The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

March 17, 2010 #3,806 Publisher-Barry Block, DPM, JD

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Feet are Often Early Indicators of Vascular and Nerve Disease: MA Podiatrist

Feet often mirror general health. Such conditions as arthritis, diabetes, nerve, and circulatory disorders often first signal their symptoms via the feet. Dr. Gloria Krason, a podiatrist at Holyoke Medical Center, notes that because the feet are far from the heart and nerve systems, they are most susceptible to problems, as blood flow has to course through smaller branches to get to them.

Dr. Gloria Krason

"You shouldn't delay seeking treatment for foot problems because that's where problems first show up due to their distance from the heart," she said. "But foot problems also get worse more quickly for the same reason; they're at the extremities."

Source: The Republican [3/10/10]

CSPM Holds Its 14th Annual White Coat Ceremony

On March 12, 2010 the California School of Podiatric Medicine (CSPM), a school within Samuel Merritt University, held its 14th annual White Coat Ceremony for the class of 2013. Nearly fifty podiatry students in the Doctor of Podiatric Medicine (DPM) program formally received their first white clinic coat in the presence of families, guests, faculty members and CSPM leaders. The ceremony provided an opportunity for faculty and mentors to welcome the first year students into a wider circle of colleagues, and it allowed students to recognize significant individuals who provided them with support throughout their education.

CSPM Students at White Coat Ceremony

"The symbolism and power of the White Coat Ceremony lies in its ability to correlate the scholastic endeavors we delve into on a daily basis, with a future in medical practice, a goal we share together as fellow podiatry students,” said Gregory Vidovic, student and Class President, CSPM 2013.

Docs Pressing CMS on Meaningful Use

To facilitate meaningful use of electronic health records, The CMS should abandon its all-or-nothing approach to awarding financial incentives, eliminate goals and measures that don't directly apply to EHR adoption, and widen the eligibility for certain hospital-based physicians, according to a letter sent to acting CMS Administrator Charlene Frizzera. The letter was signed by the American Medical Association and 95 other state and specialty medical societies.

The 37-page letter stated that “physicians are deeply supportive and committed to incorporating well-developed EHRs into their practices,” but the “aggressive” criteria included in the proposed requirements for federal EHR-investment subsidies will deter many physicians from participating in the incentive program, which was included in the American Recovery and Reinvestment Act of 2009. “Encouraging physician adoption of health IT, especially small physician practices, is critical to ensuring widespread EHR use,” the letter concluded. “Unrealistic timelines and criteria will only serve to undermine this effort.”

Source: Andis Robeznieks, Modern Healthcare [3/15/10]

Query: Medicare Payment - Subtalar Arthroereisis 
 
Is anyone having luck getting reimbursed by Medicare for subtalar arthroereisis? I submitted a paper claim for CPT 28899 (unlisted foot/toe procedure) with an op report and a letter of explanation only to receive remittance denial, "N130 - consult plan/benefit documents/guidelines for information about restrictions for this service."

I was unable to find any National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) on subtalar arthroereisis, billed either as CPT 28899 or S2117. I did find a communique (Dec 2009) listing CPT 28899 as a procedure payable to podiatrists.

Jonathon Fallis, DPM, Moberly, MO

Response: I know of no one being reimbursed by Medicare for performing a subtalar arthroereisis, CPT 28899 (unlisted code) or S2117. There are no LCDs or NCDs (National Coverage Determinations) for subtalar arthroereisis.

Billing CPT 28899 forces a manual review of the claim (and possible request for records) because, obviously, an unlisted code represents a procedure not otherwise described by an existing code. The fact that there is no regular CPT code for a subtalar arthroereisis is a major stumbling block in hoping for reimbursement since the procedure has not either been introduced or made it through the CPT process.

Your argument for reimbursement must be compelling enough to convince the payer reviewer that the procedure, while not having its own CPT code, is 1) medically necessary, 2) standard of care, and 3) backed by recognized published studies validating (1) and (2).

