The Voice of Podiatrists

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March 08, 2008 #3,188 Editor-Barry Block, DPM, JD

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Stability and Cushioning Key to Good Running Shoes: DC Podiatrist

Running shoes are highly technical footwear that provide stability and cushioning while heroically bearing up to three times the wearer's body weight; sneakers, on the other hand, are fashion accessories designed to look cool at the mall. "If you run for more than five minutes at any time, you might as well have running shoes," advises Stephen Pribut, a Washington, D.C.-based podiatrist specializing in sports medicine.

Dr. Stephen Pribut

Pribut has a three-phase sequence for checking stability: First, he bends the shoe toe to heel to see where it flexes. If it's not at the forefoot -- where the foot actually bends -- be afraid. He then grips both ends and twists in opposite directions. If he can wring it like a towel, that means there's zero support. Finally, he squeezes the heel in both directions right above the midsole. A stable heel won't cave in.

Source: Vicky Hallett, Washington Post, [3/6/08]

Bill Seeks Major Curbs On Doc-Owned Hospitals

Specialty hospitals are once again the target of Congress as the U.S. House passed a mental-health parity bill with a provision that seeks to place major restrictions on physician-owned facilities. A lengthy provision in the Paul Wellstone Mental Health and Addiction Equity Act of 2007 would prohibit current physician-owned hospitals from expanding and would threaten the viability of these facilities in the future, said Molly Sandvig, executive director of the trade group Physician Hospitals of America.

The measure calls for hospitals to submit annual reports detailing ownership interests. It also states that physician owners in the aggregate must not own more than 40% of the total value of investment interest in the assets of the hospital or in an entity whose assets include the hospital, while individual physicians cannot invest more than 2% in a hospital. Also, if a facility admits a patient and does not have a physician available, it must disclose that to the patient, according to the bill.

Source: Jessica Zigmond with Matthew DoBias, Modern Healthcare [3/6/08]

Query: Dealing With Employee Theft

What do people do when they suspect employees are stealing money from them? What do practices do when they have proof? Can anyone suggest a good company to perform an audit of a practice with this in mind? Should a forensic accountant be used?

Name Withheld

Editor’s Note: To view some related previous responses on this topic see:

http://www.podiatrym.com/search3.cfm?id=7238
http://www.podiatrym.com/search3.cfm?id=4443

Query: Post PVR Testing ICD-9 Coding

If a diabetic patient with neuropathy has a chronic non-healing ulcer, and you perform PVR (pulse volume recording) testing, but the results come back normal, can you use ICD-9 440.23 (atherosclerosis of the extremities with ulceration) as your billing diagnosis code? Or should you use ICD-9 250.60 (diabetes with neurological manifestations) and ICD-9 707.14 (ulcer of heel and midfoot)?

Mark Friedman, DPM, Albany, NY

Response: You have a patient with 1) diabetes, 2) neuropathy, and 3) a chronic non-healing ulcer. Considerations for the non-healing nature of the lesion would include vascular insufficiency, neuropathy, immunopathy, and/or and/or compliance issues. You ruled out - I assume to your satisfaction - that any vascular insufficiency present is not clinically significant to result in the non-healing nature of the ulcer.

You are, at present, left a patient, an ulcer, diabetes, and neuropathy. While you are working on the rule outs, you can bill the diagnoses/conditions as

ICD-9 250.8x (diabetes with other specific manifestations)
ICD-9 707.14 (ulcer, of heel and midfoot) or

ICD-9 250.6x (depending on the type diabetes)
ICD-9 337.1 (peripheral autonomic neuropathy) or
ICD-9 357.2 (polyneuropathy)
ICD-9 707.14

Rick Horsman, DPM, Olympia, WA

Codingline subscription information can be found at:
http://www.codingline.com/subscribe.htm

RE: Pain Sub 2nd & 3rd Mets (Matthew Etheridge, DPM)
From: John Scheland, DPM

I would advise NOT to resect the met. heads or place implants in a 30 year old active person. These solutions will have no lasting effect and will doom your patient to revisional or salvage surgery before he is 40. At this patients age, unfortunately an attempt to correct the deformities should be attempted. Just one x-ray view makes it impossible to advise on how to approach this challenging case. However, there appears to be evidence of a skewfoot-type deformity with the adductus portion of the deformity having this attempted correction.

