The Voice of Podiatrists

Serving Over 12,500 Podiatrists Daily

April 16, 2011 #4,136 Publisher-Barry Block, DPM, JD

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Women Continue to Suffer From Wearing Stylish Shoes: NV Podiatrist

Many women suffer for the sake of a stylish shoe. Dr. Christine Clark, a local podiatrist has witnessed this too many times to count. Clark explains exactly how bunions and/or hammertoes are formed. Instability from excessively high heels causes the former and improper fit explains the latter. Translation: A pair of pointy-toed stilettos will make your feet look pretty -- until it's time to take them off. 

Dr. Christine Clark

"What we're seeing now are 5-inch heels and women think they're great because they're platforms," Clark says. The extra distance between the foot and floor convince women they aren't doing as much damage. On the contrary, Clark says a platform with height will spur back and knee problems on top of foot problems.

Source: Xazmin Garza, Las Vegas Review-Journal [4/14/11]

OCR Officials Send Clear Message on Internal Privacy Audits

In case the $5.3 million in penalties it assessed less than two months ago wasn’t strong enough, officials with the HHS Office for Civil Rights had a “clear message” for covered entities and business associates attending the 19th national HIPAA Summit in Washington, D.C. “In light of OCR’s clearly articulated intention to aggressively enforce the HIPAA privacy and security rules, covered entities and their business associates should review their current HIPAA compliance programs,” Valerie Morgan-Alston, deputy director of enforcement and regional operations, said at the Summit.

“CEs should be training their employees that compliance is as essential as patient safety,” she said. “Policies and procedures can’t be something just sitting in notebooks on shelves gathering dust. They must be an everyday part of an organization’s culture.” Alston tried to hammer home the need for audits, saying, “CEs must conduct regular internal audits to find non-compliance themselves rather than waiting for complaints and OCR to come in.”

Source: Nina Youngstrom, AIS Health [4/6/11]

Make Progress on Team Goals

Drive team performance by showing that you are serious about action and progress. Here’s how:

• Set the example. You should personally drive progress, demonstrating how much you can accomplish and showing your team how to do the same.
• Use milestones to force action. Focus dwindles when your staff works on long-term goals without interim targets. Review progress periodically, whether you choose to use informal updates or more formal review meetings.
• Follow up. Require people to take action on the items they assume responsibility for. Log problems and questions, and review those logs periodically to make certain that overlooked concerns are not hampering your team’s progress.
• Listen. Every leader needs to develop a reputation for an open mind and an open door. When you demonstrate good listening skills and a keen appetite for information, you will discover potential obstacles in time to remove them before they cause damage. Actively seeking input from others allows you to compensate for your own blind spots. If you act alone every time, you eventually will lead your team into a dead end.

Source:  Adapted from “An Action Environment,” Projects at Work via Communication Briefings

Query: Evaluating All-Purpose Lasers

I am thinking of buying an all-around laser for the office for treatment of  warts, veins, nails, etc. What is a good objective resource to evaluate the different types of lasers and the criteria for applications, e.g., watts, wavelength spot size, etc..

John Moglia, DPM, Berkeley Hts, NJ

Query: Billing for Cortisone Injection?

Can a doctor bill for a corticosteroid injection proximal to and into the surgical site shortly after closing? I usually like to give Marcaine 0.5% with a little bit of dexamethasone. I bill CPT 20550. Most patients relate no pain during the first three days following surgery, and patients have no problems with healing. Can I bill CPT 20550?

Walter Perez, DPM, Brooklyn, NY

Response: Most payers would consider that injection "incident to" the surgical procedure and not pay for your injection service.

They would usually pay the hospital or ASC for the injectable supplies.

Paul Kinberg, DPM, Dallas, TX

Codingline subscription information can be found here APMA Members: Click here for your free Codingline Silver subscription

RE: Uric Acid Crystals, Post-op
From: Tip Sullivan, DPM

I have never had this occur post-op, but it would make sense when one chooses to do a small MIS procedure. I am not a great MIS advocate, but I do use it on occasion. When I use it, I do not put a suture in it, and it usually drains a little. Did you see any gouty material when you did the original procedure? Do you have the patient on any empiric antibiotic? You got what you got - I imagine it could happen to anyone. I would look back at the pre-op x-ray to look for the little mouse bite bone lesions. I would then open this up, and clean out as much gouty material as reasonable (you will never get it all).

