May 31, 2006 #2,594 Editor-Barry Block, DPM, JD

A service of Podiatry Management http://www.podiatrym.com
E-mail us by hitting the reply key.
COPYRIGHT 2006- No part of PM News can be reproduced without the
express written permission of Kane Communications, Inc.

Some subscribers using Excite, USA, and some other ISP's did not receive yesterday's issue of PM News, which contained a clinical photo. We have corrected this problem. Yesterday's and previous issues can be viewed at www.podiatrym.com

Awareness of Foot Health Still Lags Behind: NY DPM's

Summer's coming, meaning other people will be looking at your feet when they're in sandals or flip-flops or bare. "The foot is neglected quite frequently," says Mark B. Friedman, a podiatrist with a private practice in Albany. Next month, Friedman assumes the presidency of Northeast division of the New York State Podiatric Medial Association.

"People seem to think it's normal to have foot pain, but it's not," says Friedman. "No pain is normal. It's a problem if there's pain." Friedman, who estimates that a third of his practice deals with diabetes-related foot problems, says he has often correctly predicted a patient would be diagnosed with diabetes after seeing his or her feet.

"All kinds of things can go wrong with the foot. Every system that's in the body is in the foot," says D. Joel Valentini, a podiatrist who, with partner Thomas Couch, has offices in Albany and Troy. "The foot," Valentini says, "is really very complex."

The doctors agree that while Americans today are better aware of health issues than ever before, awareness of foot-health issues still lags behind. Says Valentini, "People see a problem with their foot and think there's nothing that can be done about it. That's just not true."

Source: Steve Barnes, The Times-Union [5/30/06]

MD DPM Organizes Race to Benefit Leukemia Research

Frederick has a lot of runners who give their time at local races to register, hand out drinks, stuff packets or direct runners. A few, however, go the extra mile and actually organize a race. Dr. David Grace and wife Michelle Mikesell are one couple who do. Every year since 1999 they have organized the Frederick Memorial Hospital 5 Mile Race for Leukemia. It's become a tradition for Frederick runners on the second Saturday in June, and this year's race, the eighth annual, is on Saturday, June 10.

Grace, a local podiatrist, wanted the race to benefit leukemia research. His collee running friend, Dan Price, died of leukemia at age 22. The two were cross-country teammates at Youngstown State. "He was always the happiest guy," recalled Grace. Four years ago, Mikesell's father was diagnosed with lymphoma, a blood-borne cancer similar to leukemia. The race has raised $5,000 to $6,000 for medical research each year. It bears the name of Frederick's local hospital because the hospital is the race's largest benefactor. Other sponsors donate money, food, awards and prizes.

At one time, the race was known for giving away free airline tickets, but that ended a couple of years ago. The race still has gift certificates to local restaurants and other good prizes. "We go out of our way to get good door prizes," Grace said. "This is a very friendly course," Grace said. It's five flat miles from the hospital, around Baker Park, past Hood College and through the streets of downtown Frederick. It's mostly level, with no noticeable hills. At the end the runners get pasta, bagels, cookies and fruit, and a chance at one of the door prizes.

Source: Karen Gardner, Frederick News-Post [5/30/06]

Undiagnosed Diabetic Rate Unchanged Despite Increased Awareness: Study

About one-third of U.S. residents ages 20 and older who have diabetes are undiagnosed, according to a new study. For the study, researchers from CDC and NIH analyze data on U.S. adults ages 20 and older from 1988-1994 and 1999-2002. According to the study, the rate of diagnosed cases of diabetes among participants increases from 5.1% in 1988-1994 to 6.5% in 1999-2002, but the rate of undiagnosed cases remains at about 2.8%. Lead study author Catherine Cowie, a researcher with the National Institute of Diabetes and Digestive and Kidney Disorders, says that that the rate of undiagnosed cases of diabetes has remained about the same despite increased awareness about the disease.

Source: American Health Line [5/30/06]

Query: Employee Manual

I'm looking for a good employee manual. Does anyone know where I can find one?

Frank H. Graham, DPM, NY, NY, fhg9@juno.com

Editor's comment: Two good sources are Codingline.com (subscriber benefit) and the American Academy of Podiatric Practice Management www.aappm.org (membership benefit).

Query: Follow-Up E/M Services & Procedures

When is it appropriate, exactly, to bill a follow-up E/M service when the patient has the same diagnosis as the previous visit, and a procedure is also being performed? For example, is it a "separate, significantly identifiable" evaluation and management service when, during that follow-up visit, the decision to add or change a NSAID; or begin physical therapy; or get an x-ray; or dispense DME; or given an injection (or follow-up injection); or decide not to give the injection?

