The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

April 28, 2010 #3,843 Publisher-Barry Block, DPM, JD

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Foot-Related Problems Increase Over Summer Months: TN Podiatrist

As the weather is getting warmer, we are beginning to see toes peeking out the ends of sandals and open-toed shoes. Many of us are getting inspired to get pedicures, go barefoot and increase our physical activities. As Foot Health Awareness Month comes to an end and summer nears, podiatrist Dr. David Franklin reminds us that “how your feet feel and function is directly related to your overall health.

Dr. David Franklin

“Our feet are our primary mode of transportation and ambulation, and therefore, when they are not functioning well, we do not function as well,” he said. Some of the most common foot health problems include plantar fasciitis, ingrown toenails, foot deformities that limit activity due to pain, foot fractures or sprains, ankle sprains and skin infections involving the foot or ankle. Some of these problems, including plantar fasciitis, infections, and sprains are seen even more during the summer months.

Source: The Daily Times [4/26/10]

Another SGR Reprieve - Good News For Hospital-Based Physicians

President Barack Obama signed legislation this month that temporarily holds off a steep cut in physician Medicare payments and lengthens benefits under the COBRA program. The legislation extends until June 1 the current higher level of physician payment, and extends until May 1 federal assistance for Consolidated Omnibus Budget Reconciliation Act premiums.

The legislation also effectively reverses an interpretation by the CMS in a rule it issued in December that made many hospital-based physicians ineligible for federal electronic health-record subsidy payments under the American Recovery and Reinvestment Act of 2009. The new law attempts to clarify that Congress wants physicians who work in hospitals and in outpatient settings to be eligible for subsidies to computerize their offices.

Source: Modern Physician [4/26/10]

Website to Collect Patients' Views on Adverse Events

Patients who have been the victim of an adverse medical event will now have a new way to share the details of their experiences, according to the Empowered Patient Coalition. The San Francisco-based not-for-profit group, in collaboration with the Austin, Texas-based Consumers Union Safe Patient Project, has released a 40-question online survey that patients can use to report on their perspectives of incidents of medical harm.

The survey prompts respondents to provide the details of the incident including the state where it occurred, the type of provider involved, contributing factors, whether they considered litigation and providers' response following the event. Patients have the option of submitting the surveys anonymously. Patients can also choose from several checklists to indicate the procedure or treatment that was associated with the adverse event. For instance, in the section of the survey related to surgical errors or complications, the respondent can check boxes to indicate “wrong-site surgery” or “post-operative complication.” There are also fields to provide details about healthcare-associated infections, falls, adverse medication events and other types of incidents.

Source: Maureen McKinney, Health IT Strategist [4/26/10]

Editor's Note: PM News is proud to present excerpts from Meet the Masters.

Bret Ribotsky: What type of protocols do you use in your practices?

Dr. Neal Frankel

Neal Frankel: We adapted a lot of our protocols from the American College of Foot and Ankle Surgery Guidelines. We actually have quarterly meetings to discuss what happens when patients come in and they have a particular diagnosis. We discuss the optimum way of treating it from two standpoints: One is the optimum coding and billing aspect; the other is taking care of patients in the most efficient way and what is going to give us the best outcome.

We present that in a format to employees who then go to the employer. Let's say you're in a community with a large manufacturer. You go to the employer and you say, "look, I have a group here in this area, and we are going to save your company real dollars. We will keep your employees out of the hospital."

Dr. Tilden Sokoloff

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). This week's show features Tilden Sokoloff, DPM, MD, an advocate for MD degrees for podiatrists. Dr. Ribotsky's interview of Jeffrey Toobin can also be heard on the Meet the Masters website. You can register for this event by clicking here

Toenail Pain from Nail Polish

A friend has distal toenail pain whenever she wears toe nail polish. It only happens on the left hallux nail. The pain resolves with polish removal. It has been going on for one year. The nail is slightly incurvated on both sides, with a distal superficial yellow discoloration. Exam and x-rays are normal. I think it might be the nail polish contracting on the nail as it dries, causing the pain. Has anyone seen this before? Any other considerations would be appreciated.

