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May 31, 2008 #3,260 Editor-Barry Block, DPM, JD

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TX Podiatrist Provide Advice on Buying Flip-Flops

When the mercury rises, flip-flops are the sole of summer. This season, there are more styles, colors and options when it comes to comfort. Whatever your flavor, smart shopping is a must, says Houston podiatrist Dr. Ulla-Britt Larka. "Flip-flops tend to not stay on the foot well, and the cheaper, trendy ones don't provide much support or shock absorption," Larka said.

Dr. Ulla-Britt Larka

Flip-flops are basically sandals with no back or strap. The name refers to the sound the shoes make when you're walking in them. They are great for days at the beach or pool and/or tooling around, but they also can stress your feet since the toes work harder to grasp while walking."The flatness of flip-flops also can aggravate some feet," Larka said. "If you can bend the sole, it's probably too soft and offers too little cushion." Natural materials such as cork and rubber tend to make walking more comfortable, she said.

Source: Joy Sewing, Houston Chronicle [5/29/08]

CA Podiatrist Found Not Guilty on Sexual Battery Charges

Closing arguments ended Tuesday afternoon and a day later a Fresno County Superior Court Jury found Fresno foot doctor Matthew Sciaroni "not guilty" of all nine charges against him. Those charges ranged from... "child molestation" to "sexual battery" and if convicted, Sciaroni could have faced 7 years in prison.

Dr. Matthew Sciaroni

"I love those jurors. They listened. They did exactly what my attorney told them to do and they paid attention," said Sciaroni. The Fresno podiatrist was arrested after a patient complained that the doctor touched her breasts and groin area during an examination for an ingrown toenail.

But Sciaroni's lawyer maintained throughout the trial, that those examinations, were necessary to make sure the infection hadn't spread to the lymph nodes. "He explained to the jury what he did and why he did it... And he denied any breast grabs with these other victims. This isn't about a podiatrist dispensing free breast exams," said Steve Smith, Defense Attorney. And Sciaroni says, his focus now will be on regaining his surgical privileges and his reputation.

Source: Ariana Duarte and Caryn Kochergen, KMPH (Fox) [5/29/08]

Claims Processors See Rejections Spike With NPI

Healthcare industry claims processors and claims-flow watchers report at least four-fold increases in rejected Medicare claims, similar or even higher rejection rate spikes for Medicaid claims, and a doubling of rejection rates for claims processed by Blues plans on May 23, the first day a federally mandated National Provider Identifier was required.

For all Medicare plans, “We’re seeing a rejection rate of 24%,” said Miriam Paramore, senior vice president of corporate strategy at Emdeon Business Services, the Nashville-based claims clearinghouse and IT service provider. By Emdeon’s analysis, that represents $25.8 million in claims that were turned down, which compares with an average rejection rate of 6% or $10.6 million before May 23, she said.

The NPI was required under the Health Insurance Portability and Accountability Act of 1996, but its implementation was delayed by HHS until last week.

Source: Joseph Conn, Modern Healthcare [5/29/08]

Hard Learned Lesson About Interviewing Job Applicants

“You can interview somebody for an hour or two hours, and never know what you’re hiring until you get them in the job,” says real estate tycoon, Donald Trump. “To a certain extent, it’s a chance. There are many people who give great interviews and are lousy employees, and then there are people who give terrible job interviews and are fabulous employees.

Source: Excerpted from "222 Secrets of Hiring, Managing and Retaining Great Employees in Healthcare Practices" by Bob Levoy

Query: Post-op Hypergranulation

This is the photo of the left foot of a 55 y/o woman who underwent bunion and hammertoe repair on 4/16/08. She went on to fracture the 1st methead, requiring repeat surgery 2 weeks later. She then developed a post-op infection requiring surgical I&D on 5/16/08. The infection appears to be controlled at this point, however significant hypergranulation tissue has developed.

