June 08, 2006 #2,600 Editor-Barry Block, DPM, JD

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Bromhydrosis Can be Controlled: NC DPM

People should start asking for help when their foot odor becomes an issue, said Eric Siceloff, a podiatrist at Piedmont Foot and Ankle. "When it bothers the individual, when they're having difficulty because it's a psychological or social thing, or if they don't want to take off their shoes because they're afraid it would create an embarrassing situation, then it's time to do something about it," Siceloff said.

About 90 percent of foot-odor cases can be controlled by taking a few simple measures, Siceloff said. Attacking the problem requires work on two fronts - cutting down on sweat and the bacteria that live on your feet. Siceloff does not recommend Botox injections because sweating is the body's way of cooling itself. "If you eliminate all foot sweat, it could create a lot of problems," he said.

Siceloff said that there is nothing to suggest that men's feet smell more than women's feet. But women do tend to seek help from him more often than men, he said.

Source: Lisa O'Donnell, Winston-Salem Journal [6/6/06]

NYCPM Graduates 58, Microsoft’s Crounse Delivers Keynote

Bill Crounse, M.D., Healthcare Industry Director for the Microsoft Corporation, delivered the keynote address to the graduating class of the New York College of Podiatric Medicine (NYCPM) and received an honorary degree of Doctor of Humane Letters-Honoris Causa, during the College’s 95th Commencement Ceremony at Alice Tully Hall in New York City on Monday, June 5th.

Louis L. Levine, President and Chief Executive Officer of the college, presided at the commencement ceremony. Dr. Crounse addressed the 58 graduating seniors—who received their Doctor of Podiatric Medicine degrees—and an audience of nearly 1,000 faculty members, parents, family and friends.

In addition, Christine C. Quinn, Speaker of the New York City Council, and Abraham Lavi, President and CEO of Vilex, Inc., were also awarded honorary degrees. David M. Schofield, D.P.M., President of the American Podiatric Medical Association (APMA), delivered greetings to the graduates from the APMA, and also received an honorary degree.

Nurses, Others to Push for Expanded Scope of Care

Nurses, chiropractors, and several other types of healthcare professionals have formed an alliance to try to expand the types of services they can offer. The National Coalition for Patients' Rights, which says it represents more than 3 million licensed health professionals, will kick off its campaign with a news conference Thursday. Member groups include the American Nurses Association, the American Association of Nurse Anesthetists and the American Psychological Association.

The American Medical Association, along with state medical societies and medical-specialty organizations, has opposed attempts by nurses and allied health professionals to expand their scope of care into areas that might conflict with treatments typically delivered by physicians. The issue will be the subject of a special report by the AMA's board of trustees during the group's annual meeting, which begins Saturday.

Source: Michael Romano, Modern Healthcare [6/6/06]

Query: Pediatric Onychomycosis

Any ideas for treating a 3 y/o female with painful onychomycotic nails? Her mother related a history of tinea pedis which was treated successfully with topical antifungals, followed by progressively painful thickened discolored nails. PAS stain was positive and I am awaiting culture results. Of note, her mom has a history of recurrent tinea pedis.

Paula Marella, DPM, Duxbury, MA, Duxftdoc@aol.com

Query: Possibly Pregnant Teenager

A 16 y/o female patient presents with her mother. Her c/c is a painful right first MPJ. Prior to taking an x-ray, I asked the mom to leave the room. I then asked the patient if there is any chance she might be pregnant. She appreciated the fact that I did not ask this question in front of her mother. The patient told me that there might be a chance, but she won't know for a couple of weeks.

I told mom that my machine is not working properly and we would have to wait to take the x-ray. I would like to know how this situation could or should be handled?

Charles Morelli DPM, Mamaroneck, NY, charles@themorellifamily.net

Query: CROW AFO Coding Update

I am a novice when it comes to DME, and would appreciate help regarding which series of codes would be used when billing for a CROW device (used in diabetic patients with Charcot midfoot changes) in one of my diabetic patients with a Wagner grade 0 lesion?

I was told that the codes will change depending upon the components and materials used to create and line the CROW. Any help would be appreciated.

J.P. McAleer, DPM, New York, NY

Response: The Charcot Restraint Orthosis Walker (CROW) is a custom ankle foot orthosis (AFO) which contains the following components:

L 1960 - AFO, posterior solid ankle, custom-molded
L 2340 - Pre-tibial shell, custom-molded
L 2820 - Interface lining

I would caution against your justification to use this AFO for the treatment of a Wagner Grade 0 ulceration, particularly if your patient is Medicare-eligible. Medicare will not cover ANY ankle foot orthosis if the primary purpose is to off-load an ulceration. The CROW boot is reserved for use in only the most severe Charcot deformity. In most cases, the standard of care for long-term off-loading minor diabetic ulcers and pre-ulcerative lesions is the use of therapeutic footwear.