I know colleagues who routinely bill follow-up visits along with procedures, and add a "-25" modifier to the E/M code. They argue that are doing a "significant separate" exam every time they see the patient.

Charles Perry DPM, Cambridge, OH

Response: Medicare clarified back in 1993 in a letter from CMS (then HCFA) to the carrier medical directors that a separate diagnosis was *not* needed (same diagnosis, but a different body area amounts to basically the same thing). http://www.donself.com/documents/mod25.txt

CPT also explicitly states that a separate diagnosis is not needed in its definition of modifier "-25" (found in Appendix A of the CPT Manual).

While I understand that some non-Medicare payers won't PAY unless it's a separate diagnosis, that's an individual carrier reimbursement policy decision, not a coding one. From a coding perspective, having separate diagnoses simply isn't required.

Editor's Note: Additional letters on this topic appear at www.codingline.com Codingline subscription information can be found at http://www.codingline.com/subscribe.htm

RE: Familial Keratoderma (Al Musella, DPM)
From: Bryan C. Markinson, DPM

Dr. Musella's case presentation represents a distressing situation for both patient and clinician. Firstly, the terminology may be slightly inaccurate. Congenital usually means at birth or occurring within the first year of life. Since this patient developed lesions at five years of age, this probably represents familial keratoderma, hereditary keratoderma, or hereditary tylosis, which all are the same thing. The palms are usually involved, but in this case they are not. Treatment is ultimately supportive (debridement, topical softening agents and moisturizers, and perhaps Vitamin A) in the overwhelming majority of cases, and use of Accutane involves much risk.

Hereditary tylosis seems to predispose individuals to esophageal carcinoma, so I would certainly recommend screening of the father. This would involve endoscopy by a gatsro-enterologist, and may involve a survey of the entire GI tract.

Bryan C. Markinson, DPM, NY, NY, profpod@aol.com

RE: Sharp Shape Scanner (Larry Huppin, DPM)
From: Bruce E. Williams, DPM

Dr. Huppin detailed an excellent list for evaluation of any technology for the production of or evaluation of foot orthoses. I disagree that any digital casting unit should allow the practitioner to hold the foot in subtalar neutral and allow the first ray to be plantar-flexed.

In my experience utilizing the AMFIT digital scanner, the technique for casting and evaluating a good scan can be done with the foot flat on a scanner's foot bed, and while the patient is in partial weight-bearing neutral. I've been using this technique for about 1.5 years now with success. It has even enlightened me that if you can get the 1st and 5th metatarsal heads in the same plane, and with equal pressure, while capturing the STJ in slightly pronated neutralposition, that this will optimize the alignment of both the medial and lateral column's in their most stabile positions. This can be easily evaluated by over-pronating or over-supinating the capture technique and comparing it to the more neutral-positioned technique.

I have also utilized this technique in a non-weight bearing position with plaster casting, where the lateral column is plantar-flexed and supinated as opposed to maximally pronating the lateral column. I think that if you attempt this technique, you will find that the medial column is then unable to be plantar-flexed below the level of the metatarsal head in the majority of instances, whereas with the lateral column maximally pronated will allow the 1st ray to be plantar-flexed to an extreme position You will also tend to find that the FF and RF alignments will be within 1-2 degree of varus or valgus on a regular basis.

The point is that if your technique is reproducible, and you know what you are attempting to accomplish, that casting techniques can be modified for any type of cast; plaster, digital, non-weight-bearing or partial weight-bearing Finally, the AMFIT scanner is very cost-effective Couple that with their in-house CAD/CAM system and you have your own orthotic lab with almost instantaneous turn around times!

Disclaimer: I am a non-contracted consultant for AMFIT on occasion.

Bruce E. Williams, DPM, Merrillville, IN, uwalk4me@comcast.net

RE: Competitive Acquisition Program for DME (William Godfrey, DPM)
From: Paul Kesselman, DPM

Despite Dr. Godfrey's error and the fact that using a single supplier for DME in Army, this proposal (in my estimation) simply will cost the government and patient's more, and increase the complexity of delivering many acute health care services. The realities of the civilian world are far different than for those in the military. It would be unfair to compare the delivery of any health care service to a young healthy acutely wounded soldier to that of an 80 year-old senior citizen living alone in an inner city.