Bill Weis, DPM, Oak Creek, WI

Query: Discontinued Office Visit

This week, during a diabetic foot exam, my patient, who has an extensive medical history including 3 recent hospitalizations for TIAs, began to feel nauseous, slur her words, and become somewhat mentally confused. The exam, which was mostly, but not entirely finished, was ended by me. The patient's son, who was with her, indicated she had taken her insulin, but skipped lunch. She was given a glucose tablet and responded only partially. EMTs were called, and she was transported to the hospital.

I am not looking to bill anything extra, but am I able to bill for my the foot exam having not entirely completed it? If it makes any difference, it was probably about 75% complete. There are codes for a discontinued surgery when due to some medical or intra-op problem, but how would I bill for an interrupted office visit?

David E. Gurvis DPM, Avon, IN

Response: There are no specific codes reflecting a discontinued office visit. I would suggest you bill the E/M service actually performed prior to terminating the examination.

Mark Schilansky, DPM, Catskill, NY 

Codingline subscription information can be found at:
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RE: Ultrasound-Guided Injections
From: Multiple Respondents

I have been using diagnostic ultra-sound in the office for 10 years now. I find it invaluable as a diagnostic modality. I have also given many US-guided injections over the years, on a case by case basis. I do not use it for every injection I give, but I do find it extremely helpful when injecting the posterior tibial tendon, neuromas, Achilles tendon, and plantar fascia. I have also used it to locate abscesses in diabetic/PAD  patients, where abscesses are not near the ulcer site, but somewhere proximal or distal to the wound. Overall, I think it should be in every podiatry office. The argument being presented here that there is no literature to show improved outcomes with guided injections is a very circular argument.

What I believe is going on here is the thought that if you can't prove efficacy to the insurance companies, then they will not pay for your work. I believe it is really not about proving efficacy. I think my colleagues have forgotten that medicine is one part science and two parts art. If, in your clinical judgment and in your hands, a guided injection is most prudent, DO IT! If this is something that "won't be covered", charge your patient for the time and expertise associated with the procedure. For all of you doctors who work really hard to please the insurance companies and accept that they don't have to pay you because there is no proof, I say you are selling yourselves short...really short.
 
Bob Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com

I began using diagnostic ultrasound (more recently 10-18MHz probe high resolution) in my practice about 5 years ago. Regarding US-guided intra-articular injections, other than 3rd, 4th tarsometatarsal joints in certain patients, US is probably not indicated. While injection of the plantar fascia or a neuroma may be rendered more precise in the right hands with US, I have continued to have good success for 24 years with blind injection of those areas.  As pointed out by others, more controlled studies or EBM is needed regarding successful outcomes for US-guided fascial or neuroma injections.

On the diagnostic side, US is valuable in imaging plantar fasciosis, fascial tears, fibromas, soft tissue masses; Achilles, posterior tibial, and peroneal tendinopathy; lesser MPJ plantar plate pathology, and small interdigital neuromas ("fat foot", clinical neuropathy, equivocal clinical findings, overlap with predislocation syndrome) to name a few. US is helpful in more specific diagnostic "characterization" of inflammatory soft tissue conditions, can affect treatment plans, can help our patients, and is more cost-effective than MRI. 

Diagnostic ultrasound requires training, a learning curve, and does require more face-to-face contact time with the office patient.  It can be over-utilized as can any of the services we provide as podiatric physicians. Let's not make it another podiatric "bastard child." 

Mark K. Johnson, DPM, West Plains, MO, DDR004@centurytel.net

Editor's Comment: Dr. Kenneth Meisler's extended-length letter can be read here.

