The Voice of Podiatrists

Serving Over 13,500 Podiatrists Daily

March 07, 2012 #4,403 Publisher-Barry Block, DPM, JD

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Wearing High Heels Can Cause Knee and Back Problems: FL Podiatrist

According to Dr. Shelley Garrow of A Step Ahead Podiatry in Palm Bay, problems caused by elevated heels where the shoe-wearer is walking on the balls of her feet extend well beyond the lower leg: “They can cause knee and back problems, too,” she says. "You are not meant to put two to four times your body weight on the balls of your feet,” Garrow adds.

Dr. Shiela Garrow

She’s not impressed by arguments that high heels make a better backside, either. “I hear women say high heels make their butts look great, and that’s because having the feet pushed forward pushes the behind out, not the natural way to walk,” she says. “Think of your center of gravity and then think of the way you walk; when you walk in heels, you are thrown far forward. You can hurt your back badly.”

Source: Lyn Dowling, Florida Today [2/22/12]

NYCPM Students Win First Place in ACFAS Student Poster Competition

Four NYCPM students, under the direction of faculty member Johanna Godoy, DPM, won first place in the recent ACFAS student poster competition at the annual ACFAS Scientific Conference in San Antonio, Texas.  

NYCPM students Britton Plemmons, ‘13 (left) and Spencer J. Monaco, ‘13 (right) with their poster

The poster titled "A Rare Incidence of a Fibrosarcoma in the Plantar Foot that Mirrored Fibromatosis: A Case Report" was submitted by NYCPM students Britton Plemmons ‘13, Spencer J. Monaco ‘13, Samantha DelRegno ‘13, and Todd M. Chappell ‘14.

Sprained Ankles Can Be Complicated—and Misdiagnosed: TX Podiatrist

Ankle sprains may be one of the most common injuries, but they’re also commonly misdiagnosed. That’s because the two major types of sprained ankles—high ankle sprains and lateral ankle sprains—often look the same, even though they affect entirely different ligaments. Surgeons took a closer look at the treatment of ankle sprains at the Annual Scientific Conference of the American College of Foot and Ankle Surgeons in San Antonio last week.

Dr. Marque Allen

The less common type—a high ankle sprain—is often mistaken for a lateral sprain. Misdiagnosis can delay getting the right treatment—and that can impair recovery. “One problem is that the symptoms of high ankle sprains parallel those of the lateral ankle sprain, which occurs in the lower ankle area,” says Marque Allen, DPM, FACFAS, foot and ankle surgeon from San Antonio, Texas and a Fellow of the American College of Foot and Ankle Surgeons.

PA Podiatrist Charged With Aggravated Assault

A local foot doctor was arrested late Friday after throwing a purse at his girlfriend, which left her lip so severely cut that she will be permanently disfigured, according to a criminal complaint. Dr. Elmo Baldassari, 43, threw his girlfriend, Kara Schmidt, to the ground when she went to leave his home Friday night, according to a criminal complaint. Dr. Baldassari was charged with aggravated assault, simple assault, false imprisonment, disorderly conduct, and harassment.

Source: Denis O'Malley, The Times Tribune [3/5/12]

What's New in Meaningful Use Stage 2

The Centers for Medicare & Medicaid Services released a proposed meaningful use rule for the next stage of the EMR incentive program, which for some doctors will start in 2014. There are several key differences between stages 1 and 2 for physicians. 

Comparison of Stage-1 vs. Stage-2 Requirements

Source: Centers for Medicare & Medicaid Services, Electronic Health Record Incentive Program -- Stage 2, Feb. 23; Medicare & Medicaid EHR Incentive Program, Meaningful Use Stage 1 Requirements Summary, 2010, via AM News [3/5/12]

Query: Centrifuge-less PRP   

I recall seeing an ad for a company that has a centrifuge-less PRP system. The separation of the platelets occurred by gravity. Does anyone know the company I am trying to recall?
 
