The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

February 16, 2009 #3,470 Publisher-Barry Block, DPM, JD

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NY Podiatrist Narrowly Escapes Injury During Fierce Windstorm

Fierce winds blew through Long Island yesterday, reaching near hurricane-force gusts that ripped limbs off trees, took over steering wheels and downed utility poles. In Huntington, a 100-foot tree blew down on Ash Place about 8 a.m., crushing Adam Cirlincione's 2008 Acura sport utility vehicle in his driveway. Had it been 10 minutes later, he and his young children might have been in the car. "It's not such a bad day," said Cirlincione, a podiatrist.

Dr. Adam Cirlincione

The tree fell as he, his wife and their two children, ages 3 and 5, were inside having breakfast. It also took out power lines to the house and destroyed part of a fence between his and a neighbor's home. Cirlincione said his homeowner's insurance agent told him that he might not be fully covered. "It'll cost some money, but if you look at it that way, that's all it will cost," he said.

Source: Alfonso A. Castillo. Newsday - McClatchy-Tribune Information Services via COMTEX   [Feb 13, 2009]

Business Booming for TX Podiatrist

The foot business is booming in Groesbeck. Dr. Brian Battles, a Waco podiatrist who sees patients every Tuesday at the new Family Medicine Clinic, has been so busy lately that he is considering expanding his Groesbeck operation. "I'm thinking about opening the Groesbeck office every other Thursday as well," the Hubbard native said last week. Battles has been seeing patients at Family Medicine Clinic since October 2006, but before the new clinic opened last week he shared space with other physicians.

Dr. Brian Battles

"Now we have our own space," he said. "We have three examination rooms plus an office." Battles specializes in feet and ankles, and he handles "problems from the skin to the bone." That includes skin and nail diseases, bunions and reconstructive foot surgery, he said. "I can do the surgeries at either Waco hospital, the Corsicana hospital or in Mexia," Battles said. "Whichever is the most convenient for the patient.  I may be the only doctor in Central Texas who has privileges at four hospitals," he said.

Battles grew up in Hubbard and graduated from Hubbard High in 1992. He graduated from Baylor University in 1998 and later received a doctorate of podiatric medicine from Barry University in Miami. He said working in a clinic with family medicine doctors can be a big benefit to patients, "If one of the other doctors sees a patient with a foot problem, I'm right here," he said. "And, if one of my patients needs to see a family medicine doctor, they can do so without leaving the building."

Source: David Stone, The Groesbeck Journal [2/12/09]
 

Query: Documentation Requirements

I have been contacted by a small rural medical center wanting me to provide podiatry services at their clinic one day a month.  The arrangement is simple, but I have a question about it. They are designated as a "rural health provider."  Their contract pays me a flat fee per patient I see in the clinic. I don't have to bill, collect, etc. They simply take the # of patients I see, multiply it by a price, and pay me each month. It doesn't matter if the patient is seen for routine foot care, or a diabetic foot infection -- it's the same fee. They have told me they are not billing any government agency under my name. My question is this: I'm assuming they are getting some money from the Federal government somehow since they are a rural health provider. How concerned do I have to be with all the billing / documentation rules under this scenario? Since the contract is with the medical center directly, do I have to "worry" about audits etc? 

Alex Dellinger, DPM, Little Rock, AR

Editor’s comment: PM News does not provide legal advice. Regardless of which entity is being billed, documentation should always be a high priority. A licensed professional has the responsibility to accurately and comprehensively document a patient’s condition, diagnosis, and treatment. This protects both the practitioner and the institution for both auditing purposes and potential malpractice litigation.

Query: Modified Bunionectomy Coding

Can anyone tell me what the correct code would be for a Green-Waterman osteotomy procedure for hallux limitus?

Lani Smith, Office Manager, Office of Kash Siepert, DPM, Roseburg, OR

Response: A Green-Waterman-type bunionectomy incorporates a bicorrectional osteotomy of the first metatarsal. Correct coding is CPT 28296 (correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy). The capsular work and ostectomy of the metatarsal prominence are included in this single code, and not separately billable.

Rick Horsman, DPM, Olympia, WA

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RE: Dilated Venous Structure (Mike Boxer, DPM, DPM)
From: Juliet Burk, DPM, Thomas A. Graziano, DPM , MD

I can tell you that dilated venous structures CAN and DO cause pain. One of my patients had a tortuous varicosity in the plantar arch of his foot that caused all kinds of painful symptoms.  I’m all for a vascular consultation—let a trained expert sclerose or excise the affected vein. Refer, refer, refer…
 
Juliet Burk, DPM, Muskogee, OK, juliet-burk@cherokee.org

I would respectfully disagree with Dr. Boxer who stated that "dilated veins do not cause pain." Chronic dilated and static veins do just that. These veins are not functioning, i.e., not draining, and stasis is the result. As long as they remain open, they cause an inflammatory reaction within the vein walls and produce a local phlebitis. They do respond to either sclerotherapy and/or phlebectomy. The current choices of sclerosing agents include sotradecol, polidocanol and sclerodex. Although sotradecol is the only one of these that is FDA-approved, it is the most irritating and one that many in the business refrain from using. A review of the literature will show those interested that the later two agents are used regardless of their so- called "off-label" use.
 
