The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

April 02, 2009 #3,509 Publisher-Barry Block, DPM, JD

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 Patient Grateful to DC Podiatrist Who Really Listened

Karen Abrams' original podiatrist recommended hammertoe surgery, but a second podiatrist disagreed. When she told a friend about her upcoming surgery, he suggested that Abrams consult  Washington podiatrist M. Joel Morse, for another opinion. "He's not one of those guys who jumps to surgery," Abrams remembers being told. Morse runs the Cherry Blossom Dermatology Seminar each April.  

Dr. M. Joel Morse

After examining Abrams, Morse thought her primary problem was not a hammertoe but a "sausage toe," a term podiatrists use to describe swelling often due to injury or infection. He asked Abrams if she had injured her toe; she didn't remember doing so. Morse suggested she undergo an MRI to check for an abscess or other problem before any surgery. Within hours, she underwent an MRI and a procedure that opened the toe to look for an abscess. Afterward several grim-faced doctors filed into her room and told her to forget about any hammertoe operation. She had osteomyelitis, an infection that was eating away at the bone in her toe.

Ultimately, the toe needed to be amputated. To Morse, Abrams is "a very unfortunate case. Had [the MRI] been ordered earlier, she might not have lost her toe." Abrams said it took her a long time to get over her fear that any injury might conceal a smoldering infection. She remains grateful to Morse, who, she said, "was the first doctor who really listened and was thoughtful."

Source: Sandra G. Boodman, Washington Post [3/3/09]

TOPAZ Treatment Effective for Chronic Heel Pain: GA Podiatrist

A retrospective study of 100 patients who received a radio frequency treatment for heel or tendon pain found that the procedure improved their level of activity and significantly reduced pain. Thomas A. Brosky, II, DPM of the Foot and Ankle Clinic of Oakwood, GA presented his research findings at the Midwest Podiatry Conference in Chicago.

Dr. Thomas A. Brosky, II

The entire TOPAZ procedure typically takes less than 20 minutes and the patient is ready to leave the clinic once they recover from light anesthesia. In Dr. Brosky’s study, patients who had not responded to conservative treatment were given Topaz. Then, he and his research team surveyed 100 of these patients to determine their satisfaction and level of success with Topaz. Of the 100 patients surveyed, 93 responded. When asked about pain levels during the six-week post-operative period, 47 said they had no pain, 27 had mild pain and 18 said their pain level was moderate. More than 9 of 10 indicated they were happy with this procedure and would recommend it to a friend.

“The results of our survey indicate that many patients who undergo Topaz do very well, even when surveyed a year after the procedure,” Dr. Brosky said. He said that almost eight of 10 patients said they could walk several blocks without pain after the surgery and that while 47 patients indicated they couldn’t run before the surgery, 65 said they could run afterward. Brosky stressed that Topaz isn’t a first-line treatment for heel pain. “All of the patients in the study had conservative treatment first such as ice, stretching, and over-the-counter pain relievers,” he said.

Source: CMPR [3/31/09]

PICA Members Overwhelmingly Approve Demutualization

ProAssurance Corporation announced Tuesday that the policyholders of the Podiatry Insurance Company of America (PICA) have overwhelmingly approved the sponsored demutualization that will bring PICA into ProAssurance as a standalone subsidiary. The transaction, which requires final regulatory approval in PICA's domiciliary state of Illinois, is expected to close early in the second quarter.

Under the agreement, approved today in a special meeting of policyholders, a total of $120 million is being paid to current and certain former policyholders in accordance with the approved plan of demutualization. The plan of demutualization also provides a total of $15 million in premium credits to eligible renewing PICA policyholders beginning in 2010 and spread over three years.

Policyholders who are due to receive a cash payment have until the close of business on Friday, April 10, 2009 to furnish properly completed paperwork to PICA or its paying agent, BNYMellon Shareowner Services. Policyholders who do not furnish the proper paperwork will be subject to federally mandated tax withholding on the payments due to them.

Source: ProAssurance Corporation via PRNewswire [3/31/09]

Most Providers Get On-Call Compensation: Survey

Almost two-thirds (62%) of healthcare providers receive some form of additional compensation for on-call coverage—mostly in the form of a daily stipend or hourly rate—with compensation rates varying by specialty, group size and region, according to a new report by the Medical Group Management Association which surveyed online 317 medical practices representing 2,536 providers.
 
The survey, titled the Medical Directorship/On-Call Compensation Report, marks the first time the MGMA polled its members on this topic, and it found that 70% of providers in hospital-owned group practices received additional compensation, compared with 58% of providers in practices not owned by hospitals. At $2,000 a day, neurosurgeons reported the highest daily compensation for on-call coverage, while pediatricians and urologists received $895 and $500 respectively.

