SALE

Cosman Radiofrequency Generator for Sale! Model RFG-1B Like New Condition. Comes with Manual, 17 Dispersive Electrodes, 2 CSK-R 10 Kits, 2 CSK-R 5 Kits, 11 CC RF Cannula 10cm/10mm/22G, 4 CC RF Cannula 10cm/5mm/22G, 1 - 5cm RF Cannula/22G (4mm Sharp Curved Tip), & 2 Replacement Fuses. Asking $10,500 OBO Please Contact: nffpbosk@gmail.com

EQUIPMENT FOR SALE - COOL BREEZE COOT TOUCH VARIA

Cool Breeze Coot Touch Varia. Very low use. You won't find a laser at this price. $39,500. Has about 19 hours of use of it. E-mail for photos, and ask any questions. Will go fast. David Zuckerman DPM  856-229-2939 footcare@comcast.net

EQUIPMENT FOR SALE - ARE YOU CONSIDERING A PADNET UNIT?

If so save thousands of dollars on a lightly used unit with venous option and laptop. Why pay full price for our unit which is in perfect working order. We also have a SIUI CTS 200 ultrasound with 7 mHz probe and SONY printer. Let's Make a Deal!! Call 516-220-8258 today.

PM News Classified Ads Reach over 13,500 DPM's and Students
Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 13,500 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. Weekly ad rates start as low as $115 for a 50-word ad. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451.

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