The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

June 09, 2007 #2,957 Editor-Barry Block, DPM, JD

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Champion High Jumper Credits CA Podiatrist For Her Return to Competition

High Jumper Sharon said there isn't a day she takes her ability for granted. After what she endured to reach her third outdoors finals after claiming the national outdoor crown in 2005 with a personal-best 6-4, it makes sense. Sharon broke her left foot in December of that same year. While walking through her San Luis Obispo neighborhood, Sharon said she tripped over a curb, not knowing she fractured her fifth metatarsal.

Sharon Day

Devastated is how Sharon said she felt about missing an entire year of not only jumping but playing soccer. The injured foot was her plant foot. She said the first surgery, taking place a week after her injury, didn't improve things. She couldn't even take off before trying to fling herself above the bar using the head-first Fosbury Flop. To her the only flop was her first surgery. A second surgery was needed.

Dr. Amol Saxena

The surgery took place in May. Sharon just wanted to jump again, even if meant struggling to clear the routine jumps of 5-6 and 5-8. She can thank Amol Saxena, a highly-regarded podiatrist in Palo Alto, CA for allowing her the opportunity. "I was just hoping this second doctor could help me," said Sharon of Saxena, who works for the Palo Alto Medical Foundation's Sports Medicine Department and serves as a member of the U.S. Track and Field Sports Medicine medical staff. "He just had more experience and really worked hard to get the pin in there correctly and help my foot heal. "He gave me the normal timeline, up to six weeks. This time I believed the doctor when it happened."

Source: David Carrillo Peñaloza, Daily Pilot [6/5/07]

PA Podiatrist Denied Parole

A podiatrist who smothered his wife with a dry cleaning bag does not deserve parole and will serve his maximum sentence, the Pennsylvania Board of Probation and Parole said. Karl Long, 48, of Ligonier, PAwas convicted of third-degree murder in the October 1999 death of his wife, Elaine. His five- to 10-year sentence will expire on July 3, 2012, the parole board notified Long.

Dr. Karl Long

Parole Board spokesman Nathan Bortner said the board not only rejected Long's parole, but also decided not to schedule a review hearing next year, which is normally done, the Pittsburgh Post-Gazette reported. By law, Long can request another parole hearing in a year, which must be granted.

The parole board found that Long continues to minimize his crime and lacks remorse. Westmoreland County District Attorney John Peck also recommended that Long not be paroled. Peck contends Long suffocated his wife with a dry cleaning bag during an argument. Long has always claimed his wife stabbed him and that she was suffocated when he passed out and fell on top of her.

Source: The Associated Press [6/7/07]

Giuliani to Propose Shift Toward Individual Health Insurance

Former New York Mayor and presidential candidate Rudy Giuliani (R) plans to announce a health insurance proposal that would shift tens of millions of U.S. residents from employer-sponsored to individual coverage "as a way of giving people more coverage choices," the Wall Street Journal reports. The proposal, which Giuliani plans to announce in detail this summer, would not eliminate employer-sponsored health insurance but would promote a health care system in which neither state regulations nor federal tax laws force residents into expensive health plans. The proposal would allow residents to purchase health insurance from any state, regardless of their place of residence, to help them find more affordable coverage.

In addition, the proposal would provide tax deductions for all residents who purchase health insurance, regardless of whether they obtain coverage through their employers or the individual market. Giuliani said that the health care system requires a "paradigm shift" toward the individual health insurance market. Currently, about 17 million residents have individual health insurance, compared with about 175 million who have employer-sponsored coverage. Giuliani said, "What I would do is change the whole model that we have for health insurance in this country. The problem with our health insurance is it's government and employer dominated. People don't make individual choices."

Source: American Health Line [6/7/07]

Query: Prolotherapy to Strengthen Ligaments?

I have a patient with a mild midfoot sprain in the metatarsal-cunieform area. The MRI shows sprain though no complete tear of LisFrancs ligament and no current displacement. Has anybody ever utilized prolotherapy in this area to strengthen the ligaments?

Carroll Kratzer, DPM, Raleigh, NC

Query: Medicare DME Not Dispensed

I had an Arizona Brace made for a patient who has taken ill, resulting in a drastic change in his medical condition. Due to massive lower extremity edema, which, so far, is uncontrollable, as well as the presence of cellulitis, I will not be dispensing this device anytime in the near (or perhaps distant) future. Of course, my bill to the brace company is now due.

1. Assuming I will no longer be able to dispense this brace, due to poor fit secondary to a change in size of the patient’s leg along with his change in medical condition, how do I bill Medicare to at least make my cost back?

2. What happens, if in the future the patient undergoes stabilization, and the brace does fit, and is dispensed, what do I do then? This is not foreseeable, but could happen.
.
David Gurvis, DPM, Avon, IN

Response: The following provision from the Medicare Carriers Manual should partially resolve this issue for you.

