The Voice of Podiatrists

Serving Over 12,500 Podiatrists Daily

May 25, 2011 #4,169 Publisher-Barry Block, DPM, JD

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CT Podiatrist Discusses Pulmonary Embolisms

Each year in the United States, pulmonary embolisms (PE) kill more people than AIDS, breast cancer, and motor vehicle crashes combined. According to the American College of Foot and Ankle Surgeons, this little known condition occurs when a blood clot in the leg travels to the lungs, blocking one or more arteries. 

Dr. Peter Blume

Connecticut foot and ankle surgeon and assistant clinical professor at Yale School of Medicine Peter Blume, DPM, FACFAS, explains that women are at the highest risk for blood clots and pulmonary embolisms, as well as men and women who are overweight, smokers, and those taking oral contraceptives. “Surgery is also one of the leading causes of blood clots in patients, which means those at highest risk need to be diligent in speaking to their surgeon about their elevated risks so preventive measures can be taken,” Dr. Blume said.

AAPPM Arizona "Bikers" Ride For Educational Fund

Prior to the AAPPM Spring Conference at the Firesky Resort May 19-22, the association held its first Motorcycle "Bike" fundraiser for the the AAPPM Education Fund. The 7 riders experienced Arizona's incredible scenery by riding to Tortilla Flats and having lunch at "local" hot spot - Superstition Saloon. Those participating in the fundraiser as pictured (L-R) were: Flynn and Terri Wilson, CEO, Fidelis Diagnostics, Chris Kindsvatter, Executive Director of AAPPM, Jelena and Eric McNab, Hotchkiss Podiatry, Ernesto Castro, President of Arizona AFO and Jon Purdy, DPM, AAPPM Board member.  

Participants in AAPPM Motorcycle Fundraiser

Not only did the participants enjoy the sunny Arizona weather and fantastic countryside, but the riders raised a substantial sum of money for the AAPPM Educational Fund. Next year's bike ride is being planned, and AAPPM is sure that even more participants will want to ride.

Interoperability Key to Realizing Health IT Goals

Without "seamless interoperability," health information technology's potential will go unmet, a report on the healthcare digital infrastructure from the Institute of Medicine found. That was the conclusion of health IT experts during a series of “expert meetings” organized by the Institute of Medicine in the summer and fall of 2010 at the request of the federal Office of the National Coordinator for Health Information Technology.

Those experts - researchers, computer scientists, privacy experts, clinicians, healthcare administrators, HIT professionals, and representatives of patient advocacy groups - agreed that a digital health infrastructure cannot be effective unless it is integrated seamlessly within the healthcare processes "from which it draws and is meant to support care delivery, research, quality improvement, and population health monitoring." Other critical components for the success of health IT, as identified by meeting participants, include the ease of technology use for health system stakeholders, attention to systems' effects on work flow, and the delivery of useful decision support at point of care.

Source: Rich Daly, Modern Healthcare [5/23/11]

Query: EHR Certification Charges

Does anyone else have experience with their EHR system charging for updating to a certified version? We have been using MD Logic for three years. They are about to go through the testing for certification, and then they will roll out a new version of the software. Their position is that all the other companies charge for the update as well. They are having a mandatory meeting that is required to start using the new version to meet meaningful use. Have others had similar situations with their vendors?

Andrew Levy, DPM, Jupiter, FL

Query: Debridement of Transmetatarsal Stump

I debrided an infected transmetatarsal amputation stump with excision of necrotic soft tissue. Additionally, I trimmed all 5 metatarsals back about 1 cm each. The bone was infected distally. The wound was left open. What is the proper way to code this procedure?

Marc Lipton, DPM, Baltimore, MD
 
Response: Since a transmetatarsal amputation was already done, I recommend billing CPT 11044, debridement skin, tissue and bone, for this case.

Howard Zlotoff DPM, Camp Hill, PA

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RE: Niacin, Cherry Juice and Acute Gout (Tom Silver, DPM)
From: Marc Garfield, DPM

Niacin increases uric acid in the body. It has been a while since biochemistry classes, but I believe that niacin is generally well absorbed and generally will be converted to nicotinamide adenine dinulceotide (NAD). When metabolized, adenine (a purine) is broken down to uric acid. There may well be a better explanation, but the package inserts on Niaspan and other forms of niacin caution that niacin may cause or exacerbate gout or other symptoms of hyperuricemia.