"Historically, on-call duties have been sporadically compensated by hospitals, however, we're seeing more hospitals compensating physicians and we're seeing hospitals paying more," said Jeffrey Milburn with, MGMA Health Care Consulting Group in a news release. "Hospitals are realizing they must compensate group-practice physicians for on-call duties."

Source: Andis Robeznieks, Modern Healthcare [4/1/09]

Query: Scanners for Orthotic Fabrication

I would like to hear from opinions from bio-mechanical/orthotic  mavens on orthotic scanners to replace plaster impressions. Yes, you avoid the postal service (one way) so it speeds up delivery time. It also cuts plaster cost and clean up. But is this method accurate? Do these devices take scans in neutral? Do they fabricate good orthotics from these scans? Are the results reproducible? Can you build a good accommodative device in addition to a bio-mechanically accurate one?

David E. Gurvis, DPM, Avon, IN 

RE:  Frieberg's Infarction (Mitchell Wayne, DPM)
From:  Multiple Respondents

We have had very good results using MicroVas therapy on one patient. There was a rapid decrease in pain and disability.
 
Bob Kornfeld, DPM, Lake Success, NY, Holfoot153@aol.com
 
Current literature indicates that steroid injections may be beneficial. I've had a few patients whom I've given 1-2 therapeutic injections with 2-4 mg of dexamethasone about the neck of the metatarsal. This has been very beneficial. Temporary immobilization, followed up with orthotics, may be indicated.

David S. Tarr, DPM, Lowell, MA, tarrdpm1@aol.com

I have a 14-year old active girl with the same problem. X-rays show collapsed cartilage cap with sclerotic changes in the metaphyseal bone of the 2nd metatarsal and no angular deformity or jagged bone.  I tried one steroid injection without significant long-term pain relief. I tried orthotics with no real relief. I scheduled her for a joint clean-out shortening metatarsal osteotomy (Weil) to decompress the joint.

I considered a joint resurfacing implant, but was concerned with implant stability in this distal avascular portion of head.  I feel that a longer osteotomy that encompasses the entire head would give an osteotomy better healing changes than an implant. I also have as a plan B, a Biopro hemi-implant if the cartilage is degenerative.   
 
Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

RE: Hyperuricemia Management (Eugene Batelli, DPM)
From: Multiple Respondents

Dr. Batelli states he routinely starts his patients on allopurinol as part of his gout/hyperuricemia patients. I was always under the impression that allopurinol is an option for a patient who overproduces uric acid and probenecid is given for underexcretors of uric acid. Does allopurinol work for underexcretors as well?

I usually order a 2- hour urine to distinguish between the overproducers from the underexcretors. I then make recommendations to the internist, but leave the long-term management to them. I provide NSAIDs or colchicine if the attack is caught within 24 hours. If pain is severe, an injectable steroid is given and or sympathetic nerve block. I choose to defer long-term or chronic care of the gout to the internist and or rheumatologist as gout can adversely affect the kidneys, and I feel that to be more of a systemic issue than a localized foot issue.
 
Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com  

Podiatrists are commonly faced with the issues of medical management on a day-to-day basis for a multitude of diseases that range from diabetes to hypertension to heart disease to renal failure. Gout is one of those diseases, by license, you are treating.

While I am not an attorney, I am both a pharmacist and podiatrist. On any given day, there are Rx's from ALL physicians of ALL types that may not be in their everyday realm, but it is in the scope of what they do. As a podiatrist, any given drug that may or may not have indications (off-label or otherwise), if it is in scope of what is being treated, can be prescribed by you. All physicians who are licensed to prescribe drugs face the question of scope of practice. In certain circumstances a podiatrist can and does Rx many unusual drugs.

A pharmacist will look at the Rx, and if it seems to be out of scope, will call the practitioner. Treating acute and chronic flares of gout are well within federal Rx scopes of podiatrists; however, each state may have its own rules. You have to make your own decision just like family practitioners do. Some will treat; others will say it belongs in the hands of a specialist.

Larry Kollenberg, RPh, DPM, Jacksonville FL,lkollenberg@hotmail.com

Both sides of this argument have excellent points. One can counter each side. Is treating hyperuricemia with medications for long term control within our scope? How different is it than treating hyperglycemia, and medicating patients with insulin or other meds? Bottom line is that it doesn't matter what individual opinions are, or how strongly you feel about our ability to manage these conditions. Everyone should check with their State Board as to how they interpret that individual State's practice act. They are the ones with the last word on the matter.
 
Brian Kashan, DPM, Baltimore, MD, drbkas@worldnet.att.net

RE: Chronic Calluses and Skin Fissures (James M. Petko, DPM)
From: Mark K. Johnson, DPM

Debride callused tissue, apply Amerigel to fissures under occlusion for 3-4 days, then begin 40-50% urea BID, including wearing cotton socks to bed frequently. The patient may have a hereditary hyperkeratosis condition.