Jeffrey Kass, DPM, Forest Hills, NY

Query: Wound Treatment Coding Question

When we see a diabetic patient with a foot wound, we generally dictate that they are diabetic, have a wound, where it is located, and how it was treated. On the superbill we check, for example, ICD-9 250.60 (diabetes with neurological manifestations; type II) and ICD-9 707.15 (ulcer, toes) indicating that the patient is diabetic with a complication and a foot/toe wound.

We are now being told by the coders at our hospital that we must also dictate in the note that the diabetic patient has a "diabetic foot wound" or Medicare will deny the claim if reviewed because the documentation will not support the claim. We claim that the ICD-9 codes tell you that the patient is diabetic and has a foot wound - but that there is no "diabetic foot wound" code. Are we just being difficult or is Medicare really requiring us to be that redundant?

Kevin Brattain, DPM, Peoria, IL  

Response: Actually, the coding of a diabetic ulcer would be ICD-9 250.80 - ICD-9 250.83 (depending on type diabetes) - diabetes with other specified manifestations. ICD-9 specifically instructs the coder to also bill ("use additional code to identify manifestation"):
...any associated ulceration (ICD-9 707.10 - ICD-9 707.19, ICD-9 707.8, or ICD-9 707.9)

The diabetes with neurological manifestation code does not sufficiently validate your care/treatment of a diabetic foot ulcer. ICD-9 250.8x plus the appropriate foot ulcer ICD-9 code does. This may seem picky, but it happens to be ICD-9 coding guideline. What you may be looking at as redundancy, payers are looking at as consistency and validation (ICD-9 coding matches [makes sense billing with] the wound care CPT code which is all evidenced in the medical record). All must tell the same story, or, at least ICD-9 to CPT inconsistency or disconnect on the claim, will result in reimbursement denials.

Harry Goldsmith, DPM, Cerritos, CA

Editor's Note:  Dr. Goldsmith will be lecturing at the upcoming Greenbrier Coding & Practice Management Seminar, August 20-22 (following the APMA National Meeting. For details click here.

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

RE: Lapidus or Fusion (Philip Graham, DPM)
From: Gino Scartozzi, DPM, Michael Forman, DPM

Upon evaluation of the radiographs and the clinical information presented with this case, I suggest the following:
 
1. The first metatarsal-phalangeal joint demonstrates 55 degrees of dorsiflexion with "mild" pain on the end ranges of motion only. Why would fusion be considered with the near-normal ranges of motion noted and the pain being described as "mild" on end ranges of motion only? If pain was noted throughout ranges of joint motion, fusion should be considered. The preservation of the joint would certainly be more advantageous than fusion in the case of this 67 year old female. The distal metatarsal cartilagenous adaptation can be corrected with a Reverdin-Laird osteotomy with peripheral exostectomy of osteophytes about the first metatarsal head;
 
2. The faulting noted between the medial and middle cuneiform bones and the high intermetatarsal angle certainly contribute to the instability of the first ray. A Lapidus procedure could be considered and would offer an advantage over the closing base osteotomy to provide better post-operative stability of the first ray;
 
3. Most importantly and not mentioned, the second metatarsal-phalangeal joint demonstrates Frieberg's infraction with arthropathy. The second metatarsal protrusion is elongated pre-operatively as compared to the first metatarsal and will be made worse with any bunion procedure selected. A shortening osteotomy of the second metatarsal with post-operative orthotic management would be recommended.
 
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com

It was upsetting to read Dr. Brower's response to the case Dr. Graham presented. While I may be wrong, it seemed that Dr. Brower was accusing Dr. Graham of operating on something "over his head." This forum affords us the opportunity of getting a second opinion. A response given in this light only denigrates the writer, not the questioner. I hope an apology follows. Dr. Brower did not give us any suggestions at to which procedure he would do.

Michael Forman, DPM, Cleveland, OH, im4man@aol.com

RE: Painful, Discolored Toe (Chuck Ross, DPM)
From: Barry Mullen, DPM

Yes, it sounds very much like Raynaud's Disease, which often is accompanied by the kind of changes described in this case. The toe's length may contribute to that appearance through repetitive microtrauma. Your Northeast practice locale and time of year is certainly conducive. Is the toe temperature cool? Does the appearance improve with warming of the part? Does the patient complain of burning discomfort (vasospastic ischemic pain)? Those are corroborative of vasospasm. On the other hand, does the toe's discoloration blanch when pressed? If NOT, then think vascular tumor; given the skin appearance description, think hemangioma, glomus tumor, etc.
 