I don’t think the MOA on cherries has been proven. I caution patients with DM that it is a fruit full of sugar. I do not treat gout with cherries, but I do include it in a list of recommendations dispensed to patients, along with other dietary recommendations. Feedback is frequently favorable. I cannot cite specific studies, so my opinions would be considered anecdotal.

Marc Garfield, DPM, Williamsburg, VA, mgarfield1@cox.net

RE: Cracked Arm of Smart Toe Implant (Jay Hassenfratz, DPM)
From: Robert Fridman, DPM

If you notice, the fracture of the implant did not occur at the intended fusion site - it occurred intramedularly. The tapered neck of the proximal implant also happens to be the weakest part of the implant. This "fracture" should not affect the intent of the implant as the shape will resist rotation and appropriate internal splintage should occur. There are some Smart Toe implants that do not wholly fuse at the PIPJ with bony union on XR, but still have clinical fusion - you may be used to seeing this same effect with some of your K-wire fusions. I recommend that you Coban/splint the toe and keep the patient in a post-op shoe for an additional three weeks. Incidentally, I used to see this with some of my cases that I placed into a shoe too soon. I now keep them in a post-op shoe for at least 3-4 weeks - this allows the fusion site to consolidate a little better.

Disclosure: I am a consultant for MMI.

Robert Fridman, DPM, New York, NY, RFridmanDPM@AOL.COM

I don't recommend taking the implant out. I did try to remove one, but it proved very difficult due to the prongs latching on the cortical wall. You may have to break the osseous cortex to remove the implant, as cutting into the center core is not an easy task. From the x-ray, the crack does not appear to have much effect on the function of the implant. The more than average pain, may just be subjective to the patient's post-op pain and not really due to the implant failure. Give it 8-12 weeks for the fusion to be more obvious on x-ray and then re-assess/consider surgery. I also recommend contacting your SmartToe implant rep. for further input.

Ash Soleymani, DPM, Los Angeles, CA, ashkans@aol.com

RE: Idiosyncratic Reaction to a Foot Injection (Elliot Udell, DPM)
From: Barry Mullen, DPM

What Dr. Udell describes is facial flushing. This is not an idiosyncratic reaction, rather, a fairly common post-steroid injection side-effect. Literature varies regarding frequency (up to 15%), but onset occurs within 12-24 hours post-injection with 24-36 hours duration. Small absorbed steroid quantities can initiate transient adrenal gland stimulation that rarely requires treatment. This is also seen following niacin administration. Conversely, idiosyncratic reactions occur very rarely, but most frequently in the elderly and very young patient populations. They represent an exact opposite medication effect from its intended purpose, i.e. one prescribes a sedative and the patient becomes hyper.

I've witnessed facial flushing on rare occasions post-Triamcinolone injection for plantar fasciitis (estimate = 2%), but haven't witnessed this side-effect following soluble steroid injections, i.e. dexamethosone. Patients receiving steroid injections should be alerted to this side-effect. More importantly, diabetics should especially be warned that they will likely incur a transient blood sugar rise, sometimes as much as 50 points, within 24 hours post-injection. It generally resolves within 48 hours. I suggest that clinicians educate those patients not to make any major adjustments in their glycosuric control to avoid an iatrogenic, hypoglycemic incident.

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

RE: Source for Dexamethasone (Michael DiGiacomo, DPM)
From: Jack Hickey, DPM

We get our dexamethasone sodium phosphate and dexamethasone acetate from Teregen Labs in Ohio. Our most recent delivery came in last week. Teregen Labs compounds by individual patient prescriptions for podiatrists. We have not had any of the backorder problems that others have been experiencing. Teregen has been a big supporter in our field and they are great to work with. We have been super-satisfied customers for over 25 years. Their phone number is 800-848-0055.

Disclosure - We do not have a financial interest in this company.

Jack Hickey, DPM, Levittown, NY, jhickeydpm@earthlink.net

RE: Cerner EMR in a Clinical Setting (Lea Elliott, DPM)
From: Carol A. Callahan, DPM

We just went live with Cerner Powerworks. It is awesome and the support is superlative! Cerner is world-class. We have a dedicated Integration Team Manager. Our 4-day onsite trainer is brilliant and worked well with myself and my office team just last week. I started with Don and Debby Roger's DR-DOS program in the 1980's. It became Wisdom PM. I also added Medinotes over a decade ago.

We would have gone to Epic, the Yale system, however, all our practice management is in Wisdom PM. I cannot say enough about how phenomenal Cerner is!