If this is the case, my advice is to correct any rearfoot deformity to align the midfoot (Evans, Dwyer) based on the plane of deformity. Then align (likely by fusion) the 1st met to the midfoot using the medial and middle cuneiform as reference points for correction (not to correct the angle but to lateralize the entire 1st met). Then use the corrected 1st met to correct the 2nd and 3rd mets by osteotomy and plating making sure the met heads are at the level of the 1st met in the sagittal plane. Digital correction with pinning should then be attempted. Perfection is not possible, but maybe you can get him into an orthotic after correction with a met. bar to relieve any residual plantar pressure.

John Scheland, DPM, Clarks Summit, PA, limblengthener@yahoo.com

RE: Non-Compliant, Drunk Patient (Name Withheld)
From: Elliot Udell, DPM

Dr. Block in his response indicates that if all of your records are order as well as the records of the emergency room documenting alcoholism, it is highly unlikely that the patient will be able to retain an attorney and litigate against you. I am wondering however if there is psychopathology presenting here in addition to alcoholism. Munchausen's Syndrome comes to mind and patients with this will do all sorts of bizarre things to complicate their medical conditions so as to create the need for more medical or surgical treatments. Did this patient have a history of having other foot surgeries? I had one patient who after numerous surgeries by numerous doctors took her BK cast and smashed it against a brick wall, displacing all of the bones at the osteotomy sites. This patient later went on to have many other surgeries by many other podiatrists in many different cities.

Another possibility is malingering behavior. Homeless people might opt to complicate a surgery so as to get themselves admitted to a hospital, especially in the Winter months. Drug addicts might create a post op complication so as to get morphine based pain killers. If this turns out to be the case, don't be surprised if the patient returns to your office along with her boyfriend and uses guilt to try to get you to prescribe Oxycontin or some other narcotic based pain killer. Don't fall for it.

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

RE: Podiatric Assistants Performing Routine Foot Care (Lynn Homisak)
From: Hal Ornstein, DPM, Elliot Udell, DPM

I applaud Lynn Homisak’s response about formal training of podiatric medical assistants. Our staff is our most valuable asset, and utilizing them most effectively in the office will result in better outcomes, reduced stress, improved efficiency, create a higher level of customer service, and the ability to see more patients without compromising quality. I am not concerned that primary care physicians will start a trend to hire them to perform routine foot care. I am not naïve as to how the medical community is now performing podiatric procedures but let’s not focus on the exception but instead of the rule. As Chairman of the American Academy of Podiatric Practice Management (AAPPM) ,I have recently had discussions with other large national groups to start an initiative for a national formal training program for podiatric medical assistants.

One of our board members, Ben Weaver, DPM, is working to organize a high level AAPPM two-day seminar for training of podiatric medical assistants focusing on development and use of protocols, improve communication skills, hands on workshop for training on things such as use of DME, ancillary care and wound care. This meeting would also involve role playing and how to best assist the podiatrist to succeed as a TEAM, while increase patient care and revenue. We do recognize the efforts of ASPMA and state assistants group for working to grow the podiatric medical assistant. Any input on the subject would be appreciated.

Hal Ornstein, DPM, Howell, NJ, hornstein@aappm.org

Dr. Mendoza points out to all of us a potential problem that really could impact on all of our practices. If schools start training podiatric assistants who become qualified to do all of the work that we do with the exception of surgery, we might be sowing the seeds of our ultimate demise. Medicine has learned with the advent of the PA profession that most of the evaluations, treatments and even diagnoses can be done by a PA whose professional education is little more than 2 years of non-doctoral training. One of the doctors who I personally went to has his PA do all of the initial work-ups and the writing of prescriptions. The doctor himself only sees the patient after the third visit. At an allergy clinic I visit, the PA does all of the examinations and frankly I find him very knowledgeable.