Hypergranular Tissue S/P Bunionectomy

I warned her about the likelihood of having a substantially larger left foot compared to her right, as well as subsequent shoe fitting issues, etc. The patient is hesitant to undergo any further surgery. Does anyone have any experience with this type of problem or any treatment suggestions?

Chris Seuferling, DPM, Portland, OR

Query: Dealing With a Claim of Racism

I had an unsettling occurrence in my office this week and would like others' opinions on how this should be handled. I saw a lady who had a Winograd-type matricectomy done 10 days ago by another DPM in town. She wanted a second opinion about her toe being red and blisters that began to arise 3 days ago. She had been back to the operating surgeon twice for dressing changes. The first visit was at her own initiative due to severe pain and a tight bandage. She said the doc made her wait for 45 minutes in the waiting room while no one else came in or out before he would remove the dressing. She also stated that when the doc numbed her toe s/he held the needle in his/her fist and jabbed it into her toe maliciously. She said the doc was dismissive of her complaints and said all would be fine.

The kicker her is that she said she felt she was treated this way because she is white and the doc is black and the doc has a "hatred of whites." I told her that I was sorry she had a bad experience and that I knew all the DPM's in town and didn't know anyone who would intentionally mistreat a patient. I also told her she needs to be comfortable with her doctor and that I would see her through the healing process. How should I proceed if she persists in claiming racial mistreatment? Should I inform the operating doc of the situation?

Name Withheld (North Carolina)

Query: Converting Closed Tx Fracture to Open

May one bill an initial office visit and CPT 28470 (closed treatment of metatarsal fracture), and then 3-4 days, if the doctor was not satisfied with the results, later take the patient to the operating room for open treatment of metatarsal fracture, and bill CPT 28485?

Juan Rivera, DPM, South Tampa, FL

Response: Yes, you may bill for the initial office visit, but append that code with a "-57" modifier to indicate that E/M service was performed on the same day and a decision was made for a major "surgery" (to be performed within 24 hours).

If after you attempted to reduce the fracture that procedure was not adequate or failed, and you need to convert it to an open reduction, you would bill the subsequent procedure - open treatment of fracture - code with a "-58" (staged) modifier.

Make sure you document the reason for the initial closed reduction attempt, and the medical necessity for converting several days later to an open procedure.

Tony Poggio, DPM, Alameda, CA

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RE: Gouty Ulcer (Frank Graham, DPM)
From: Multiple Respondents

I have found it nearly impossible to heal over the tophi. Generally, serial curettage/debridement of the deposits will eliminate them as long as new ones are not forming. Usual wound management applies.

Doug Smith, DPM, Raleigh, NC, footfixer@nc.rr.com

Gouty tophi may be treated medically, however, once a tophus has ulcerated, it should be excised. The proper medication to treat a tophus is a uricosuric agent such as probenecid and not allopurinol. Allopurinol is a xanthine oxidase blocking agent and merely inhibits uric acid production. It will not get rid of or reduce a tophus like the drug probenecid will over time.

It should be pointed out that the prescribing of allopurinol is the treatment of a systemic disease systemically. By doing so, you are probably outside your scope of practice. It is similar to the prescribing of insulin for a diabetic. Additionally, the patient needs to be evaluated with a twenty-four hour urine to see if allopurinol is needed or probenecid is needed.

Mike Boxer, DPM, Woodmere, NY, mcbdpm@aol.com

All ulcers in diabetics, especially the one pictured have some level of ischemia. So before I did anything I'd get an arterial Doppler or an arterial color flow ultrasound to make sure there was adequate circulation. Second, while I believe gout can be "eyeballed" I would opine from a medico-legal standpoint that you do a CBC/esr, uric acid and kidney function profile. Gout is not a localized disease, the manifestations are.

Third, in this instance I would treat with colchicine 0.5 mg hourly until pain is gone, nausea or diarrhea. Maximum 5-6 tablets. Allopurinol is for CHRONIC gout and in fact can precipitate a gouty attack and make things worse.

Fourth, ask yourself why there is a wound? Is it the inflammatory gout or the ischemia? If the latter, I would improve the blood flow with an anti-platelet drug (aspirin, cilostazol, clopidogrel or pentoxyfylline) or consult vascular or interventional cardiology.