I use a mechanical wound lavage system. I might even consider removing some of the the underlying bone if there is any hint of a suspicion and send the "bone" cultures to micro and the material to histopath. I would close it primarily, and would use some antibiotic-impregnated beads (only one or two small ones) if an infection was a concern. I would also discuss this with the patient's primary care physician and suggest chronic maintenance with a xanthine oxidase inhibitor, with a goal of <6mg/dl serum uric acid.

Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net

RE: Mosaic Wart Treatment (Stephen Merena, DPM)
From: Barry Mullen, DPM

When utilizing off-label cimetidine to enhance an immune response for verruca, I suggest following Seth Orlow's original protocol of 20-25 mg/kg per day in divided doses.(1) Therapy duration varies, but average response times in children = 6 weeks.(2) The previously recommended 35 mg/kg/day dose is not needed. The suggested 45 day duration will likely be inadequate in nearly 50% of cases. Should no immune response occur at 6 weeks, parents should previously be educated that therapy duration could last as long as 90 days before considering  the treatment a failure; so, patience is critical to success. Lesions generally darken and become less symptomatic as the HP virus is successfully eradicated through immune system enhancement via heightened T cell response from thymus gland stimulation. Lesions simply self-desquamate. Success rates in children parallel Orlow's = 85% (1,2).

Thoroughly review cimetidine's side-effects and potential drug interactions, especially with those medications concurrently metabolized through the citochrome p450 system before embarking on such a treatment regimen. In my professional opinion, this is the ideal treatment regimen for resistant, multiple, mosaic lesions.
 
References: (1) Orlow- J Amer Academy Derm, 1994; (2) Mullen- JAPMA, 2005

Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

RE: Laboratory Confirmation of Dermatophyte Infections (Bryan C. Markinson, DPM)
From: Mark E. Spier, DPM

Again, I must proffer my opinion on the accuracy of clinical vs. laboratory diagnosis of onychomycosis. Dr. Markinson admits that the clinical diagnosis is accurate only 80-85% of the time. With the additional patient history of onset, etiology, and prior partial response to oral agents, I suggest that this number may be higher, but for argument's sake, let's accept Dr. Markinson's range. Drs. Baran, Hay, Haneke and Tosti, in the definitive publication, Onychomycosis, published in 1999, state that "direct microscopy may be negative in up to 20% of cases, and cultures may fail to isolate a fungus in up to 30% of cases."

Certainly, Dr. Markinson is not advocating the use of PCR which is the most definitive diagnostic test currently available, since the cost of that procedure approaches the cost of the laser treatment itself. Some of my laser patients with a questionable presentation have become upset with the laboratory bill for the PAS and culture that I requested. Without becoming too philosophical or politically incorrect, there comes a time in every clinician's life when we have to emulate Nancy Reagan and learn to JUST SAY NO to overutilization and the needless waste of insurance dollars. I still don't have a financial interest in any laser manufacturer.

Mark E. Spier, DPM, Reisterstown, MD, Spierfoot@aol.com

RE: HIPAA and Doctor Reviews on Websites (Richard Boone, Esq.)
From: Bob Hatcher, DPM

I agree completely with Richard Boone’s recommendation to ignore Internet criticism by patients but would add that it might prove a good time to carefully evaluate the validity of the criticism and use it as an opportunity to perhaps make a change in behavior  - if warranted.

Bob Hatcher, DPM, Raleigh, NC, bob.rfc@intrex.net

RE: Peromax Braces (JE Shiller, DPM)
From: Josh White, DPM, CPed

The Peromax is a wonderful pre-fabricated AFO for the treatment of flaccid drop foot and should always be considered prior to casting for a custom device. The Peromax is made from carbon graphite and so is very lightweight and thin enough to fit into any depth shoe. No casting is required. Many patients present with drop foot that is untreated, and others with custom polypropylene devices made years ago. Given the opportunity to try one, many will love the Peromax. The suggested Medicare code is L1951 that has a maximum reimbursement of $905.

SafeStep is the exclusive podiatric distributor of this device and has educated podiatrists about its merits for years.

Josh White, DPM, CPed, President/Founder, SafeStep, Joshwhite@SafeStep.net

RE: Routinely Taking Patients' Blood Pressures in a Podiatric Setting (Elliot Udell, DPM)
From: Lynn Homisak

From day one that I worked for Dr. Roy La Barbera in NJ, we routinely took BP's on all of our patients. They loved it - felt they got extra special service. To us, it was just good medicine. But that wasn't the best part. The best part, similar to Dr. Udell's story, was having identified one patient who was literally on the verge of a stroke (off the charts BP.) We literally had her transported directly to the hospital from our office. Up until that point, she was unaware that she was hypertensive and couldn't thank us enough for "saving" her.