*****Artificial Limbs, Braces, and Other Custom-Made Items Ordered But Not Furnished

Reference for this requirement is in the 2005.3 section of the Medicare Carriers Manual.

If a custom-made item was ordered but not furnished to a beneficiary because the individual died, or because the order was cancelled by the beneficiary, or because his/her condition changed and the item was no longer medically necessary or appropriate, payment can be made based on the supplier’s expenses. In such cases, the expense is considered incurred on the date the beneficiary died, or the date the supplier learned of the cancellation, or the date that the item was no longer medically necessary or appropriate. Payment can be made on either an assigned or unassigned claim. If the order was cancelled by the beneficiary for any reason, payment can be made to the supplier only.

The reasonable charge is based on the services furnished and materials used up to the date the supplier learned of the beneficiary's death, or of the cancellation of the order, or that the item was no longer medically necessary or appropriate. The DMERC will determine the services performed and the amount of reasonable charge appropriate in the particular situation, taking into account any salvage value of the device to the supplier.

Since at the present time the use of this device is highly unlikely, I would go ahead and bill this under the provisions noted above. Since there is no salvage value (to you, to this patient at this time, or any other patient) you will be reimbursed at least your costs and perhaps up to the full reimbusement schedule. Submit the claim, non-electronically with the appropriate documentation. Bill for the full reimbursement amount and be specific in your correspondence that this device since it is custom-made has no salvage value, and cannot be used on another patient.

As for your second question, if the DMERC reimburses less than the full reimbursement amount and the patient does finally receive the brace, you could always file for an adjustment.

Paul Kesselman, DPM , Woodside, NY

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RE: Mildred Butterworth, PMAC
from: Gayle Johnson

It was with much sadness that I read of Mildred Butterworth's passing, but I also found myself smiling at her memory. As the Chair of ASPMA's Qualifying and Examining Committee, she upheld high standards for those podiatric assistants who wanted to become certified, offering encouragement and guidance while demonstrating fairness and integrity. Like Zelda Vicha and Frances LeBlanc, Mildred was loved and admired by many, not only as a professional role model but also as a treasured friend.

Gayle S. Johnson, Edmonds, WA

RE: Fibromyxoid Sarcoma (Doug Mason, DPM)
From: Bryan C. Markinson, DPM

Dr. Mason's experience details clearly what I have been passionately writing about the handling of soft tissue masses. He called it an "unexpected experience removing a mass on a heel that I thought was a simple plantar fibroma." This unexpected experience, certainly NOT unique to Dr. Mason, is proof positive that most handling of soft tissue masses by non-musculoskeletal oncologists leaves too much to simple "luck" as a variable in the final outcome.

This circumstance is very common amongst general orthopedic surgeons, general surgeons, vascular surgeons, and podiatric surgeons, all of whom for the most part are simply not the specialists of choice in the handling of these lesions, medically and surgically. Due to ease of excision, the possibility of malignancy is too often an afterthought, or a surprise, or unexpected. A much better approach to soft tissue lesions would be the scheduling of an open incisional biopsy of the mass after getting plain x-rays and an MRI with contrast.

Upon frozen section diagnosis which indicates malignancy, which takes 20 minutes waiting time, the surgeon would be able to close the wound leaving the tumor behind, and a planned wide excision could be done at a later date, after staging is done. Some tumors require hemotherapy and or radiation before they are completely excised. Low grade fibromyxoid sarcoma is a bad tumor. The "low grade" is a histologic finding but it does not mean that the biologic behavior of the lesion is not dangerous. It has almost a 50% metastatic rate over time.

Assuming a malignant foot lesion in any patient has not spread to distant sites, the patient is still left with an excised malignant lesion for which definitive margins are now impossible to define, requiring wider local surgery than might have been needed if the tumor to be excised were still present.

Lastly, it is my opinion based on many such cases that I have observed, that the final surgery be left up to a musculoskeletal oncology surgeon. If this surgery is done in the office, the patient is robbed of the ability to get frozen section diagnosis, and therefore, in my opinion, all soft tissue mass surgery should be hospital based. In short, the following of these principles by all of us will virtually eliminate the occurrence of "unexpected malignancy," which believe me, is highly desirable for all concerned.

Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org

Erythromelalgia with Hyperhydrosis( Elliot Udell, DPM)
From: Elliot Udell, DPM

A correction to my last message on this topic. I inadvertently said that Lyrica was a serotonin uptake inhibitor. This is not correct. I meant Cymbalta. According to the study published out of Mt Sinai, Lyrica would not necessarily be effective in the treatment of erythromelagia and Cymbalta might.

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

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