If the vein is not easily accessible, I would suggest an attempt at sclerosing the vein. One can access the vein by inserting a 1 cc tuberculin syringe containing the agent of choice into the area near the vein. Once the needle is passed through the skin, pull back on the plunger. Blood will enter the syringe, assuring you are in the vein. It is then safe to inject the sclerosant. Use some compression post injection, for at least 1 week, 
 
The patient may still experience some symptoms for a short time post-injection. This is normal and reflects the inflammatory reaction you want to create with the sclerosing agent. Once the vein collapses and its walls "stick" together, this inflammation will subside. If sclerotherapy is unsuccessful or if the vein is easily accessible, it would be best to perform a local phlebectomy. Have the patient stand so that the vein engorges and mark it. If the vein is superficial, make a stab incision next to the vein and "hook" it with a vein hook. Once hooked, use a series of hemostats to pull the vein out. Again, follow with compression.  
 
Thomas A. Graziano, DPM, MD, Clifton, NJ, TGrazi6236@aol.com
 

RE: Dancer’s Foot Revisited (Seth Rubenstein, DPM)
From: Multiple Respondents

Dancers have a name for a red foot like the one in Dr. Rubenstein's photo:"Crab Boil." This could be caused by sweat and chemicals, whether it be detergent, fabric softener, adhesives, or other chemicals in natural materials. It could also be a chemical burn. And no, that is not the typical shaped dancer's foot.
 
Robert Scott Steinberg, DPM, Schaumburg, IL, doc@footsportsdoc.com

Dr. Rubensteins’s clinical photo is consistent with psoriasis (note nail changes and absence of toe web involvement). Psoriatic manifestations are exacerbated via the Koebner phenomenon, easily fostered from the digital trauma incurred during en pointe dance. Review your patient's medical history. I suspect you will uncover additional signs and symptoms consistent with this diagnosis and then treat accordingly. Contact dermatitis and lichen planus are also in this differential. Erythromelalgia would typically not create such a well-demarcated color change in the digits as depicted in the picture offered. Approximately 10% of patients with psoriasis exhibit "dactylitis" of the distal IPJ's of fingers and/or toes. As with her skin, en pointe trauma can exacerbate this manifestation. Several x-ray findings exist w/ psoriasis, so I am curious if any images were taken of the forefoot. 
 
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

This is a case of acrocyanosis. Acrocyanosis is frequently confused with Raynaud's phenomenon and erythermelalgia. Raynaud's produces acute vasospasm where one or two digits turn white. Acrocyanosis and erythermalgia look similar because of similar skin color changes.  They can be easily differentiated by skin temperature changes. In erythermalgia, the skin is red and skin temperature is warm to hot. In acrocyanosis, skin is cold and tends to have more of a cyanotic color change. None of these conditions have anything to do with footwear.  In this picture, the diagnostic giveaway is the second toe with the cyanotic color.

Mike Boxer, DPM, Woodmere, NY, mcbdpm@aol.com
 

RE: EMR Pricing (Brad Shollenberger, DPM, Reading, PA)
From: Alan Kalker, DPM

Look at emrupdate.com/prices/ for some EMR prices. These are not podiatry-specific programs. Make sure you are comparing apples to apples. Some are EMR only, some PM. You are looking for both. Also, with the anticipated federal stimulus plan, the assumption is that the software will need to be CCHIT-approved which means a higher end system. Still, the GE Centricity program is very costly compared to any of the systems we looked at. We are three doctors using eMDs and it has worked well for us. It is a very complete program. Though not a podiatry-dedicated package, it does have many podiatry-specific templates. The templates are easy to modify or write from scratch. The program has easily paid for itself in about 3 years.

Too often. doctors look only at the upfront costs and forget to look at ease of use, ability to change templates, how often the software is updated and how good the help line is when you need it. Also, different programs have different hardware requirements that can have an enormous impact on the final cost. Our software expense was less than half the total when you include the needed hardware upgrades and training.

Alan Kalker, DPM, Middleton, WI, ajkalker@wisc.edu
 

RE: In-Office Physical Therapy (Lynette Thomas, DPM)
From: Jonathan Moore, DPM

Physical therapy services offered within a podiatric practice can be an incredible way by which we can improve care and achieve better outcomes in our practices. The services a PT can offer in your practice are not only a direct extension of what we do at physicians and surgeons, but these services offer a great way to improve the practice bottom line. I have had physical therapy in our office for 4 years now and have employed a full-time PT for two years during that time. 