Harry Goldsmith, DPM, Cerritos, CA

Codingline subscription information can be found at:
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RE: Moldable AFO for Dropfoot (Ira Meyers, DPM)
From: Susan Bartos, 
 
There is a carbon/fiberglass AFO designed for dropfoot called the Matrix Max by TruLife (aka Seattle Systems).  It is an off-the-shelf brace that is adjusted, padded, and heat-molded to your patient. It has one medial bar, making for an easy shoe fit, is orthotic-compatible, and requires no casting.  An instruction booklet for fitting the Matrix Max comes complete with pads and a step-by-step pictorial. The Matrix costs around $300.00, and is billable under the code L1932. Earthwalk has provided this AFO to many DPMs with excellent fit and comfort feedback from patients. This may be a good choice for your runner.

Susan Bartos, President, Earthwalk Orthotics, eworthotics@neo.rr.com

The sciatic nerve injury, if caused by a GSW, I assume, was neurotemetic (complete transection of the nerve). Even if the nerve was end-to-end cable-grafted, or sural nerve graft was used, the chances of re-inervation are slim to none at best. There will, therefore, be no motor function below...

Editor’s note: Dr. Albert Nejat’s extended-length letter can be read here.

RE: ADA Comprehensive Diabetic Foot Exam Format (Mark K. Johnson DPM)
From: Alan Berman, DPM, Paul Kesselman, DPM

Regarding Dr. Johnson's question about methods for scanning as a part of the comprehensive diabetic foot exam, I have been using the Aetrex scanner for the past two years. The scan documents the patient's arch type, pressure distribution, and foot size. The color printouts are a wonderful aid in patient education, and the scan is very reliable and easy to administer.

Alan Berman, DPM, Carmel NY, anbdpm@aol.com

The "Comprehensive Diabetic Foot Examination" (CDFE) is not a new term, having first been mentioned by Foot Logics Corporation seven years ago when it initially released its Pressure Stat device. The actual coding of this examination was documented in the podiatric literature several years ago by Dr. Ken Malkin. However, a uniform definition of the essential components of a CDFE was not defined by the ADA until very recently. It has appeared in numerous publications, including...

Editor’s note: Dr. Paul Kesselman’s extended-length letter can be read here.

Post-op Numbness Status Post-EPF (Neal Kramer, DPM)
From: Frederic Schwartz, DPM

I am not a proponent of endoscopic plantar fasciotomy (EPF), but for the life of me, I can't understand how a reasonable performance of this procedure could directly injure a major plantar nerve. A very small incision placed medially and located adjacent to the calcaneal/plantar fascial junction is made with no retraction. An endoscopic cannula is inserted and pushed into the heel, plantar to the fascia and the fasciotomy is performed using a tiny hooked cutting edge, sliding along the top of the cannula. Outside of a small medial calcaneal nerve, I cannot imagine running into any plantar nerve. Studying the anatomy, I would think it very hard to damage the lateral plantar nerve from this location, even if it was the surgeon's desire to do so.

Frederic Schwartz, DPM, New Bedford, MA, footfixed@comcast.net

RE: Unscrupulous Billing of Routine Care (Dan Klein, DPM)
From: Brian Kashan, DPM

There are very few patients who are on the borderline of what would constitute qualified routine foot care (RFC). It is usually cut and dry. The statutes clearly define what is RFC, and I use these definitions in explaining the rules to patients. Whenever a patient presents to me with the story of what another podiatrist billed, I give them a copy of the guidelines for coverage. The comments I get include that they had hip replacements, a bad heart, TIA's, poor vision, etc. Although I am sympathetic to their plight, I explain that I have to go by these guidelines, as I am sure they would never expect me to do anything illegal. I suggest that I actually agree with them that it should be covered and that they call their congressman to have the guidelines changed.
 
That being said, once patients understand what is covered, I rarely lose them. They get accustomed to the policy, just as they would with any office policy. If you bend rules, you will develop a reputation for that, and see more and more of these patients. Not only is this fraudulent, but it is financially punitive for your practice, as most RFC pays less than an office visit fee you would charge for the service.
 
