The Voice of Podiatrists

Serving Over 10,800 Podiatrists Daily

April 19, 2008 #3,224 Editor-Barry Block, DPM, JD

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Prolonged Wearing of High Heels Can Cause Bunions: LA Podiatrist

Many women wear high heels because it enhances the appearance of their calf muscles, but Dr. Clif Richardson, Baton Rouge Foot Care podiatrist, said precautions must be taken to prevent damage. "Building calf muscles [are] fine," Richardson said. "Lots of people like that. But it can create ... a [really] tight Achilles tendon. A lot of people need to do some calf muscle stretching so they don't have a [really] tight Achilles tendon."

Dr. Clif Richardson

Richardson said many of the physical deformities caused by wearing high heels for an extended period of time require surgery because there are no other options for reducing the pain they cause."A higher percentage of people who wear high heel shoes overall get bunions," Richardson said. "That is a long-term problem that will require surgery because we don't have conservative fixes for bunions ... some people think that the risk is worth it."

Source: Sarah Aycock, The Daily Reveille, [4/17/08]

More Physicians Backing National Coverage: Study

More physicians in 2007 supported the creation of government-financed national health insurance than in 2002, according to a new poll. However, physician organizations said that can't be equated with support for single-payer healthcare.

Fifty-nine percent of 2,193 physicians surveyed last year backed the creation of "national health insurance" with a main goal of "financing health care for all U.S. citizens." That's an increase of 10 percentage points since 2002, according to the survey, published in the April 1 Annals of Internal Medicine. Fifty-five percent of physicians supported "achieving coverage through more incremental reform," a question that was not asked in 2002.

"Across the board, more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy," said survey co-author Ronald T. Ackerman, MD, MPH, associate director of the Center for Health Policy and Professionalism Research at Indiana University.

Source: Doug Trapp, AMNews [4/21/08]

Query: Wound Debridment

Is there a difference in CPT coding for CMS guidelines using the term "excisional debridement" for ulcer care vs "traditional sharp debridement of tissue?" Are they the same?

My local hospital asked me to clarify my medical record whether I used excisional debridement. I used CPT 11041 with a description of the location size, level, and depth of tissue involved in the treatment with description of the ulcer and surrounding tissue. I did not excise the ulcer itself. They faxed me a reference from Quality Solutions from 2000 which describes both physician and non-physician services. Is this something old, or is it coding/charting different in hospital settings?

Glenn Weinfeld, DPM, Cortlandt Manor, NY

Response: There are some fundamental semantics, which are essential to coding.

The CPT 1104x series of codes reflect sharp debridement, which means and implies cutting through layers of tissue with a blade. Appropriate coding is based upon the ultimate level of tissue removed. Such codes are most commonly used to reflect treatment of ulcers - not skin lesions.

"Excisional debridement" implies, and requires, that such debridement has removed any such troublesome lesion in its entirety. That implies the lesion is "gone," perhaps into a specimen container for the pathologist

CPT provides a series of codes for "shave excision." This is the CPT 1130x code series. The implication and expecation is that such lesion are also "gone," even though this is not a full thickness excision.

There remains another level of CPT codes which reflect full thickness excision of skin lesions. Such excision requires primary closure with suture, and is most appropriately coded with the CPT 11420 series. It is fundamental to recognize that appropriate coding is based upon "excised diameter" which is defined in CPT. And there is yet another set of CPT codes which reflect removal of devitalized tissue from wounds using selective debridement and non-selective debridement without anesthesia.

Rick Horsman DPM, Olympia, WA

Codingline subscription information can be found by clicking here:

Query: Generating Reports from Lytec

Last August, my office had Lytec and Medinotes-e installed. One of the reasons we switched over from WISDOM to Lytec was that Lytec purportedly could provide much more meaningful reports regarding the business side of the practice. We have inquired about having simple reports such as Per Visit Value (PPV) generated and have been told by our vendor that they would have to write a special program for us (at a cost) to have this calculated by the Lytec.

