The Voice of Podiatrists

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March 13, 2008 #3,192 Editor-Barry Block, DPM, JD

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NV Podiatrists Act to Prevent Needle and Syringe Misuse

The Nevada Podiatric Medical Association (NPMA) has announced a statewide initiative to make certain all personnel in podiatric offices and facilities are following correct procedure guidelines for handling syringes and needles, according to Lawrence M. Rubin, DPM, a Las Vegas podiatrist and chairman of the NPMA Public Information Committee.

Dr. Lawrence Rubin

The NPMA is developing a special instructional bulletin that will soon be mailed to Nevada podiatrists for training new personnel and making certain present personnel are following correct guidelines to prevent contaminations of needles, syringes, and injection medication. It stresses the fact that needles and syringes must be used only once and immediately discarded after use. The NPMA initiative follows the discovery that 40,000 patients treated in the Endoscopy Center of Southern Nevada may have been exposed to hepatitis and HIV viruses due to reuse of syringes that should have been used only once.

“Physicians need to be certain that the surgical assistants and other health professionals they employ are properly trained and are handling syringes and needles correctly,” says Rubin. “After what's happened in the Southern Nevada Endoscopy Center, physicians can’t be complacent and presume proper injection techniques are being followed. We have to make sure."

Some Pronation Needed for Normal Ambulation: MD Podiatrist

Pronation isn't as sinister as it sounds -- it's merely the flattening of the arch as you move through your step, which makes your foot roll inward. "There should be a degree of that occurring," explains James Christina, a podiatrist who serves as director of scientific affairs at the American Podiatric Medical Association.

Dr. James Christina

"Pronating loosens up the structures in the foot and allows it to adapt to changes in the ground. But if it happens excessively, you have problems." Think shin splints and tendinitis.

Of course, under-pronation comes with its own host of maladies because your foot doesn't absorb shock effectively. Without proper cushioning, that's a recipe for stress fractures and knee and hip issues.

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

Federal Court Denies Tax Evasion Conviction Appeal of AR Podiatrist

A federal appeals panel has refused to throw out 25 federal tax convictions handed down to a Gassville podiatrist. Clifford B. Marston was sentenced in 2006 to serve 26 months in prison and to repay nearly $300,000 to the Internal Revenue Service. He was also given three years of supervised release for his May 2006, conviction on charges of income tax evasion, filing false income tax returns and other charges.

The IRS said Marston stopped withholding employment taxes from his workers' pay during 1999 and went on to make false filings until he stopped filing employment and personal returns altogether in 2001.Marston claimed at trial that he believed he did not owe the government taxes. Prosecutors showed that Marston followed the teachings of anti-tax proponents who themselves got into trouble with the law.

The court also found that there was no reason to review Marston's sentence.

Source: Associated Press [3/11/08]

Query: Unilateral Deep Itching Pain

A 72 year old apparently healthy woman, on no medications presented with severe deep itching pain in the anterior part of her left foot affecting forefoot and digits 1-4. She was in agony and stated that she has had this pain about once a year since having bypass surgery 10 years ago. The pain lasts only a day or so and it resolves. This time it has not resolved .

Physical examination revealed minimal edema, no deformities, Gross sensation was intact with no skin abnormalities, no open lesions and no signs of infection. I injected lidocaine and Marcaine in her midfoot and performed a Mayo block. This resolved the itching. I prescribed Lyrica 75 BID to be tried if the condition returns after the block wears off. Any suggestions as to an etiology, diagnosis or further treatment is welcomed.

Alan Mauser, DPM, Louisville, KY

Query: X-Ray Coding Modifiers

If I am taking x-rays of both feet on the same day, other than "LT" and "RT", what other modifiers are needed for Medicare? "-51"? "-59"?

Adam Klein, DPM, Lynbrook, NY

Response: If it's the identical study (same body part, same number of views), the clearest picture would be painted with "-LT" and "-RT". ["-LT" and "-RT" are a subset of "-59", so you would not report them together]

It's a similar study on contralateral sides (same body part, but different views OR contiguous body parts and same (or different) views), then don't use the "RT/LT" modifiers. Modifier "-59" would be most appropriate - and should be placed on the study that could potentially be considered a component of a more extensive study).

Modifier "-51" would never be reported on the same CPT code that you were reporting either "-59" or "RT/LT" on. By CPT coding rules, modifier "-59" (or it's subset "RT/LT") can only be reported when no other modifier appropriately describes the circumstances.

Joan Gilhooly, CPC, CHCC, Deer Park, IL

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RE: Diagnostic Ultrasound Units (Brian Kiel, DPM)
From: David E. Gurvis, DPM, Marc Katz, DPM

There are many very good office diagnostic ultrasounds out there. One of the best ways to decide is to attend a large seminar near you and just play on each unit, and also see what kind of features suit you. At the least, I would look for a unit with 10Mhz. Many are now featuring 12 and up to 15 Mhz and the higher MHz will give you more fine tissue detail for smaller structures such as a neuroma.

Look for training. Us “old timers” learned on our own, and by sharing with each other. With the various lectures given today, this just isn’t necessary any longer. There are many things to actually look for, and if you are interested, I know the Chicago Midwest later this month will have a plethora of units from all the re-sellers present.

David E. Gurvis, DPM, Deg1@comcast.net, Avon, IN

I have had several units over the past few years. I now have a Medison Pico which is amazing. It also has full vascular functionality which has been very useful in my practice.The clarity is far superior to Mindray units and the others in the same category. I've also looked at GE Logicbook and Sonosite Titan and I liked the Pico much better.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

RE: Tighter Standards For DME Suppliers (Jeffrey Kass, DPM)
From: Jason Kraus, Timothy Tillo, DPM

I would like to respectfully disagree with Dr. Kass' sentiments regarding his opposition to the upcoming accreditation requirements for DME suppliers. It is this very lack of facility certification that has hurt podiatry in the past. By making this a requirement, the podiatric community will likely be able to increase their DME dispensing as many of the currently non-compliant suppliers of DME items will be vetted out. Like most things in this profession, there have not been standards of excellence established, and in some ways, this accreditation process will help to provide uniform standards for DME dispensing.

While I am no fan of creating more administrative hoops to jump through, I do believe that in the end, this process will elevate the podiatric providers of DME items in the eyes of all insurers. One of the accreditation requirements is to integrate some form of outcome measurement. This has clearly been lacking in the past. Finally, the cost, while not insignificant, is very low compared to the financial consequences of providing integrated DME solutions to podiatric patients.

Jason Kraus, SOS Healthcare Management Solutions, LLC, jkraus65@gmail.com

Editor’s Note: The APMA’s responseto Dr. Kass by Dr. Tillo appears at: http://www.podiatrym.com/letters2.cfm?id=18412&start=1

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