The Voice of Podiatrists

Serving Over 10,700 Podiatrists Daily

February 27, 2008 #3,179 Editor-Barry Block, DPM, JD

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Minimal Downtime From Shockwave Therapy: NC Podiatrist

“Some people suffer from plantar fasciitis for months, sometimes years,” said podiatrist Dr. Kirk Woelffer. “Those people usually progress to a surgery where part of the ligament is cut and other procedures are done to help control the irritation in the area.” Shockwave treatment offers similar results, with no cutting or anesthesia. It operates with the same technology as a lithotripsy machine, causing what Woelffer calls a controlled injury.

Dr. Kirk Woelffer

“The same focused sound wave energy that breaks up kidney stones stimulates ligaments to heal,” he said. The patient’s foot is numbed in advance of the procedure, so they don’t feel the pinprick-like shocks, as many as 3,800 per treatment. The whole procedure lasts about 20 minutes.

Patients wear a boot on their foot for a few days, sometimes a few weeks, to give the healing process time to start. Complete results usually take about four months. But the downtime is minimal compared to surgery. Because of the low risk to the procedure, Woelffer says most patients are eligible.

Source: Julie Henry, NBC17, [2/25/08]

OH Podiatrist Indicted on Felony Drug Charges

A U.S. Federal Grand Jury has indicted a Western Hills physician on a felony charge of conspiring to distribute prescription drugs. Court records stated Dr. Mark Stieby wrote prescriptions for the drug Percocet, a pain reliever, to another individual and would meet him in parking lots in Kenton and Boone counties to exchange money and split half the drugs.

The court documents also stated the podiatrist is licensed in Ohio but is not licensed in the state of Kentucky. The records noted that Stieby has admitted an addiction to pain medicine. Dr. Stieby was released on bond and will be back in court in March. If convicted, he will face up to 20 years in prison and a fine up to $1 million.

Source: Shannon Kettler, WCPO-TV (Cincinnati) [2/25/08]

Alcohol Hand Rubs Not Enough to Curb Hospital Infections

Making alcohol-based hand gels common and accessible in hospitals increases their use and cuts the amount of microbes on the hands of nursing staff. But it does not cut the rates of device-associated infections, illness caused by drug-resistant bacteria or cases of Clostridium difficile, says a study published in the January Infection Control & Hospital Epidemiology.

Authors and other experts say this situation is not because the products are ineffective. Rather, increases in their use need to be carried out in conjunction with other infection control strategies beyond current recommendations. For example, the October 2002 Centers for Disease Control and Prevention guidelines urged fingernail lengths of no longer than a quarter of an inch.

Improving hygiene and, more important, decreasing nosocomial infections, has long been a focus of various medical societies, public health agencies and quality improvement organizations. American Medical Association policy urges everyone, including health professionals, to consider hand washing a priority.

Source: Victoria Stagg Elliott, AMNews [2/25/08]

Query: Diagnose This Lesion

My patient has essentially a non-tender, non-ulcerating lesion, sometimes producing chronic fissures to the plantar skin. It is only minimally pruritic and has not responded to strong topical steroids, multiple types and vehicles of anti-fungals.

Diagnose This Lesion

Bacterial cultures and fungal cultures are inconclusive. The affected skin is the feet only. My guess is a pemphigoid reaction. A biospy planned next. Any suggestions as to a diagnosis?

Philip E. Larkins, DPM, San Marcos, CA

Query: Keller Revision Coding

I have a new patient that had a Keller-type bunionectomy performed six months ago by another doctor. She is still in pain at the level of the phalanx-metatarsal head contact point. It is clear from the x-ray that very little of the base was removed.

I am planning on going in to resect more of the phalanx and purse-string the capsule. Since this is not a full Keller procedure, how should I code it?

Bob Kornfeld, DPM, Lake Success, NY

Response: Since you are not performing another Keller-type bunionectomy procedure, I would suggest billing CPT 28124 (ostectomy, partial, phalanx.

This reflects exactly what you are doing, and seems reasonable to me.

Howard Zlotoff DPM, Camp Hill, PA

Codingline subscription information can be found at:
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RE: Topical and Oral Treatments for Tinea Versicolor (Frank DiPalma, DPM)
From: G.. Dock Dockery, DPM, Carl Ganio, DPM

If tinea versicolor is severe or doesn't respond to over-the-counter medicine, the patient may need a prescription-strength topical or oral medication. These topical medications for tinea versicolor treatment include the azoles (i.e., clotrimazole, ketoconazole, and miconazole). They are applied t.i.d. for 10-14 days. Other topicals include selenium sulfide (Selsun) 2.5% lotion, ciclopirox (Loprox) lotion, and ketoconazole (Nizoral) shampoo.