Lastly, the patients who you think you are doing a favor for by billing RFC as a covered service, will be the first ones to call Medicare and report you if you, one day, do an injection on them for another problem, and the voucher states the injection was "surgery", or if, G-d forbid, your office makes a billing error. 
 
Brian Kashan, DPM, Baltimore, MD, drbkas@att.net

RE:  Defeat of Podiatry in NJ Diagnostic Ultrasound Case (Larry Cohen, DPM)
From: Barry Mullen, DPM, Larry Cohen, DPM

Of the many life's lessons learned is that one should never express an opinion about a given issue until one's emotions have thoroughly subsided. Clearly, this was the case pertaining to my recent rant regarding the diagnostic ultrasound issue. One's ability to successfully reform inequities imposed against our profession often has little to do with the competence and dedication of those who represent us. As such, my heartfelt apologies are humbly extended to NJPMS' leadership and legal counsel who were subjected to my disparaging and inappropriate comments. Anyone who knows me personally understands and appreciates my passion for our profession; however, misguided energy that results in negative, unjust criticism of those who work so diligently behind the scenes on our behalves cannot be condoned. For that, I am truly sorry.
 
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

Somehow, I think the point is being missed. I don't think that any insurance company gives a hoot about how much extra training you have in performing a needed service. If they can have the service done at an "authorized center" and it costs them less money, that’s what matters.  My point is that if an orthopedic surgeon with advanced training and equipment wants to do an ultrasound of the knee, he can't, even if he believes that he is the best at performing and interpreting the results of the exam.

When you sign an in-network agreement, you play by their rules. I would think that if that same test is performed out-of-network, it would have a higher chance or being paid. I don’t think that the society would have a leg to stand on in fighting this, unless of course the Medical Society of NJ would want to take up the cause with us on behalf of all their members. Fat chance.

Larry Cohen, DPM, Clinton, NJ, larrydpm2002@yahoo.com

RE: Maryland Podiatrist Opens a New Shoe Store
From: Robert Bijak, DPM

In a nutshell, this represents the entire problem with podiatry;  our association with shoes, arch supports, and business. Furthermore, that a "specialist" goes on to become a CPed after podiatric medical schooling is an embarrassment. The MD's are holding their stomachs and rolling with laughter. I'm sick to my stomach.

Robert Bijak, DPM, Clarence Center, NY, rbijak@aol.com

RE: Laser Holds Hope for Treating Onychomycosis: (Stanton Southward, DPM)
From: Eric Weinstein, DPM, Michael Turlik, DPM

I take great offense to Dr. Southward’s comment about “Hoodwinking the trusting public…” with regard to laser treatments for onychomycosis.  I have been using the PinPointe Laser system for almost 10 months and have treated approximately 400 patients. As I have been seeing many follow-ups over the past few months, I can assure you that I have not been “hoodwinking” anyone. I have many happy patients who are excited about finally have clear nails.
 
Treating onychomycosis with vinegar and tincture of green soap is like to listening to 45 records on a turntable, while using a laser is comparable to today’s I-Pod. Times are changing and it is time to move forward. Does the laser work in 100% of the cases I have done? No, but I repeat the procedure if necessary at no cost within the first year. I have had NO adverse reactions. My goal is to have happy patients who refer others. There are millions of desperate patients with onychomycosis out there who are longing for a cure. The frustration of using topicals or  playing Russian Roulette with your liver using oral meds, just doesn’t cut it for them.
 
Are plastic surgeons and dermatologists “hoodwinking the public” when they use Botox or Restalyne that lasts for ~ 6 months? Are dentists “hoodwinking the public” when their patients' teeth yellow a year after they have had their teeth whitened?  Botox was also used “off-label” for ~ 10 years prior to FDA approval. I see nothing wrong with marketing a new innovative treatment. Does Apple market its I-Pod? The public will do its own due diligence and make their own informed decision as to whether they want to spend their hard-earned money on a new therapy. With the direction third-party insurance is going, getting paid the day services are rendered is a beautiful thing. 
 