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

ASSOCIATE WANTED - NEW YORK

Associate Wanted - Rockland County, Rockland County. Associate with minimum 5 years experience, high volume established general practice. Reply with CV to nypodiatry111@aim.com

ASSOCIATE WANTED - MINNESOTA – MINNEAPOLIS SUBURB

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with buy-in opportunity. Looking for PSR 24/36 trained individual, to help increase surgical volume. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

1st YEAR RESIDENT SLOT AVAILABLE - CALIFORNIA

Sherman Oaks Hospital, in Sherman Oaks CA, has a (PM&S-24 I 1st. year) program available, beginning 7/1/06. Our program offers the Residents a wide variety of cases from ankle fractures, subtalar joint, fusions, & tendon transfers as well as all other podiatric forefoot & rearfoot cases, with very impressive procedure activity numbers at a "C" level. The Residents meet & exceed the requirements for surgical case loads, usually by the first 6 months. Residents will also see an average of 250 to 300 wound patients per month.

The stipend for the 1st year Resident is Thirty Thousand dollars ($30,000) and 2nd year Resident; Thirty- Four Thousand dollars ($34,000). For more information please call Dr. Boghossian at (818) 905-2222 or e-mail him at gbogi@sbcglobal.net

PRACTICE FOR SALE – ARKANSAS

Thriving Ozark Mountains practice in prime retirement area seeks to sell on long term note. Two locations: Mountain Home and satellite office in Harrison, Arkansas, both with established patient base with full range of services and nursing homes available. Hospital privileges. Wonderful Staff. Fully equipped. Priced to sell. (870) 425-1466 orchristinag@centurytel.net

POSITION WANTED - NEW YORK

Non surgical podiatrist with 20 years experience is seeking practice opportunity 1-2 days/wk. ABPOPPM board certified, own malpractice insurance, many insurance plans. Please call (516) 557-6862 or e-mail Joelme@aol.com.

ASSOCIATE POSITION- NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

EQUIPMENT FOR SALE - ESWT

If you are using or thinking of using ESWT, I have a new machine that has only been used twice. There is no Orbasone in the country priced like this one. Will provide training and installation. Take a look at http://www.orbasone.com Call 1-856-229-2939.

ASSOCIATE WANTED - NORTH CAROLINA

Growing practice in beautiful western North Carolina seeking qualified DPM. Great mix of office and surgery center care. Must have NC license and ABPS qualified/certified. Send cover letter and CV to dpmcareer@aol.com

POSITON AVAILABLE - WASHINGTON, DC

The George Washington University Medical Faculty Associates, a large multi-specialty practice affiliated with a teaching hospital, is seeking a full-time podiatrist. The practice has a diverse population encompassing inpatient and outpatient surgery, as well as a thriving outpatient clinical practice. Must be board certified/board eligible and have experience in diabetic limb salvage. Send CV to cdugan@mfa.gwu.edu or fax to (202) 741-2241.

SURGICAL INSTRUMENTS FOR SALE

Complete Surgical Instruments, Hundreds; Stryker Power Set Electric motor; Reciprocating & Oscillating saw, Roto-osteotomes, also two major bone sets including DePuy osteotomes, several soft tissue sets, etc. Office instruments also. Call for exact items. Art Korbel DPM, (MD) 954 753 7621

Partnership possible after two years. Two office practice. Palliation; biomechanics/orthotics; woundcare; office/hospital surgery. Must have Virginia license. Associate will do most of the practice’s surgery. PSR24/36/Board qualified/certified in surgery preferred. Available SAP. Send CV to: Dr. Marc Jay Pinsky; 9550 Midlothian Turnpike; Suite 104; Richmond, VA 23235; mjpinsky@juno.com.; FAX: 804-320-6627.

WEEKLY SPECIAL - One week of ads (6x) for only $75

PM Classified Ads Reach over 7,500 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most- effective way of reaching over 7,500 DPM's. Write
bblock@podiatrym.com for details. Note: For commercial or display ads contact David Kagan at (800) 284-5451 dekagan@aol.com

• To Post a message, send it to:    bblock@podiatrym.com
• Notes should be original and may not be submitted to other publications or listservs without our express written permission.
• Notes must be in the following form:
  RE: (Topic)
  From: (your name, DPM)
  Body of letter. Be concise. Limit to 250 words or less). Use Spellchecker
  Your name, DPM City/State
• Subscribers are reminded that they have an ethical obligation to disclose any potential conflicts of interest when commenting on any product, procedure, or service.