 RE: The Passing of Gerald Stein, DPM
From: Carl Solomon, DPM

It was gorgeous today in Dallas and I wound down the weekend taking our dog for a walk. When I got home, I read that we lost Dr. Gerald Stein. For the four years we were classmates at ICPM (before it was Scholl), our seating arrangement was alphabetical, so the order was "...Solomon, Stein...etc."  Although geography has prevented me from seeing much of him for the last several years, we went through a lot together and shared some good times.  Gerry worked hard, enjoyed a good laugh and could get along well with anybody. I've heard of the good that he's done for the profession.  He'll be missed.

Carl Solomon, DPM, Dallas, TX

RE: Treatment Room Flooring (Jill Scheur, DPM)
From: Multiple Respondents

I recommend Amtico American Cherry (W745). It is a vinyl product laid down in planks, like Pergo. It is beautiful, warm, and easy on the feet. We have been in the new office for a year, and there is no sign of buckling or wear. It gives my office the look and feel of a spa.
 
Shari Kaminsky, DPM, Florissant MO, sharikaminsky@hotmail.com

I second the use of Amtico. We moved and rebuilt an office about 1.5 years ago and get compliments on the flooring from patients and other doctors in the building who still have carpeted floors. When shopping flooring companies, everyone kept telling us that Amtico was the superior product, and that many companies have products that are "like" Amtico. It requires very little maintenance besides cleaning. You need to find someone who knows how to install this product since it requires a "special " flooring glue that the company makes. You need a very clean flat surface like cement to apply this on, but this is true with most vinyl flooring. Most people think that this flooring is real wood, but it is soft to walk on due to the rubber pad underneath.

Larry Kosova, DPM, Chicago, IL, lkosova@yahoo.com

When I built my last office, we used an epoxy resin poured flooring system. See hitechflooring.com/index.html It's perfect for podiatry - the speckled finish hides everything. You never see debris. The wheels of the stool or whirlpool glide nicely on it, and it lasts forever (ours lasted 10 years with no signs of wear - then we moved to a new office that already had a floor.). It's simple to clean - broom or damp mop. It's indestructible. It's not slippery and has no seams. Your entire office can be done and it looks real nice.
 
Al Musella, DPM, Hewlett, NY, Musella@aol.com

RE: Safely Removing Scalpel Blades (Jeffrey Kittay, DPM)
From: Robert A. Boudreau, DPM, Chuck Ross, DPM

Dr. Kittay asks what people are afraid of?  Well, for starters, AIDS, Hep B, Hep C, not to mention every microbe we studied in microbiology class that causes infections!  Why be nonchalant when it's so simple to grab a hemostat and remove the blade using an instrument instead of fingers?
 
Robert A. Boudreau, DPM, Tyler, TX , rbftdoc@aol.com

After reviewing many comments about blade removal by hand, as I used to do as well-but not for 20 years now, my only comment is what about OSHA regulations?
 
I have attended many courses over the years as a refresher for myself, and guess what? If you tell an OSHA inspector that you remove blades by hand, you may risk serious fines. Can one of our legal experts comment?

Chuck Ross, DPM, Pittsfield, MA, cross12@nycap.rr.com

Editor’s comment: PM News does not provide legal advice. OSHA is designed to protect employees, not employers. Thus, if a podiatrist chooses to use his fingers to remove a blade, he (or she) assumes the risk. If, however, the podiatric assistant is given this task, it’s a whole different story because the OSHA safety rules would now be in effect.

RE: Scope of Practice (Barry Drossner, DPM)
From: Russell F. Trahan, DPM, Jon Purdy, DPM

I am very surprised at the number of readers who believe that the "only" way to professional equality for podiatric physicians is through an MD or DO behind one's name. Firstly, there is plenty of hand wringing among the osteopaths about how they are discriminated against because of their degree being a DO. I personally know of a brilliant osteopath specializing in neurology who has had trouble getting a job with medical groups because the powers that be in the group do not want a non-MD physician on the business card! In my view, the goal of parity for podiatric physicians can be achieved by:

1. Having our professional organizations such as the APMA aggressively educate the medical consumer, through advertising, on the qualifications of the profession.