The ultimate problem is that if we train people to do all of the podiatric care that we do on a regular basis, there would be nothing to stop these people from taking jobs either working for primary care physicians as Dr. Mendoza suggests or more likely working for local orthopedic surgical groups. This could wipe out a significant amount of work that we do for patients and there are very few podiatrists, if any, who can sustain a practice solely based on pedal bone surgery.

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

RE: Are Those Orthotics Really Custom-Made? (David J. Marko)
From: Michael Zapf, DPM, Jeff Root

The information on the System Rx orthotics of DPM Orthotics written by Dr. Marko has me rethinking what makes a "custom" orthotic and if I need to keep paying so much for my current devices. If enough pre-formed orthotics are available and one fits the needs of the cast exactly, is it not, then, a "custom" orthotic? My local 1-hour optometry shop does the same thing with prescription lenses. They have a large number of prescription lenses in stock and find the one that matches the prescription of the optometrist and then grinds it to fit the frames and the location of the pupil. Evidently the number of lense blanks available to do this job is not infinite. My wife gets her contact lense prescriptions "in an hour" the very same way. If these qualify as prescription lenses, are not DPM Orthotics System Rx "prescription orthotics" as well?

Michael Zapf, DPM, Agoura Hills, CA, footdr@ix.netcom.com

Editor’s note: an extended-length letter by Jeff Root appears at:http://www.podiatrym.com/letters2.cfm?id=18329&start=1

COLORADO PRACTICE OPPORTUNITY

inquiry@axint.net This is an auto response. Thank you.

FULL-TIME ASSOCIATE WANTED - CHATTANOOGA,TN

Well established, well-respected surgical/medical practice seeking full time associate. Send CV/ inquiries to: chattfootdoc@yahoo.com

TEXAS - SEEKING ASSOCIATE TO FULL PARTNER

Busy multi-physician podiatric group with 2 locations seeking BQ/BC surgically trained doctor. Applicant should be well-trained in all aspects of surgical and conservative care. Seeking ethical, hard working and outgoing physician to join our 4-physician group. Excellent quality of life in suburban Houston, near NASA and the Gulf of Mexico. Email CV and cover letter to Dr. M. Rockett at Mrockettman@comcast.net

ASSOCIATE POSITION - MONTANA

Two Doctor group seeks individual with three years of surgical training with emphasis on the forefoot. Diabetic foot fellowship desirable. Practice includes two physical therapists that work on site. Rural setting with excellent outdoor activities. Competitive salary and benefit packages with opportunity for partnership. Respond to: jclough@sofast.net or Fax to: 406-761-7219

PRACTICE FOR SALE - DALLAS TX

10 year old general podiatry practice, including, geriatric care, diabetic care, surgery, biomechanics, etc. Grossing approximately $185,000 part-time, can be made full-time. Hospital privileges available. Will stay for transition. Please reply to: footdoc8390@yahoo.com

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 POSITION MASSACHUSETTS-BOSTON NORTHERN SHORE AREA

Innovative Practice on Boston’s North shore seeking motivated associate to join high, energy doctor to assist in growing practice. Competitive compensation package and partnership after two years. consulting@providerresources.com

ASSOCIATE POSITION - NEW YORK CITY

Excellent opportunity for foot/ankle surgeon, Manhattan and Brooklyn Associate position leading to possible partnership. Requirements: Two years enrollment in a surgical residency program Qualities of self-motivation and impeccable skills in forefoot and rear-foot surgery. Package Includes: Malpractice insurance, Health Insurance plus salary, Incentives. Terms negotiable Email CV to Manfootcare@aol.com 212-349-7676

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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