Eric Weinstein, DPM, Weston, FL, drweinstein@Browardfootcare.com

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

RE: $1,475,000 Settlement for MD's Failure to Diagnose Charcot Foot (Allen Jacobs, DPM)
From: Tip Sullivan, DPM

I have been out and just read Dr. Jacobs’ response to my post of 3/12/10. Either I did a poor job of making a point, or it was simply misunderstood in my last post. I was not trying to debate whether or not surgery or any other care was the answer to Charcot foot or any judgment in a lawsuit, but that we should be careful about what we write and/or relate to our patients.
 
"The diabetic patient with a Charcot's deformity is at no greater statistical risk for amputation than the diabetic patient without such deformity," is quoted from Dr. Jacobs' post. My thought of a person with Charcot deformity is the typical Lisfranc fx dislocation. That is what we see as the deformity of Charcot's neuroarthropathy. I could much more easily believe that a person with Charcot's neuroarthropathy WITHOUT deformity might have a different risk than someone with a deformity--perhaps this is just a terminology issue? My post was a simple comment about a quote that I think could be interpreted or misinterpreted and result in the wrong message reaching our patients. That is all.
 
Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net

ASSOCIATE POSITION - SAN FRANCISCO, CALIFORNIA

We’re seeking an energetic and enthusiastic Associate to help our thriving non-surgical practice grow. We provide state-of-the-art sports medicine, trauma and lower extremity care. Excellent compensation package. Visit our website to apply.

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes. Top hospitals. Fax CV with references to 703-491-9994

PRACTICE FOR SALE - FLORIDA CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

PRACTICE FOR SALE – CONNECTICUT

Outstanding practice for sale in northern Fairfield county, CT. Shared space with other medical professionals. Very low overhead. Grossing almost $300K on 30 hours per week. Referrals from three different primary care physician offices. If interested e-mail CTPodiatry@gmail.com

OFFICE SPACE TO SHARE - NYC

Wanted- Licensed podiatrist to share space in a State-Of-The-Art medical office in the midtown area. Please call Dr. Robert Singer (212) 921-5775 or e-mail dr.roberth.singer62@netzero.net

FULL-TIME PODIATRY OPPORTUNITY - BOSTON, MA

HealthDrive is seeking a caring podiatrist to join our group practice. We currently have a FT non-surgical opportunity available in the Boston, MA area. We offer a competitive salary, Paid malpractice Insurance, health and dental Insurance, long & short term disability, flexible schedule (No weekends), established patient base, equipment, supplies and complete office support provided. If interested in this opportunity, please call Maria Kelleher (toll free) at 877-724-4410 or email caring@healthdrive.com

ASSOCIATE POSITION - CONNECTICUT

Associate needed full or part-time for Nursing homes in Connecticut. Need hard-working, ethical individual. Must have CT license. Excellent salary. Please call Zina (347)307-4333 for additional information.

ASSOCIATE POSITION - TAMPA BAY

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Preference given to a PSR 24+ training and must have a Florida license. Well-established practice, high-tech with EMR and digital x-rays, with specialties in sports medicine, surgery and wound care. No nursing homes or HMOs. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family second to none. Kindly forward C.V. to e-mail drcosentino@tampabay.rr.com

ASSOCIATE POSITION - DAYTONA BEACH, FLORIDA

Associate position with buy-in potential. Daytona Beach, Florida Great opportunity for PSR 24-36.trained physician to join state-of-the-art practice. Please forward resume to pfk4@yahoo.com

ASSOCIATE POSITION-INLAND EMPIRE, SOUTHERN CALIFORNIA

Associate needed full or part-time for multi office practice. Must be ABPS BC/BQ. Hard working, ethical individual who is looking to a possible partnership opportunity. Looking for current licensed or resident completing program this spring. Email CV to bkatzman2@earthlink.net or call Martha 909 984-5614.

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

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