2. Have the same organizations have a strategy to educate the younger members of the medical profession (medical students, residents, fellows) on the podiatric profession to prevent the prejudices that may be held by older and perhaps more stubborn MDs (who may need to 'die out' to extinguish professional prejudice).

3. Lobby professional organizations to include the podiatric profession. There are many medical resources on the Web that ask for a user's specialty, and "podiatry" is not included. Just a few months ago, PM News readers complained of one professional medical website that blocked access to podiatrists solely on the basis of the DPM degree. Our organizations MUST lobby to prevent such practices.

Russell F. Trahan, DPM, NY, NY, dr.trahan@att.net

There is always an ongoing discussion on our scope of practice and medical field inclusion. Dr. Barry Drossner noticed podiatry was eliminated from a medical media conversation on foot ailments. Whenever a patient asks me (which they often do) what type of doctor is best at treating a certain foot condition, I give the same answer, a...

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

RE: ACFAOM Objects to Dr. Scholl’s Commercial
From: Arnold B. Wolf, DPM

When Dr. Scholl released their "Custom Fit Orthotics" over a year ago, I immediately took offense to the product. I saw the product release as an effort to go in direct competition with podiatrists - the principal group that significantly supports their company's success. Upon that product release, I stopped recommending any Scholl product. Viewing the product critically, the device is nothing more than a cushioned insert with a pliable (read soft) arch plate available via shoe size; and low, medium and high arch configurations. This is hardly custom. We should not support companies that, directly or indirectly, subvert a portion of our income stream (and ultimately our success). The old axiom seems to apply in this case: "Keep your friends close, keep your enemies closer." In closing, the mission statement for Dr. Scholl's should incorporate a non-compete covenant with the profession that directly (or indirectly) supports their business.
 
Arnold B. Wolf, DPM, Sterling Heights, MI, omnifootcare@prodigy.net

CANADIAN PODIATRISTS COME BACK HOME!

ASSOCIATE POSITION – LONG ISLAND 
 
Busy Bellmore, NY office. Motivated, board certified, hard-working, experienced in all phases of podiatry. F/T, P/T hours available. excellent salary, call 516 242-7540 or Fax Resume 516 826-9036 or email jobke@aol.com

ASSOCIATE POSITION – GEORGIA

Immediate opening for a surgically-trained individual for associate position in northern suburb of Atlanta. Hospital privileges available. Position could lead to partnership or purchase of practice. Send resume and CV to pd751@hotmail.com

ASSOCIATE POSITION - LAS VEGAS, DALLAS, HOUSTON, AND SAN ANTONIO AREAS

Seeking well trained ABPS board rearfoot/ankle certified/qualified foot surgeons for surgical practice with national foot/hand/orthopedic surgery group. Excellent salary/benefits. Email CV and cover letter to: slb99@pdq.net

ASSOCIATE POSITION – MICHIGAN

Well established practice in Southeast Michigan suburbs seeking full time associate. Must be ethical, personable and professional. This is a solid opportunity for a PSR-36 graduate or experienced practitioner. Must be able to diagnose and treat everything from general podiatry to reconstruction of severe deformities of the foot and ankle. The practice is currently maintained by two board certified surgeons. This practice is residency affiliated. Please forward current location and availability with C. V. to HKANEDPM@gmail.com

ASSOCIATE POSITION  - THE BRONX, NEW YORK

Growing Hospital-based practice in the Bronx. Part-time and full-time positions available. Compensation based on training and level of experience. If interested email: nblitz@bronxleb.org

ASSOCIATE POSITION - TEXAS

Dynamic, growing practice in Dallas/Fort Worth area, seeking surgically trained, Board Certified/Board Qualified Podiatrist. Excellent salary and benefits compensation package, for the right candidate, with partnership/buyout opportunity. Contact/Send resume to: jmh6122@yahoo.com Texas Podiatry License Required.

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

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