Mark K. Johnson, DPM, West Plains, MO, ddr004@centurytel.net

RE: Services Rendered During Application Period
From: Paul Kesselman, DPM

Medicare recently announced several significant changes impacting your ability to be paid for services rendered during your application period for billing privileges. Previously you could select a retroactive date for services rendered prior to your application’s submission. However, in a recent posting (MLN Matters Number: MM6310), that has been clarified. Now, the carrier will select the effective date of Medicare billing privileges as the later of the date of filing or the date you first began furnishing services at a new practice location.

This can have a huge impact on those thinking of moving their offices, changing tax identifiers and tax status (solo to group), adding additional physicians to your practices and incorporating DME into your practice.

For more details, contact your local MAC or the NSC (for DME). More details may be found at  the following link

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

RE: Should I Keep My DEA Active? (Jay Wenig, DPM)
From: Alan L. Bass, DPM

Pharmacists and pharmacy computer billing systems DO NOT require a doctor’s DEA number to fill all prescriptions, only controlled substances and narcotic prescriptions. What is now routinely needed by pharmacists is your NPI number. That is becoming more of the standard. As long as the pharmacist has it (which most of us now have on our prescription blanks or can be searched on the NPI website), they can fill your non-controlled prescriptions.

Alan L. Bass, DPM, Manalapan, NJ, abassdpm@optonline.net

RE: Coding for the Topaz Procedure (Harry Goldsmith, DPM)
From: Bruce Werber, DPM

I respectfully disagree with Dr. Goldsmith's response in regard to coding for radio frequency coblation (Topaz being one type of handpiece that provides a low temp bipolar plasma field). Radio frequency coblation is an instrument, just like a scalpel, or arthroscope, or a retractor. This modality is used in a variety of procedures from arthroscopic synovectomy, to tendon repair, to treating plantar fasciosis.

Would you submit an unlisted CPT code if one used a new type of scapel or saw blade to perform a chevron osteotomy? Of course not, so why would we use an unlisted CPT code for using radio frequency coblation for tendon repair, or in treating plantar fasciosis. If you are treating tendinosis using radio frequency coblation, use the appropriate code for tendon repair. If you are performing an arthroscopic synovectomy, then use the appropriate code for that procedure. 

The literature is clear that radio frequency coblation has a measurable effect on the tissue to initiate angiogenesis and release of growth factors within tendon and fascia that have been injured to resolve the tendinopathy and/or fasciosis and return the patient to more normal functioning.

Bruce Werber, DPM, Scottsdale, AZ, docwerber@gmail.com

PRACTICE FOR SALE - CENTRAL FL

Practice and medical building for sale, in beautiful, high quality of life, growing area, Central Fl.; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion & investment; good insurance climate. 352-223-2713 / E-mail: windnwave@earthlink.net

ASSOCIATE WANTED - FLORIDA

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Partnership opportunity for the right candidate. Preference given to a PSR 24+ resident completing their education this spring/summer, 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 HMO's. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family that is second to none. E-mail: kimvelez@tampabay.rr.com

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

PART-TIME NON-SURGICAL PRACTICE FOR SALE - NORTH JERSEY    
 
23 yo practice recently relocated to a spectacular newly-constructed and equipped storefront next to a busy supermarket with ample parking and senior citizens in vibrant downtown. Accepting Medicare and Blues only with great potential. Perfect for expanding to full-time, a second office or new practitioner with means and office experience.  Priced to sell. Financing possible. E-mail interest with contact to Mikedup1215@yahoo.com

PODIATRIST NEEDED FOR MIAMI-DADE COUNTY

Multi office practice needs doctor of podiatry for full time and/or part time for private office, clinics, and nursing homes. Great opportunity to grow with and unlimited income potential. Offices in Miami, Hialeah, Westchester, and Cutler Ridge. Email to feetdoctor@aol.com

ASSOCIATE NEEDED- SOUTHEAST MICHIGAN

Well-established practice needs to replace a departing partner and is looking for a reliable, personable podiatrist to step into a busy practice. This is an outstanding opportunity with full benefits that may lead to partnership. Please contact dr.hughes@comcast.net

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.

ASSOCIATE POSITION - CHANDLER/GILBERT/PHOENIX, ARIZONA

Seeking a well-trained, ethical and hard working graduate of a PSR 24+/36 Residency to join our growing multi-location practice. This is a practice with a nice mix of 35% surgery/trauma, 20% diabetic/wounds, 25% biomechanics, 20% pediatric. ER Call. Opportunity for partnership at 2 surgery centers. Very modern offices with EMR, U/S, Digital X-Ray, ESWT, Vascular Testing Machine. Excellent referral base, and a well-trained staff. Board eligible/certified a plus. Competitive salary, bonus structure, benefits. Please e-mail CV and references to  FootAnkleAZ@aol.com

OFFICE SPACE/ MRI RENTAL – NYC, LI

Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, and Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

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