The American Podiatric Medical Association (APMA) has recently made available the 2006 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Primer as a free online member benefit. If you are a member of APMA, you can download this directly from APMA's website, www.apma.org

Doug Richie, DPM, Seal Beach, CA

Additional notes appear at wwwcodingline.com

Codingline subscription information can be found at http://www.codingline.com/subscribe.htm

RE: Cardiac Arrest
From: Elliot Udell, DPM

Allow me share what happened yesterday in my office . My office manager ran into my office looking frantic. A patient passed out in the waiting room. She was slumped over on the chair. There was no carotid or brachial pulse, and no sign of breathing. We shook her, there was no life. We pulled her on the floor and I started pounding on the sternum. Everything I learned in the CPR course I took many years ago came back to me. After a bunch of sternal presses, she started breathing again. Fluid came out of her mouth and she came back. We called 911 and sent they sent her off to the hospital, but she left my office alive.

I am happy with the outcome, but very shaken up. Fortunately, I was in the right place at the exact right time. A minute or so later, the outcome could have been different. What is also going through my mind is that the CPR is so easy. It is far less technical than any of the procedures I do daily for patients’ feet, yet it made such a difference. If anyone has not taken CPR training, do so now, and let’s all pray that the only time we will ever see it is on a TV screen or at the movies.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Ruptured FHL Tendon ("Tip" Sullivan, DPM)
From: Thomas A. Graziano, DPM

When the legal limits of your license preclude you from providing comprehensive surgical care for your patient, it might be a good idea in the interest of that patient to refer them to someone who can practice within those limits.

Thomas A. Graziano, DPM, Clifton, NJ, TGrazi6236@aol.com

RE: Articles on Efficacy of Orthotics (Howard Schultheiss, DPM)
From: Paul R. Scherer, DPM

I am responding to your request about orthotics and bunions. Contemporary thought places the pathology of HAV to have its origins in functional hallux limitus (FHL). The paper that demonstrates the effectiveness of orthoses in this pathology will be published in the September issue of JAPMA, I believe. If you want an advanced copy, please contact me and I will forward it to you.

Paul R. Scherer, DPM, San Francisco, CA, hpoc@aol.com

RE: Valuing a Practice (L. Polizzi, DPM)
From: Barry Mullen, DPM, Hope Rachel Hetico; RN, MHA

Another critical piece of financial data to review includes the billing patterns of the prior owner. One must ensure that he/she followed medical practice guidelines. Falsely elevated practice values could be attributed to prior owners that earned income through unscrupulous billing tactics. Obtaining a profile of the billing patterns of the practice for the most common podiatric services for the practice in question, and comparing those numbers to national averages and your practice locale's competitors, will provide you with the necessary data to determine whether the claimed net profit is realistic or inflated.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

Dr. Polizzi is correct when he suggests that each and every line of the income statement and balance sheet should be evaluated for a valid medical practice valuation engagement. In fact, the adjustment of financial statements is formally known as the “normalization” process.

The income approach example that he used measures the present value of anticipated future practice benefits that accrue to owners and has several potential meters: cash flow, net income, net operating income, or dividend (bonus) payouts, etc. In addition, an appropriate capitalization rate, risk-adjusted for the practice by which the benefits are discounted, must be developed. And, there are several methods that may be considered under the income approach, including:

Discounted Net Cash Flow (DCF) Method - Estimates the after-tax present value of “normalized” expected cash flows distributable to owners with a residual or “terminal” value ascribed to all periods beyond the forecasted projection.

Single Period Capitalization Method - Estimates the present value of the practice by capitalizing a single year of benefits.

There are other valuation approaches to consider, as well: See: http://YAZY630@aol.com

Realistically however, none of these techniques alone captures the entire medical practice sales environment, today. Professional valuators, IRS, and USPAP guidelines suggest a cognitive and experiential blend based on economic assumptions to arrive at a valuation range that reflects real world conditions in an ever changing regulatory and competitive environment.

Finally, a practice on-site walk-through is mandatory; trust but verify tangible assets and liabilities, satellite offices, equipment, and employees, etc. Always use an informed and licensed fiduciary advisor who will sign off and defend his/her Opinion of Value if needed; rather than a broker, for this highly sophisticated financial transaction.

Hope Rachel Hetico; RN, MHA, Norcross, GA,
marcinkoadvisors@msn.com

RESIDENCY POSITION - HOUSTON, TX

RPR, PSR-24, Houston Podiatric Foundation, Starting ASAP. Must have successfully completed PARTS 1 & 2 of National Boards. Contact: Dr. Randal M. Lepow, Director (281-348-3338) (713-725-8988)

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.

PRACTICE FOR SALE - NEW YORK

FOR SALE - Rockland County. Well established, high-volume practice, general and surgical. Gross $500K, hospital privileges; excellent lease. All interested parties reply to: metroNYCpodiatry@aim.com

ASSOCIATE POSITION - OHIO

Associate needed for high volume practice with eventual buy-in. Requires highly motivated individual with immediate high volume patient load. Competitive salary with bonus, malpractice, and health insurance. Send resume to rubwalk@hotmail.com or fax to 419-473-1230

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

ASSOCIATE POSITION - PALM BEACH COUNTY, FLORIDA

Excellent for upcoming residency grad. Well rounded practice- 2 podiatrists. Fax resume: 561-637-9596.

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.

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