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

Without a picture, we are all guessing, but consider pernio (chilblains). Usually, it will self-subside in 3-4 weeks. The feet must be kept warm and dry. Steroidal creams are considered, but I sometimes use them if there is much skin irritation. Cessation of smoking is advised. Order an arterial Doppler study. I usually run a basic arthritic panel with an ANA, because occasionally it can be linked to an autoimmune disorder. If you are not sure, biopsy. 

Robert P. Thiele, DPM, Denville, NJ, drthiele@comcast.net

RE: Discharging a Non-Compliant Patient (Jeff Mennuti, DPM)
From: Howard R. Fox, DPM

Discharging a non-compliant patient is a prudent thing to do so that you can sleep better at night, and it very well may serve to limit your liability, but nothing will “exonerate” you from liability. In the course of my work as a claims consultant across numerous medical specialties and many hospitals, I can’t tell you how often doctors and hospitals are named in cases, despite the patient leaving against medical advice, or even eloping altogether.
 
What you’re doing by documenting the patient’s refusing to follow your advice and by eventually discharging the patient is making for an excellent defense. But unfortunately, you can’t remove the possibility of a lawsuit, no matter how insanely stupid your patient chooses to act and not heed your advice.
 
Howard R. Fox, DPM, Staten Island, NY, fox.howard@gmail.com

RE: ABPS Name Change
From: M. W. Aiken, DPM

I just received an on-line survey from ABPS. They seem to be interested in changing their name by dropping “Podiatry” from their title and changing their name to The American Board of Foot and Ankle Surgery. The current Board seems to be forgetting the essence of our identity as a profession. They seem to forget who we currently are and where we have come from. The fact is if you assimilate to closely with the MDs, then we basically dilute ourselves into extinction. We will lose the uniqueness that makes us so different and very special from all of the rest. And that seems to be an advantage, not a disadvantage as the Board seems to think that it is.

The Board has become an entity that pushes for more rearfoot and ankle scope, and then the lower leg, and now to do away with the title of podiatry. It's very insecure and small thinking. We can continue to progress and evolve in any way we want, but also maintain our own unique identity as podiatrists. One event is not mutually exclusive of the other as the Board seemed to believe that it is.
 
I vote to keep the name the same and to maintain in the current title “Podiatry.” I am proud to be a podiatrist and don’t want to hide behind the semantics of it all to alter the reality of my true identity.
 
M. W. Aiken, DPM, Baltimore, MD, mwaikne@comcast.net

RE: Podiatry Chairs (Robert Lagman, DPM)
From: Richard Rettig, DPM

I have had a Hill chair for about 15 years and it has held up nicely. I had a boatload of little aggravations with it, based on poor design choices, and I had to work with the company to get the chair to be serviceable. I wrote a letter to the company at the time, stating that all these changes should be made permanent, as they would be needed to meet the needs of a typical podiatrist. Sadly, I believe they ignored all my suggestions.

When another DPM recommended the chair to me, he said he bought an 'oversized' foot cushion. I didn't see any need for 'oversize', so I got the regular size. I found out in a matter of days that it was perfectly suited if your typical patient is 5 foot tall, and your tallest patient is 5'8". I had to have them remake it "oversized" to be useable. All the hand switches were poorly placed, and I had them move or change all of them. I was disappointed that the company had so little regard for getting it right the first time.

Richard Rettig, DPM, Philadelphia, PA, rettigdpm@gmail.com

RE: The Technological Imperative: A Warning (Allen Jacobs, DPM)
From: Michael M. Rosenblatt, DPM

When I was in podiatry school, one of our professors, Dr. Vinocur, an allergist teaching us pharmacology, was known for his common-sense approach to many issues. He advised us against using new drugs or drugs that had not been thoroughly tested, especially those that were not commonly used in our area of practice.