I recall someone from the AAPPM explaining that Lytec could "drill down" into the data to generate wonderful reports. So far the drilling that has occurred hasn't been into the data. If anyone has suggestions or knows how to have Lytec generate some of the basic reports that AAPPM recommends, I would appreciate hearing how to do this.

Howard J. Bonenberger, DPM, Nashua, NH

RE: Von Recklinghausen’s Disease (Adam Landsman, DPM, PhD)
From: Steven H. Goldstein, DPM

Large plantar fibromas that are associated with this disease respond extremely well to cryoablation. I have performed over 40 of these on patients with tumors as large as 7.0 x 7.0 cms. They shrink approximately 40-60% after one treatment. The large lesions will require a second treatment. Smaller tumors may respond to one treatment. procedures also work well when there is medial or lateral plantar nerve involvement, as well. I have many colleagues who perform this procedure across the United States.

Steven H. Goldstein, DPM, Royal Palm Beach, FL, stevefootdr1@cs.com

RE: Adverse Effects From Lamisil (John Cozzarelli, DPM)
From: Kathy Satterfield, DPM, Marc Greenberg, DPM

We tend to ignore those adverse effects that fall under the "< 2% category" unless they occur to our patients and then they certainly get 100% of our attention. I know I used to ignore them until I had a few incidences of odd things occur to patients like "memory loss" with Lyrica. When a patient comes in and says that they forgot where they lived after a few weeks of taking that medication, that makes you think twice about prescribing it the next time. Or when a patient gains 30 pounds over a month and becomes an overnight drunk when taking the drug. I guess that's why it takes years of study to get a license to prescribe medications - it takes proper judgement to start a medication and to stop it.

Kathy Satterfield, DPM, Boerne, TX,vksatterfielddpm@aol.com

I tell my patients that "anyone can have any reaction from any drug." I have seen reactions from patients on all kinds of drugs in less time than that, including Lamisil, which I write for quite a bit. That being said, I've never seen that particular reaction from Lamisil.

Marc Greenberg, DPM, Dayton, OH, tripperdpm@yahoo.com

RE: Limb-Length Discrepancy in Biker
From: Art Hatfield, DPM

I do not understand the concept of using mismatch cranks on a patient with an LLD. If a longer crank were placed on the side of the short leg, this would help when the crank is in the up position, but would cause problems in the down position (completion of the power stroke) as the pedal would be further away from the hip. Conversely, a short crank on the short leg side would help when the pedal is in the down position, but interfere with the beginning of the power stroke.

I agree with the thought of a spacer between the cleat and shoe on the short leg side.

Art Hatfield, DPM, Long Beach, CA, afootjob@juno.com

RE: Instrument Sharpening Service (Bryant Tarr, DPM)
From: Catherine Brigandi, DPM

The sharpening service through Bianco Bros. is excellent. I have used a "mom and pop" local service as well as a regional service available to hospital/ASC. Bianco will sharpen and repair any brand of instrument, with timely turnaround, a very fair price, and they put on an edge that lasts 8 months or more. With the other companies it was only 3 to 4 months before the edges were too dull to be used.

Catherine Brigandi, DPM, Surprise, AZ, brigandi@extremezone.com

RE: Podiatrists Vs. Orthopods
From: Robert A. Kornfeld, DPM, Barry Mullen, DPM

While I understand that we have definite issues with orthopods (and I wholeheartedly agree with Dr. Purdy that turning the other cheek does not assist in the continuing strides we are making), I think it is necessary to comment that it is not only the orthopods that have a built in prejudice against us. It is the entire allopathic medical profession. I treated a very young girl with Juvenile RA. She was on Embrel and Voltaren, and continued to have pain. In frustration, the mother came to me for a holistic approach in hopes of getting the child off drugs and helping her intense ankle pain to subside. It is now 8 months. The child is off of all meds and is pain free. The rheumatologist that was medicating the child actually called me to chastise me and told me that I "should stick to clipping toenails like a good podiatrist!". If I were that rheumatologist, I would certainly have wanted to know what treatment was rendered in the hope of helping his patients with RA. The fact that he was "shown up" by a podiatrist was more than his ego could handle.