Carol A. Callahan, DPM, Fairfield, CT, carolcallahandpm@aol.com

RE: To Be or Not to Be an MD/DO (Michael Rosenblatt, DPM)
From: Ira M. Baum, DPM

This issue seems cyclical and ineffective regarding serious changes needed for our profession. All who are interested in this debate should understand, and I take the liberty of speaking for most podiatrists who speak in favor of changes to podiatry, love our profession. Dr. Rosenblatt's statement, “Discrimination against podiatrists due to the limited license exists in most governmental and legal venues, and causes podiatrists all manner of (exhausting) continuing battles for legitimacy.” The key word is legitimacy, and from my perspective, legitimacy means inclusivity in all healthcare programs, and financial parity. Podiatrists share the same risks that any healthcare provider takes, but we don’t share the benefits!

Ira M. Baum, DPM, Miami, FL, ibaumdpm@bellsouth.net

RE: Podiatrists' Responsibility When Taking Patients' Blood Pressures
From: Richard W. Boone, Sr., Esq

A note to a patient with an abnormal vital sign suggesting follow-up with the patient's physician is an extremely good idea in most cases, but it may not suffice in every instance. The sufficiency of a physician's response when presented with an abnormal vital sign is a legal issue. Generally speaking, the law requires that the degree of care used in responding to an ominous vital sign must be commensurate with the danger of harm to the patient from the absence of timely follow-up treatment. The physician's response must also meet the patient's particularized need for information and assistance. So, a note is, at least, the minimum response, but in many cases the law will require you to do more to meet your responsibility. A simple note may be deemed to have been insufficient to inform the patient of the need for timely follow-up, the danger of not getting the follow-up, and to afford the patient assistance, when necessary, in obtaining the follow-up necessary to avoid harm.

A note to the patient is clearly one end of the spectrum of acceptable care. Calling the Rescue Squad for immediate transport to an ER is probably the other end. There are a lot of other possible combinations of activity in between. It is up to the podiatric physician to decide where the particular patient's needs fall on that spectrum, and then take the appropriate action. In this case, one size clearly does not fit all. And, as always, document what you did and why you did it. 

Richard W. Boone, Sr., Esq, Fairfax, VA, RWBoone@aol.com

RE: Diabetic Shoe Refund Demand (Allan Hetelson, DPM)
From: Sheri Jett, CPC

The claim was not denied as "not medically necessary", it was denied because the patient was in an SNF. The definition for modifier GA is: GA - Waiver of liability statement on file (used when an item or service is expected to be denied as not reasonable and necessary and an Advance Beneficiary Notice is on file). The GA modifier is used in situations in which an item or service is expected to be denied as not medically necessary and an Advance Beneficiary Notice has been properly executed.
 
There are exclusions to what does not fall under PPS when a patient is in an SNF, but there are some exceptions during the 100-day skilled benefit period. Diabetic shoes are not listed under PPS exclusions. Therefore, if the beneficiary is in a Medicare covered Part A skilled nursing home (SNF), the diabetic shoes would be considered part of the SNF's consolidated billing, and the supplier would need to look to the SNF for payment. If the beneficiary is not in a Medicare-covered Part A SNF and is NF instead, then the diabetic shoes are billed to the DME MAC for payment.
 
Sheri Jett, CPC, Suffolk, VA, sheri@1foot2foot.com

RE: CMS to Issue First Medicare EHR Incentive Payments This Week
From: Matt Werd, DPM

Our $36,000 EHR Incentive Payment was received today.

Our 2-DPM office this year converted from 100% paper charts (cut-and-paste dictated sticky notes, transcriptionist, plain-film x-ray films, etc.) to 100% EHR with digital x-rays. Our "Go-Live" date with our new podiatry-specific software was in January 2011, and in 90 days since starting, we met all requirements for meaningful use, and attested April 26 to CMS. Our payment of $18,000 for each DPM was received as a single $36,000 check (ironically, it was a paper check) issued by CMS (EHR Incentive Payment - PFDC) on May 23, 2011.

Although this payment will not cover the initial capital we invested for the conversion - which included the software, IT support, computer hardware and upgrades, digital x-rays - our EHR system has been (and will continue to be) a boost toward patient care, practice efficiencies, as well as future revenue (i.e. elimination of $1,200+ monthly dictation costs, all x-ray film/processor maintenance/supplies/re-take costs, staff labor of cutting, pasting, filing, pulling paper chart notes, etc).