We sent another patient whose BP was also extremely elevated to her MD for follow-up care. While the new core values may seem like "more work", they just might help other podiatry offices detect serious conditions that might otherwise go unnoticed...it's a good thing. Always was.

Lynn Homisak, Renton, WA, soslynn@gmail.com

RE: The Latest in Body Piercing

What's the CPT code for this?

Source: Break Media via Dr. Bret Ribotsky

EQUIPMENT FOR SALE - COOL TOUCH LASER

Cool Breeze Cool Touch CT3 plus laser used for ugly, unsightly, toe nail infections. Less than six months old. Great price won't last long. Considering a laser? We also have the Q- Clear Q- switch laser too. This laser is perfect for you. Also a used Lumix 2 laser, best price today. Dr. Zuckerman is in the Fort Lauderdale area and will demo these lasers on your patients. E-mail footcare@comcast.net

PRACTICE FOR SALE - MARYLAND, DC SUBURBS

Great opportunity. Well established and equipped practice for sale. Office includes state licensed Ambulatory Surgical Center. Present owner is retiring but will stay on as needed for smooth transition. Average gross over past 3 years is $575 K. dpmpracticeforsale@yahoo.com

GROWING PRACTICE FOR SALE- PHOENIX ARIZONA

Part of the largest multi-specialty group in Phoenix comprised of approximately 30 referral sources. Selling 50% share in practice grossing 600K. Gross is based on part-time practice but easily expandable to full-time if desired. Active, healthy client population, excellent surgical base, very minimal palliative care. PSR-36 required. Inquire at drlaurel@cox.net

PRACTICE FOR SALE - HOUSTON, TEXAS

28 year old busy, progressive practice for sale with an excellent reputation and well established referral base. Well-trained, dedicated, supportive staff. Excellent cash flow $475K income after overhead. EMR, digital x-ray, diagnostic ultrasound. Free standing building also available with large outdoor sign. Also available are two transferable surgical center partnerships(with distributions). Owner retiring and willing to stay part time during transition. Cover letter/CV to softechpodiatrist@gmail.com

SPACE AVAILABLE- NYC & LI

Office to sublet and share - East 60th Manhattan, and Plainview long island. access to an MRI, Joint Commission certified operating rooms, digital x-ray, diagnostic ultrasound, and access to a multi-specialty ambulatory surgical center. Turn-key operation - no investment needed 516 476-1815 PODO2345@AOL.COM

PART TIME PODIATRIST NEEDED- LOS ANGELES, CALIFORNIA

Busy podiatrist looking for assistance with treating home-bound patients. Flexible hours, independence, and great compensation. If interested, email CV to homefootcare@hotmail.com

ASSOCIATE POSITION – NEW JERSEY

Associate wanted full-time, for practice in East Orange NJ PSR 24-36 trained. Must be motivated to grow practice, especially build wound care and surgical services. Buy-in possible after the 1st year. send CV to Drfoot44@gmail.com

ASSOCIATE POSITION - NORTH CAROLINA

Cornerstone Health Care, one of the largest physician owned and managed multispecialty groups in the Southeast, seeks podiatric physician for office located in the Piedmont Triad of North Carolina. The physician must be licensed in NC, have three years of training, and board qualification in forefoot and rearfoot surgery. Cornerstone has over 290 providers in 75 locations. Physicians benefit from centralized billing, purchasing, and human resources, while maintaining autonomy over office practices. A state-of-the-art EMR system provides instant access to all Cornerstone patient records. Send CV to page.redpath@cornerstonehealthcare.com.

ASSOCIATE POSITIONS - NW INDIANA, CHICAGO AREA

2 Full-Time positions open - One for Northwest Indiana and one for the Chicagoland area. Must have 2-year surgical residency. Must be motivated and a self-starter. State License required. If interested email: f-massuda@footexperts.com

ASSOCIATE POSITION - CT - (FAIRFIELD AND NORTH HAVEN)

Join one of the largest podiatric groups in Connecticut. Well-established and progressive offices, including EMR, digital x-ray, vascular and NCV studies, Pinpointe and CO2 lasers, diagnostic ultrasound and electrical stimulation therapy. You can expect a full schedule of patients the day you start, and a very competitive salary. For more info www.greatfootcare.com. Send resume to Dr.Kassaris@yahoo.com

ASSOCIATE POSITION - NEW YORK CITY & QUEENS

One of the fastest growing podiatry practices in New York City and Queens seeks a podiatrist who participates with HealthFirst, Fidelis, and other Medicaid plans. Preferably a Spanish speaking podiatrist. Contact me at Podocare@aol.com

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