Oral treatment for tinea versicolor is simpler and easier for the patient in many cases. These include ketoconazole tablets Nizoral), itraconazole (Sporanox) capsules and fluconazole (Diflucan) tablets. With ketoconazole, a 10-day 200-mg daily therapy or a single-dose 400-mg treatment are popular, both with comparable results. Fluconazole is recommended as a single 300-mg weekly dose for 2-4 weeks or 400 mg single dose. Itraconazole is usually given at 200-mg/d for 7 days or 200-mg/every other day for 7 days. Oral griseofulvin and oral terbinafine are not considered effective treatments for tinea versicolor.

Even after successful treatment, the patient's skin color may remain uneven or discolored for several weeks. Also, the infection may return in warm, humid weather and the patient may need to be treated again.

G. Dock Dockery, DPM, Seattle, WA, gdockdockery@aol.com

Here's the plan: At the start of treatment, all clothes, sheets, and towels should be laundered. No sharing of towels, bedlinens, etc. It is easily passed to other family members... but just from the above, not just casual contact with the skin. Topically, one can use sulphur soap daily. At night, apply Selsun Blue (selenium sulfide) shampoo to the affected skin, and shower off in the morning. Oral Lamisil for one month or Nizoral. The skin is very photosensitive with this condition, so it is not unusual to see white, brown, or red patches. Hence "versi color" .... these patches can peel & burn easily in the sun until clear. We used to call them "sun spots" as kids. The combination of oral and topical is best, but if caught early, and the patches are small... try topical first.

Carl Ganio, DPM, Vero Beach, FL, drcarlganio@bellsouth.net

RE: DPM’s Still Prescribing Lac-Hydrin? (Marc Greenberg, DPM)
From: Elliot Udell, DPM

Dr Greenberg brought up a very interesting topic that has tremendous ramifications in terms of practice management issues and the philosophy in which we practice. The fact that the company that makes Lac Hydrin does not come to our offices and give us all of the "freebies ' that we love receiving is a blessing in disguise. Go to medical conferences. Visit the booths. Read Podiatry Management and other journals. There are countless products available to control dry skin conditions, tylomata, onychomycosis, and other foot conditions that we can purchase and dispense directly to our patients. These are most often less expensive than those provided by major pharmaceutical firms, are often more effective and by dispensing them. We not only provide a good service for our patients but we help our bottom line.

For those of us who still cling to the philosophy that physicians should only write prescriptions and never dispense, do visit your local plastic surgeons, dermatologists, ophthalmologists and other specialists who have been in the business of dispensing, skin care, eye care and other products for more than a quarter of a century. By not dispensing quality foot care products, we are not being better doctors. We are being dinosaurs.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Antibiotics for Dialysis Patients (Jim Clark, DPM)
From: Richard Gosnay, DPM, Robert P. Wunderlich, DPM

No doctor should ever stop another doctor's prescription. The neurologist that Dr. Clark described was dead wrong. I commonly call other doctors when I am concerned about dosing or an interaction. But for me to stop another doctor's prescription without speaking with that doctor is beneath standard of care in my opinion.

The concern with any renal failure patient is whether or not a drug will be cleared during dialysis. Most antibiotics are. In those cases, the patient gets a new dose after dialysis. This is an excellent time for the patient to get an iv dose. If I have any question, I call a pharmacist in my hospital, which is also our local dialysis center. (Incidentally, I was always amused by doctors who frown on giving potentially nephrotoxic drugs to patients on dialysis. Yeah, we wouldn't want to damage those dead kidneys, would we?)

Richard Gosnay, DPM, Danbury, CT, glabroushead@gmail.com

It is okay to use Bactrim on dialysis patients. The medication should be prescribed 1 tablet PO Q24h, AFTER dialysis (ref. Sanford Guide to Antimicrobial Therapy, 2001, pg 122). I agree with calling the nephrologist prior to prescribing the medication, however. They will often offer to have their nursing staff administer the medication immediately after dialysis (if it is an IV antibiotic).

Robert P. Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com

RE: Jake Bos, DPM

I knew Jake when I was a podiatry student at NYCPM. He was such a nice guy, always willing to help his fellow students. Although I have not seen him in years, I was saddened to hear of his legal trouble and death. My heart goes out to his family.