Last, check their HgA1C to see what their diabetes is doing. And, don't forget a wound culture. You are making it too simple ... you can debride that wound, reduce the uric acid and sew it up, but does that treat the underlying mechanism of why there's an ulcer in the first place?

Sloan Gordon, DPM sgordondoc@sbcglobal.net

RE: MI Podiatrist Advocates Cryotherapy For Heel Pain, MA Orthopod Disagrees
From: Michael Turlik, DPM

The larger medical community believes that case reports/series are descriptive studies which should be used to generate hypotheses. In order to truly evaluate treatment efficacies, the larger medical community believes that randomized controlled trials, systematic reviews and meta-analysis are needed. After reading postings on this site for a number of years, I am not sure that podiatric physicians share this viewpoint.

I do not know anything about the use of cryotherapy for mechanically-induced heel pain, nor have I read the articles referenced in this posting. Cryotherapy may be a very effective method of treatment, better than any other treatment intervention commonly used. However, case reports/series are not viewed as credible evidence by the larger medical community to support this statement. Case reports/series are thought of as biased sources of information. Anecdotal information from experts is regarded as even more biased.

Published information regarding foot and ankle conditions should be critically evaluated for internal and external validity by podiatric physicians prior to accepting the authors’ conclusions. Simply because studies are funded by drug companies, device manufacturers, or external agencies does not mean that the conclusions are not valid. Each individual study needs to be read and evaluated for potential sources of bias. Poorly planned, executed and reported randomized controlled trials may offer conclusions that are not believable. Simply because a study is published in a peer-reviewed journal does not mean the study is valid. The best studies are those which are carefully planned, executed and reported to allow the reader to feel comfortable that the efficacy claims made are close to the truth. For studies dealing with therapeutic interventions, the gold standard has been and remains randomized controlled trials.

I have no conflict of interest to disclose.

Michael Turlik, DPM, Cleveland, OH, mmturlik@aol.com

RE: Daniel Joseph McCarthy, Jr., D.P.M., Ph.D
From: Joe Agostinelli, DPM, Bryan C. Markinson, DPM

My first encounter with Dr McCarthy was as an applicant to PCPM when he was on my interview committee. The next time I saw him was as a student in his embryology and gross anatomy lectures. He was an amazing person in many ways. During the 1990's, we ran several Air Force CME Meetings that Jay Wenig and I attended and Dan was always the first to offer a lecture to give or workshop to run for us--at no cost. Once you were a student of Dan's and later a colleague, he always had a smile, a hello, and a funny story to tell. Although his illnesses took their toll, Dan was always at the meetings spending time with his former students, now colleagues, and always happy to see the people he trained. His scholarly achievements are awesome to behold but I will remember the times after lectures and at breaks in meetings with Dan holding court and making people laugh! He was truly one of a kind.

Joe Agostinelli, DPM, Niceville, FL

My first experience with Dr. McCarthy was in 1977, when interviewing for admission to what was known then as the Pennsylvania College of Podiatric Medicine. I had only completed three years of pharmacy school at the time, but had amassed over 100 credits. Dr. McCarthy grilled me (in a very professional way) mercilessly about why I thought that before I actually got an undergraduate degree, I would be able to handle the rigors of podiatric medical school. I responded by saying that if they gave me an interview, perhaps that may be the reason. It went all downhill from there, and PCPM was the only school that rejected me. I never forgot that interview.

Fast forward 7 years later, and I get a call from Dr. McCarthy who somehow found out that as a junior faculty member at NYCPM, I had developed an interest in podiatric dermatology. He anointed me the NYCPM faculty representative of the American Society of Podiatric Dermatology, and from then on we had a wonderful professional relationship, speaking often on the phone and glad to see each other at the annual ASPD meeting, which he had been unable to attend for the last few years. About 5 years ago, I got up the courage to remind him of our very first meeting in 1977, of which he had no recollection, probably having forgot about it three minutes into the next interview. He feigned a reaction of shock, and stated, “That was a mistake among many that I have made in my life.” I viewed that statement as a vote of confidence from a brilliant man, and one which defined his humility, and respect for his colleagues.