There are some key resources that you will need before entering into these waters.
1. I recommend a consultant to guide you in navigating what rules and LCDs govern physician-owned physical therapy in your state. Some states do not allow a PT to work for a physician.
2. A good consultant who I have had experience with among others in the AAPPM is Jon Segal (drsegal@serenityhealthsystems.net). His group is thorough and collaborates with a good health care attorney.
3. There are Stark implications, but physical therapy can be performed legally and ethically in a physician office. A good consultant (like the one above) will have a healthcare attorney that will provide guidance as to how you can avoid problems. You will need a compliance plan and your practice may need to change its designation as a multi-disciplinary group.
4. Having staff perform physical therapy services that have not had formal physical therapy training is unethical and inappropriate in the eyes of Medicare/Medicaid.
5. The AAPPM is now offering tools and educational programs on in-office physical therapy as well as other ethical and outcomes driven ancillary services one can provide in their office. (aappm.org)
 
Jonathan Moore, DPM, Somerset, KY, jonkim12000@yahoo.com
 

RE: Robber Gets Mean for Foot Cream (Bret Ribotsky, DPM)
From: Jonathan B. Purdy, DPM, Jeffrey Kass, DPM
 
I was wondering if Dr. Ribotsky can share with us which cream the guy stole - I must be carrying the wrong brand in my office. My product doesn't seem to want to move that fast.
 
Jeffrey Kass, DPM, Forest Hills, NY

You wouldn't happen to know the brand name of the foot cream would you? That would be quite a testimonial.
 
Jonathan B. Purdy, DPM, New Iberia, LA

ASSOCIATE POSITION – BRONX, NY
 
NYNJ Foot & Ankle Associates www.nynjfootandankle.com is a rapidly growing practice that was started 12 years ago. All aspects of foot and ankle services are provided including large surgical volume, diabetic wound care, trauma and general podiatry. We are now hiring part-time for our Bronx, NY location. Excellent salary opportunity for the proper candidate.  A partnership track is available for the proper candidate. Fax CV to 718-547-9232

ASSOCIATE POSITIONS - CALIFORNIA

Three podiatrists needed for busy North Hollywood office.  Full-time Monday-Friday 8am-2:30pm.  No weekends and no call. Pay negotiable. New podiatrists are encouraged to apply. Please email resume and salary request to Coasttocoastpodiatry@yahoo.com

OFFICE SPACE FOR RENT - SEATTLE, WA

Full-service, state-of-the-art podiatry office is offering office space for an independent podiatrist or podiatry group. We have digital X-ray, PADNET, physical therapy equipment, all podiatry equipment and staff to assist you to make the most out of your podiatry practice. Our office is conveniently located close to North West and Stevens Hospital right across from North Gate Mall. You can send your letter of interest to: seattlefootdoctor@yahoo.com or call 425-223-9588

ASSOCIATE POSITION – CINCINNATI, OHIO

This is your once-in-a-lifetime opportunity to join one of the most successful practices in the United States. No seniority system. If you are motivated and have completed a PSR24-36 residency, your income is limited only by your enthusiasm and desire to achieve. Fax resume to: 513-577-7261 or E-mail resume to Kroesch4poh@aol.com

ASSOCIATE POSITION -SOUTHERN NEW JERSEY

I’m looking for podiatrist who wants additional practice hours. Perfect for combining your own practice with an additional income. Must be on Aetna Insurance, Horizon Blue Shield, Medicare, and most commercial carriers. I am looking for someone who has a desire to learn how a very successful practice is run, so that I will be able to have time away from my practice. Payscale to be discussed. Could lead to partnership or sale. E-mail contact information, CV, and why you would be perfect for this opportunity. Contact foot.care@verizon.net

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

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.

NEEDED  CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

ASSOCIATE POSITION – SOUTHERN CALIFORNIA 
 
FLEXIBLE, Part-Time or Full-Time opportunity with growing podiatric medical group in a busy office in Los Angeles. CURRENT DME supplier number a plus. No nursing homes. Most days are available with flexible hours available. If interested, e-mail scpodgroup@yahoo.com.
 

PRACTICE FOR SALE – ANDERSON, INDIANA

Well established office in Anderson Indiana for sale. Seller currently works 3 half-days per week and gross over $200K. Excellent locations and growth potential. Very podiatry-friendly community. All equipment and furniture included. Seller is willing to help with transition. Contact seller at mddpm@sbcglobal.net for more information.

PODIATRY ASSOCIATE WANTED – NJ

Northern NJ. Bergen County Must be well-trained. No nursing homes or house calls. Modern well-equipped office. Digital x-ray and ultrasound. Excellent pay and opportunity. Must have NJ license. Call 973-472-4700.

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

PRACTICE FOR SALE - CENTRAL FL

Practice sale at bargain, in beautiful growing area; 2000 sf building fully equipped/ designed for podiatry; excellent location, exposure; near hospital& wound center. Great opportunity for expansion; good insurance climate. 352-357-7499 / E-mail windnwave@earthlink.net

ASSOCIATE POSITION NORTHERN CALIFORNIA

Need associate in busy office in two locations. Hospital privileges
available. Emphasis on wound care. All aspects of Podiatric Medicine and Surgery. Associate position to lead to partnership and buyout. Please contact jimf@humboldt1.com

POSITION WANTED In NY or NJ AREA

Board certified podiatrist seeks part-time position in NY/NJ area. Experienced in all aspects of podiatry, including Diabetic Foot, Surgery and in patient care. I'm available Tuesdays and Thursdays. Please contact me at nyraider1@yahoo.com

 
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