The Voice of Podiatrists

Serving Over 10,800 Podiatrists Daily

March 17, 2008 #3,195 Editor-Barry Block, DPM, JD

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Calluses May Be Sign of Rheumatoid Arthritis: NY Podiatrist

"Rheumatoid arthritis presents in the foot much like it does in the rest of the body—with either pain and/or deformity in the joints," explained Cary M. Golub, DPM, FACFAS, podiatrist in private practice in Long Beach, New York. "Deformities can range from a mild contracture of the toe to complex subluxation of a major joint of the foot or ankle."

Dr. Cary M. Golub

"The subtle deformities, often not noticed by the patient, can cause friction in footwear and pressure from a displaced metatarsal, resulting in callus formation," he told MSKreport.com. "If identified early, the deformity of the rheumatoid foot may be addressed by either an orthotic or a modification of footwear to reduce the pressure or to disperse the weight in the deformed area."

Untreated, the callus may become a source for breakdown over time, which can lead to ulceration. "With the presentation of a rheumatoid foot, the patient’s vascular status must be assessed. It will determine the healing capabilities of a pretrophic area or an ulcer," Dr. Golub said.

Source: Musculoskeletal Report, [3/12/08]

Barry Students to Wash Feet of Homeless on Maundy Thursday

Approximately 10-15 students and faculty physicians from Barry University’s School of Podiatric Medicine will be washing the feet of the homeless who come into the mission to share a holiday meal. This is the second annual event of its kind at the mission and has proven to be enormously popular, according to Marilyn Brummitt, director of community development for the Miami Rescue Mission, Inc/Broward Outreach Centers. “We fed close to 1,000 at the event last year, and about one-third of those, more than 300 people, also had their feet washed and looked at,” Brummitt said.

Barry students wash feet of homeless last year on Maundy Thursday

The staff at the mission, she noted, came up with the idea because they wanted to do something in addition to offering meals and felt washing feet as a symbol of humility, and in the tradition of Jesus washing his disciples’ feet at the Last Supper would be a good idea.

Dr. Chet Evans, dean of Barry’s School of Podiatric Medicine, added that while the spirit of the event is incredibly uplifting, it also provides an excellent opportunity for those who might not ordinarily be able to receive podiatric medical care. “Homeless people frequently have diabetes or other conditions that can have very serious consequences if left untreated; even leading to unnecessary amputations,” Evans said. “That’s why it’s so important to take advantage of opportunities like this.”

FL Podiatrist Elected Town Commissioner

Voters went to the polls here on March 4 to elect three new town commissioners and move the town's municipal elections to the fall to coincide with state and national elections. All are political newcomers.

Dr. Paul Schoppe

The youngest of the three at age 35, podiatrist Dr. Paul Schoppe, boasts a lengthy community service track record and has served as the youth minister for St. Joe's Catholic Church since 2001. In addition to focusing on the budget, he says he plans on seeking community participation in the governmental process.

"I think with each issue, I'm going to be open to setting up volunteer programs for people to start contributing and taking more part in the community," he said. "The purpose is to give people a chance to be a part of positive change."

Source: Donald Rodrigue, Hometown News [3/14/08]

Query: Gambling Addiction

I am a partner in a successful practice. I also have what has turned out to be a serious gambling problem. I lost a sizable amount of money betting on sports, and then borrowed money from the practice account, credit cards, and even my kid’s college savings account. I fear that I may lose everything. What can I do? Any advice would be appreciated.

Name Withheld

Editor’s comment: PM News does not provide legal advice You’ve taken the difficult first step in admitting you have a problem and seeking assistance. You are to be commended for that. You are not the first (nor will you be the last) podiatrist to find yourself in this situation. Others have been in your situation and returned to productive practice.