Matt Werd, DPM, Lakeland, FL, werdperfec@aol.com

PRACTICE FOR SALE - SOUTH CAROLINA

$800,000+ gross, single location practice needs well trained, energetic podiatrist. Confidential inquiries carpodpract@gmail.com

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. Owner retiring and willing to stay part time during transition. softechpodiatrist@gmail.com

PRACTICE FOR SALE - MISSION VIEJO, CA

Relocating to Tulsa. Great opportunity to buy my office. Located on Mission Regional Hospital Campus. Gross income 2010 was $340,000. Approximately 1300 sq ft with 3 treatment rooms, digital x-ray and fully computerized. Only 3 years old. Will consider all offers. 949-702-1052. David Stoller, DPM (Family Footcare) david@missionviejofootcare.com

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

ASSOCIATE POSITION – NEW YORK

Great opportunity to share “state-of-the-art” offices and equipment in mid-town Manhattan and White Plains with Board Certified podiatrist. Out-of-network or participating providers welcome. Please call 212-704-4310 for additional information and fax your CV to 212-704-4311

ASSOCIATE POSITION – IOWA CITY AREA

Modern practice seeking a well-trained (PSR 24/36) associate. Excellent opportunity for an energetic, hardworking individual with strong surgical and medical skills. Solid referral network and 13 years of growth. Come live in the Iowa City area and enjoy the quality of life and stability of a Big Ten University community. Competitive salary and benefit package available. If interested, fax CV to 319-354-1014 or e-mail to dave@341foot.com

ASSOCIATE POSITION - SW FLORIDA

Huge opportunity. Are you an outstanding person? Would you like the freedom to utilize your talents to the max? Opportunity awaits right candidate. Excellent mix of office/surgery motivated/experienced staff. Full Time Associate PSR 12-36. Great Salary/Benefits, Bonus Package, Unlimited Potential, Buy-In Opportunity. Email resume to podiatry22@yahoo.com

ASSOCIATE POSITION – NEW YORK

Well-established, multi-doctor podiatry practice with offices in Putnam and Westchester counties. Compensation based on productivity. Excellent opportunity for recent residency graduate to build skills and learn practice management. Full-time preferred but right part-time candidate will be considered. Email cover letter and CV to: Podiatry2011@gmail.com

ASSOCIATE POSITIONS - TEXAS

Texas licensed podiatrists needed in San Antonio and Austin. Great paying positions for full or part-time. Well established, unique mobile podiatry practice servicing senior living facilities. Business office locations in both cities with excellent support staff for your assistance and scheduling. Check us out before looking elsewhere. Find us at www.footmobile.com Reply with cover letter and CV to doctor.cohen@yahoo.com with a cc: to lisa.schulze@yahoo.com or call us at 210-495-6477.

ASSOCIATE POSITION - MARYLAND

Looking For The Best. Busy practice. F/T associate possibly leading to partnership. Seeking sharp, honest and hard-working associate who is extremely personable. Board Certified or eligible. Exceptional surgical skills and training needed, but is just as important to diagnose accurately. Excellent salary and benefits. Email CV to Marylandfootcare@live.com

ASSOCIATE POSITION - SOUTHERN MI (NOT DETROIT AREA)

Leading to partnership for rapidly growing 3-physician group practice. Must be residency trained and willing to learn and follow our very successful business model. Salary plus incentive. If you're unhappy with where you're at now this may be the answer! If, interested send CV to: paulapmac@me.com

ASSOCIATE POSITION- NEVADA

Well established 22-year practice in Las Vegas/Henderson, Nevada seeking full-time associate. General podiatric care with moderate amount of surgery to be done in local hospital or surgery center. Competitive salary and benefits. Modern office in new area. Please respond by email to lvfootandankle@gmail.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 - WA (KIRKLAND, SEATTLE, EVERETT, AND REDMOND)

Join one of the fastest growing podiatry practices in Washington state. Must be motivated to grow practice. Competitive salary and benefits. For more information go to seattlefootdoctor.com. Send resume to seattlefootdoctor@yahoo.com

ASSOCIATE - POSITION - SOUTHEAST GEORGIA & SOUTH CAROLINA

Seeking recent residency graduate to join practice. Must be PSR-24/36 trained. Multiple locations. Full range of services with new facility. E-mail to melissafoot@pol.net

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

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

PM News Classified Ads Reach over 12,500 DPM's and Students

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