Rest in peace, Dan.

Bryan C. Markinson, DPM, NY, NY

RE: Dox Podiatry
From: James De Meo, DPM

I have been using DOX since February. Prior to DOX, I was using another Internet-based non-podiatry-specific program. As a result, I had to "adapt." DOX is fantastic! It really has saved me hours in my office. DOX has a front office side which handles patient demographic information, as well as insurance information. It is very user-friendly and my staff mastered it very quickly. The best part about this is that new patients can add all their demographics, reason for the visit, and medical history information online, prior to their initial visit. Thus allows me to review all this information quickly and easily, prior to the patient entering the exam room. This cuts down the wasted time spent on initial visits.

In addition, existing patients can update their information at their convenience. This has cut down billing errors due to wrong information, especially now that you really need everything to be exact. The real benefit to DOX, however, is the physician part of the program. My prior program was template-based. This was bad for two main reasons: 1) every note sounded and looked the same 2) it took an awful long time to create a patient- specific note.

DOX, however, generates the majority of the note through the diagnosis code, but at the same time, it allows you to input pertinent information that makes the note patient-specific. The best part is that it puts it all together seemingly so that the note flows like a handwritten SOAP note. It does all of this in about one minute. There are many more bells and whistles. The point is that DOX is podiatry-specific, which is really important, and other programs are not. For this reason, I strongly recommend DOX!

James De Meo, DPM, Scarsdale, NY, drjdemeo@aol.com

ASSOCIATE POSITION - SAN ANTONIO, TEXAS

Seeking three-year trained resident for associateship, hopefully leading to partnership. Competent in all phases of podiatry particularly reconstructive rearfoot surgery. Outstanding opportunity for the right individual. Reply to Richard Pollak at 210-692-0279, or fax resume to 210-692-0028 or e-mail drpllk@hotmail.com

IMMEDIATE OPENING - MINNEAPOLIS, MN

Associate leading to partner in well-established practice. Seeking personable, skillful, and attentive podiatrist. No nursing homes, evenings or weekends. Competitive compensation package including health insurance, malpractice, short term disability, 401(k), generous vacation, paid holidays, and excellent salary plus bonus! E-mail cover letter and CV to jbremer@associatedpodiatrists.com or fax to (612) 866-5875 attn: Jennifer Bremer

INTERNET FOOT THEMED CANDY BUSINESS FOR SALE

Well-known foot-themed chocolate and candy company with over 6,000 customers. Unique products with trademarked names for seasonal (Mistle Toes, Valentoes, etc.) as well as everyday (A Foot of Feet, Twinkle Toes, etc.). Excellent opportunity to generate income from home with an established business. Serious inquiries to Mwolpa@ToeFood.com

PRACTICE FOR SALE - FLORIDA

Well-known practice in Coral Gables,FL for over 20 years. Excellent location on Coral Way with heavy traffic, great visibility and plenty of parking. Busy, fully equipped, full-time office with established patients. Grossing over 300K with tremendous growth potential. Office is currently open and ready to take over immediately. For additional information contact QVAN@aol.com or 305-975-5516.

ASSOCIATE POSITION – LEHIGH VALLEY, PA

Large medical/surgical practice centered in Lehigh Valley, PA looking for exceptionally trained podiatrist. Excellent opportunity for income as well as potential partnership. E-mail resume to jkaufman@lvfoot.com

ASSOCIATE POSITION – NW INDIANA (1 HR FROM CHICAGO)

Great opportunity for financial and personal success. Start at $150K plus incentive compensation, good benefits, and ownership potential. Must be highly motivated, have a great bedside manner and excellent surgical skills (forefoot and rearfoot). E-mail resume to friendlyfootcare@comcast.net or fax resume to (219)662-7290. Learn about us here

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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