Robert A. Kornfeld, DPM, Lake Success, NY, Holfoot153@aol.com

Editor’s Note: An extended-length note by Dr. Mullen appears at: http://www.podiatrym.com/letters2.cfm?id=19068&start=1

SEEKING RESIDENT FOR PSR-24 - BALTIMORE, MD (MERCY MC)

Position for a highly motivated individual with completed non-surgical residency or one desiring additional surgical training in well-established Podiatric Residency Program. Busy metropolitan hospital with high surgical numbers and inpatient care. Resident is integral member of multidisciplinary team. Begins mid June 2008. Includes competitive salary/benefits. Send inquiries to rsher18@yahoo.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently four (4)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

PRACTICE FOR SALE - MINNESOTA: PRIME LAKES AREA

Great place to live and raise a family. $400+K yearly gross with continued growth and potential. Good mix of general podiatry & surgery. Hospital privileges available. Fully computerized, electronic notes, with capability to go completely paperless. Recently remodeled office, 5 tx/procedure rooms, well-equipped in owner-occupied building (for sale or lease). 260 402-7490

ASSOCIATE POSITION – PART-TIME MARYLAND

Baltimore County, Maryland Practice seeking motivated and very personable individual with 2 years min. surgical training. Busy practice in great area with hospital grade ASC. Please fax your CV and contact information to: Dr. Maurice W. Aiken 410-602-9781.

PRACTICE FOR SALE- CORAL GABLES, MIAMI AREA (FLORIDA)

Beautiful location in the heart of Miracle Mile. Excellent opportunity for a starting practitioner. Most insurances accepted. Good mixture of surgical and general podiatry. Fully equipped with low overhead. Located in a professional building, with referrals from other doctors in the same building. Contact zoesar@aol.com or call 786-877-5149.

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. 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 -- www.homephysicians.com

ASSOCIATE POSITION – FLORIDA

Emerald Coast on the North Shore of the Gulf of Mexico, a well-established group practice with multi-offices, seeking an associate with opportunity for partnership for a PSR-24/36 Doctor well-trained in foot/ankle/diabetic problems/wound care/surgical and medical podiatric care, covering 3 area hospitals, NO nursing homes, Please fax a letter of interest, CV, and references to 850-862-5470, e-mail ecpodiatry@aol.com

ASSOCIATE POSITION – GREATER MILWAUKEE, WI

Great opportunity: our busy multi-physician, podiatric group practice, with multiple locations, strong hospital affiliations and faculty positions with PM&S-36 residency program, is seeking a full-time RRA BQ/BC, PM&S-36 surgically trained doctor. Applicant should be well trained in all aspects of surgical and conservative care. Candidate should be ethical, hard working and outgoing physician to join our practice. Commensurate pay with incentives and benefit package. Definitive plan leading to partnership tract. Contact: Daniel Hellman, M.D. @ 414.831.0512 or by e.mail @ hellmandr@gmail.com

ASSOCIATE POSITION – NW INDIANA (1 HR FROM CHICAGO)

Caring, hardworking podiatrist needed to join our busy practice. We offer great pay and benefits. Must be highly motivated, have a great bedside manner and superb surgical skills (forefoot and rearfoot surgical training a must). E-mail resume to friendlyfootcare@comcast.net or fax resume to (219)662-7290. Learn about here

ASSOCIATE POSITION- LOS ANGELES AREA

Dynamic well established practice in brand new office building with surgery center, adjacent to hospital, seeks energetic rearfoot and ankle trained associate with partnership aspirations. E-mail CV to dr4feet@sbcglobal.net.

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

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