His sage advice: “Let others shoulder the risk of new drugs and medical technologies. You have enough to worry about.” The “others” he was referring to might be university-based, medical school-backed programs that have their own built-in legal protections and attorneys on retainer. He further advised us to use only medications that...

Editor's note: Dr. Rosenblatt's extended-length letter can be read here.

EQUIPMENT FOR SALE

Summit Doppler, Hall Micro 100 set with 5 heads including burrs, drills, and rasps (pristine condition). Original Hall/Zimmer set (still works), two major podiatry surgical packs; will sell them complete or piecemeal. Titanium Synthes Mini frag set; Osteotome sets, etc. Inventory of all equipment for sale available on request. Best offer. Call 586-675-4311 or 440-285-2827 or email me at gwdocks@aol.com

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

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

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 - NORTHEAST GA

Well-established 18 year practice in Northeast Georgia seeking full-time associate leading to partnership. General podiatric care with moderate amount of surgery to be done in local hospital or surgery center. Competitive salary and benefits. Please respond by email to: Fivetoes1946@aol.com 

ASSOCIATE POSITION - CENTRAL NEW JERSEY

Associate Wanted for Central NJ offices. Looking for highly motivated self starter to build/expand practice locations. Great part-time opportunity for the right candidate. Email your CV with references to: ejema@aol.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 - MANHATTAN

Podiatrist needed for busy state-of-the-art offices in Manhattan. Offices are located near Penn and Grand Central Station. Along with CV, please provide medical plans that you are currently participating in. Please forward your information to roni@myfcny.com

ASSOCIATE POSITION - LOS ANGELES
   
Multi-specialty group seeking part time podiatrist. Opportunity to transition into full time position. Required:  3 years or surgical residency, including Charcot reconstruction, fellowship or interest in biomechanics, and ability to train surgical residents. Send CV to podiatricri@yahoo.com 

ASSOCIATE POSITION – PORTLAND, OREGON  

$120K approx. starting salary plus malpractice and benefits! Long-term possibility with a unique buy-in plan. Busy, well-established private practice has an immediate opening with an established patient base for a dynamic, motivated, surgically-trained podiatrist. Practice is mainly general podiatric medicine and forefoot surgery with very little nail care. Some rearfoot and very occasional ankle and trauma. Prefer PSR 24-36. Call (503) 652-1121 and ask for Dr. John Mozena or email jlmozena@aol.com.

FULL-TIME  PODIATRIST NEEDED - ORANGE COUNTY, NY  

Looking for a highly motivated surgical trained podiatrist in the Orange County NY (West Point) area. Hospital, wound center and surgical center affiliated. It is a busy practice that covers hospital inpatients, Wound Center, and takes ER calls. The applicant has to be trained in all foot surgery and be able to handle advanced Diabetic wound care. The practice is a 1 hour car ride from NYC and is close to hiking,fishing, skiing, and state parks. Please Email a CV and contact info to clsp4@yahoo.com

ASSOCIATE POSITION – SUBURB OF DALLAS, TEXAS

Available in suburb of Dallas 2-office practice. Excellent base salary/ bonus structure, malpractice, full benefit package with 4-5-year track to partnership. Looking for someone that wants to grow with our practice. Must have strong communication skills, excellent bedside manner and be PSR 24-36 trained. Email CV and letter of interest to myfeethurt2@yahoo.com

ASSOCIATE POSITION – ALBANY, NEW YORK

Solo practitioner looking to wind down after 29 years. Immediate position available in a well- established diversified practice. Must be ethical, hardworking and committed to quality patient care. Must have good communication and surgical skills. Patient base established with additional growth present. Excellent salary & benefits. Please send cover letter and resume to McBride719@aol.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 to www.YourFutureInPodiatry.com to find out about this opportunity.

ASSOCIATE POSITION – BROOKLYN NY

Busy multi-specialty Medical office in Brooklyn, NY is seeking an experienced podiatrist. We are offering great compensation, flexible schedule and great office environment. Our Requirements: Must have Experience Must have Medicaid & Medicare provider. Please respond by email to: ddpropertymgmt@gmail.com

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