Gerald Mauriello Jr., DPM, MA

RE: New HCPCS Code for Ankle Foot Orthoses Replacement Material
From: Paul Kesselman, DPM

Effective April 1, 2008 a new temporary "K" code (K0672 – Addition to lower extremity orthoses, removable soft interface, all components, and replacement only, each) will be established for replacement interface material. Each DME Medicare carrier (except for DME MAC D) has posted this separately over the last few days with some conflicting statements. This has been brought to CMS’ attention. The exact pricing and coverage limitations have also not been posted by either the DME Medicare Administrative or Program Safeguard Contractors. As soon as more information is available, it will be posted.

Paul Kesselman DPM, Woodside, NY, pkesselman@pol.net

RE: ACFAS to Poll Members on Membership Policy
From: Narmo L. Ortiz, Jr., DPM

With all due respect to Dr. Toepp Neuhoff, isn’t she contradicting herself by resigning from ACFAS? And, once she resigned, she still wants to cast a vote? If I am not mistaken, most professional organizations make legislative decisions without polling their membership. The decisions are made by the governing boards that are active at the time those decisions are made.

In comparison, look at the situation with the restrictions imposed by ABPS to become rearfoot certified. The decision for imposing the requirement of at least two years of a podiatric surgical residency was not taken to a membership poll. Should the members affected by this decision resign from ABPS?

It is time for podiatric medicine to define its path once and for all and stop the internal conflicts! In order to seek parity with the MD/DO degree we need to unite, define our profession, be proud of what we do, and stop the egotistical bickering!

Narmo L. Ortiz, Jr., DPM, Cape Coral, FL, nlortizdpm@embarqmail.com

PRACTICE FOR SALE - PORT ST LUCIE, FLORIDA

The office is 0.2 miles away from the hospital. Good mix of Medicine, Surgery, Wound care, and general podiatric care. Wound care center privileges available. No HMO's. Please call 1-772-475-7920 or derrico@pol.net for details

PRACTICE FOR SALE - MINNESOTA: PRIME LAKES AREA

Great place to live and raise a family. $400+K yearly gross with continued growth and potential. Good mix of general podiatry & surgery. Hospital privileges available. Fully computerized, electronic notes, with capability to go completely paperless. Recently remodeled office, 5 tx/procedure rooms, well-equipped in owner-occupied building (for sale or lease). 260 402-7490

ASSOCIATE POSITION – CONNECTICUT

Connecticut- Part time or Full time position available for a PSR 24 trained Podiatrist in the New Haven Area. We are seeking a hard working, ethical, charismatic practitioner for a well rounded established office Please email resumes to Surgeonseven@aol.com. Position available ASAP or July.

ASSOCIATE POSITION - FLORIDA , NAPLES

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills to join multi-office practice. Hospital privileges available at 648 bed hospital system, 200 bed hospital system and multiple surgical centers. Candidate should have the skills and desire to perform rearfoot surgery including Charcot reconstruction and ankle surgery. Florida has a great scope of practice law and we rotate for ER call at all 4 hospitals. Candidate needs to be ethical and motivated. Established practitioner or new practitioner OK. Base salary, percentage, benefits including 401K. Fax CV to (239)566-8778 or Email CV to Drgordon@gulfcoastfootcare.com

PRACTICE FOR SALE - AUSTIN, TEXAS

15 year established practice with good mix of surgery and clinical patients. Nice office condo for sale with practice or lease. Current podiatrist will transition the practice. 300-400K yearly gross. Flexible payment options MRobsonDPM@aol.com

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, 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

PODIATRISTS TO SHARE OFFICE SPACE - BROOKLYN, BRONX

Office space to rent on busy 737 Nostrand Avenue, Brooklyn. New Bronx building and offices at 1250 E 223 St. Bronx. PRIVATE OFFICE, 3-4 treatment rooms, separate receptionist area, waiting room and 2 bathrooms.CALL CRISPIN ADAMS: (917) 301-6284

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. 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 -- www.homephysicians.com

P/T ASSOCIATE POSITION - QUEENS, NY

10 yr old practice seeks motivated, surgically-trained individual. Fax CV with hours available to (718) 458-0053.

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently four (4)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

ASSOCIATE WANTED -BOCA RATON-DELRAY BEACH AREA

Great opportunity-must be hard-working, reliable, Responsible and good with patients & staff-surgical Training a plus-partnership after 1yr. Florida License required fax resume to 561-865-2225.

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

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