We suggest you contact the Physician’s Recovery Network Resource for Healing. They provide confidential, anonymous assistance and referral for drug and alcohol problems, depression, marital/family issues, physical impairments, etc. Call the Physician’s Recovery Network (PRN) hot-line at 800-488-4767. This is an APMA-sponsored program. The PRN’s mission statement says that it was developed to identify and assist impaired (whether by substance abuse, physical and/or mental conditions) podiatric physicians and/or members of the podiatric medical family (including, but not limited to, podiatric medical students, family members, and office staff of the podiatric physician) so that they can be restored to a full life and/or effective professional practice.”

Query: Painful Nails in Patient With Raynaud's Disease

I have a patient with diagnosed Raynaud's disease. She is seen approximately every 2-3 months with complaints of painful nails. Examination reveals significant cyanosis of digits with slow capillary filling time, along with inflammation of nail margins because of incurvated configuration of both hallux nails.

In addition to the Raynaud's disease, the patient is complaining of severe pain with even the most careful removal of offending margins (which is needed to prevent infection). Because of the pain, the patient has a very difficult time cutting her nails, as a result the nails become elongated, with minimal incurvation, along with developed margin inflammation. How should this be coded (both diagnosis and treatment)?

Barry A. Wertheimer, DPM, Redondo Beach, CA

Response: Raynaud's disease - in California, at least - is a qualifying listed systemic condition that needs the presumption of meeting class findings in order to qualify payment of routine foot care. Your description failed to include qualified Class A, B, or C findings. As a consequence, this patient would not be eligible for reimbursed routine foot care. If you are trimming her nails, it would be denied as non-covered. You can bill the patient directly for the service.

The fact that the patient has pain, "takes it out of the realm of routine foot care," but leaves you few options. If the patient has thick nails that are painful, then you would be able to bill CPT 11720 or CPT 11721, as appropriate (ICD-9 code would be ICD-9 703.8 and ICD-9 pain - for the debridement qualification).

If the patient doesn't have thick nails requiring debridement, and presents nails that are long which need trimming (maybe with some distal resection of the nail margins), this would also be routine foot care - unqualified. And the trimming of this patient's nails would be/could be billed directly to the patient.

If the patient is presenting initially with pain, long, slightly incurvated nails and Raynaud's disease, you can bill an E/M service for the initial work-up (level, as appropriate), but other than maybe the follow-up encounter, you would not - if the patient regularly presents to have her painful nails trimmed - be able to continue to bill an E/M service since there would be no basis for repeat evaluation and management when the patient is returning for a procedure, and no additional findings are obtained or management (other than trimming the painful nails) provided.

Tony Poggio, DPM, Alameda, CA

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RE: Alleged Failure to Order Bone Density Test
From Multiple Respondents

Bryan C. Markinson, DPM correctly asks: "Where were defense attorneys" when it came to the DPM sharing a settlement with other physicians treating the same patient, who turned out to have an eating disorder? This has all the hallmarks of a "forced" settlement. It usually unfolds as a "two-against one" ganging incident in a conference room of the Courthouse, just before trial.

The attorneys try to "mollify" the podiatrist, stating that their part of the settlement will be "minimal." Attorneys for the podiatrist (who was utterly blameless because podiatrists do not treat eating disorders), probably threatened the DPM that "he would have to go this on his own" if he refused to sign-on.

This is one of reasons why it is necessary to have a separate private attorney, whom YOU pay yourself. This puts all attorneys on notice that you will not be "walked-over." Your insurance company lawyer may or may not share your best interests, since someone else is paying their fee. Your own attorney could have dealt with your malpractice carrier "threatening" you. In fact, if your own attorney were present, it probably would not occur.

Michael M. Rosenblatt, DPM, San Jose, CA, ROSEY1@prodigy.net

Why in this case was the podiatrist held to the same standard as a medical doctor to diagnose, test and perhaps treat outside of the DPM "scope of practice", if in fact we do not have the same training and degree? If this podiatrist ordered the bone densiometry test, there is some chance depending on the payor that the test would be disallowed being outside the scope of practice of this specialty. I am also wondering why this podiatrist is supposed to be qualified to diagnose, test and treat osteoporosis, but medicare feels we are "unqualified" to diagnose and treat gout if we bill using the 274.0 ICD-9 code?

I was recently held accountable and admonished by a letter from their medical improvement committee at united healthcare for not ordering routing cervical cancer and pap screenings on 5 female patients. There seems to be a double standard here, that applies to limit us when the payor or licensing boards say so, but another for liability when things go wrong. I try to take a whole person medical evaluation approach to my patients, but legally, I don’t know if that's the correct way to go.

Paul Bishop, DPM, Yorkville, IL, Feetpeople@aol.com

In Florida ,Medicare and TRICARE do NOT authorize this study ordered by DPM's - funny how when we see multiple stress fractures, osteoporotic bone on radiographs ,etc --in certain patients we can ,certain patients we cannot order a bone density examination. Luckily, I can still refer those patients to my orthopaedic partners when I suspect bone density problems. This is another example where our degree of DPM makes us less than equal with real physicians, as per reimbursement issues depending on insurance categories.

Joe Agostinelli, DPM, Niceville, FL, jmpa21@cox.net

RE: NV Podiatrists Act to Prevent Needle and Syringe Misuse (Howard Lazar, DPM)
From: Lawrence M. Rubin, DPM, Paul Kesselman DPM

Dr. Lazar correctly states that Nevada podiatrists - or podiatrists elsewhere - don't have to be told that used syringes are not reusable. The PM article did not say the NPMA educational initiative is for training podiatrists. It did say the program involves providing materials for "training new personnel and making certain present personnel are following correct guidelines to prevent contamination of needles, syringes, and injection medication." These guidelines follow CDC guidelines and go far beyond simply not using used syringes. As such, the NPMA believes this to be a worthwhile personnel training program.

Lawrence M. Rubin, DPM, Las Vegas, NV, LRubindoc@aol.com

What do all the incidents of syringe and needle misuse and abuse have in common? A lack of common sense and attention to the very basics we all learned back during our intro to microbiology classes during our second year of medical school. Whatever happened to the oath we took of “Do No Harm”, not only to the patient, but to oneself and one’s family.

The savings that a practitioner may save over the course of a career by recycling syringes and/or needles pales in comparison to what he/she may spend in legal fees. This type of practice is likely to wipe out all the financial wealth one has worked so hard to accumulate.This is one scenario where NOT recycling definitely is NOT harmful to the environment or society!

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

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.

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

PRACTICE FOR SALE - BUFFALO'S KENSINGTON SECTION

Established satellite practice. In urban metropolitan area on a busy commercial street corner - commercial building with an attached retail store that allows easy advertising of the podiatric medical practice. Gross $170K+ at 2 ½ day per week. Great potential for growth. 260 402-7490

PRACTICE FOR SALE - EASTERN WASHINGTON

Established practice located in the fastest-growing city in the state of Washington. Enjoy the lifestyle available in the area. Practice is directly across the street from the hospital - surgery center located within the hospital, and podiatric surgical privileges are not restricted. Gross $200K+ at 4 days per week. Can easily grow. 260 402-7490

ASSOCIATE POSITION - FLORIDA PANHANDLE

We are looking for a hardworking, ethical physician to join our busy practice. We are well-established and looking to expand. Must be a PS24+ with interest in all aspects of podiatric medicine and surgery. Partnership available. Fax resume to (850) 478-5227, call (850) 477-9015 or email PenFootAnk@aol.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

FULL-TIME ASSOCIATE WANTED - CHATTANOOGA,TN

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

PART OR FULL TIME ASSOCIATE POSITION - NEW YORK, NY

Busy, thriving Manhattan Podiatry offices looking to hire part or
full-time in-network Podiatrist for growing private practice. Please, only in-network doctors apply. Send resume and list of in-network plans that you participate in to: Rachel@FootCareofNewYork.com

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