June 19, 2006 #2,609 Editor-Barry Block, DPM, JD

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CO DPM Uses Total Contact Casting to Save Diabetic Limbs

Diabetes can also cause problems with the feet and legs so serious they can lead to amputation. There is a unique treatment being done in Denver to try to save limbs of such patients.

The therapy is called total contact casting and is practiced by podiatrist Kenneth Morgan at Presbyterian/St. Luke's Medical Center. The process is time-consuming; it usually takes 6 to 8 weeks to heal a wound. There are also risks of causing other sores with the cast. Morgan has had great success, though.

"The cast is the No. 1 way of decreasing the pressure on the bottom of the foot," Morgan said. Morgan said that by decreasing the pressure the wound should heal. What makes the cast work is that it forces compliance, Morgan said.

Source: Kathy Walsh, WCBS 4 (Denver) [6/15/06]

States Are Turning Up the Heat on Medicaid Enforcement

Feeling the heat from the feds over Medicaid fraud and the burden of budget crunches driven largely by runaway Medicaid spending, states are cranking up the Medicaid enforcement machine. State enforcers may breathe down your neck like never before, bolstered by provisions in the federal Deficit Reduction Act (DRA).

The federal government is finally putting enforcement dollars into Medicaid. Though Medicaid accounts for 28% of HHS's budget, there are only 8.1 full-time equivalent positions overseeing state anti-fraud efforts, attorney Frank Sheeder said at the Compliance Institute session. DRA will increase that twenty-fold, said Sheeder, who is with the law firm of Brown McCarroll LLP in Dallas. Congress allocated $300 million for the Medicare Integrity Program for 2006 through 2010, plus $25 million a year for the next five years to OIG to bolster its Medicaid fraud-busting.

DRA also gave states the incentive to enact a version of the federal False Claims Act. They get to keep 10% more of the money recovered in an enforcement action. In addition, DRA requires entities that do $5 million or more a year of business with Medicaid to teach their employees about the False Claims Act and its whistle-blower provisions.

Source: Report on Medicare Compliance [6/12/06]

AMA Calls for Limits on Drug Advertising

The American Medical Association has called for moratoriums on consumer advertising promoting new drugs and medical devices until the products have shown they work and are safe.

In a new policy, the AMA urged the U.S. Food and Drug Administration to require manufacturers to wait for an unspecified period after a drug or device obtains regulatory approval before launching direct-to-consumer advertising in print, on television, or elsewhere. The association had considered a years-long moratorium, but decided to let the FDA set the time span, which could depend on whether the drug or device breaks new ground.

The AMA's House of Delegates, setting the group's policy at its annual meeting, recommended the FDA pre-approve such advertisements and ensure they are based on objective information from clinical trials, reveal the balance between a product's benefits and risks, and define warnings and potential adverse reactions clearly and understandably.

Source: Reuters [6/14/06]

Query: Fee For Expert Testimony

I have been asked to testify in a divorce proceeding. The reason is to provide testimony acknowledging the long term care of a Type I diabetic. This is not a malpractice case. I will lose a day and will have to prepare. I have never done this before and do not know what I should charge as my fee. Any help from someone who has had this experience will be appreciated.

Michael J. Schneider, DPM, Vail, CO, mailto:mjs10vail@aol.com

Editor’s comment: PM News does not provide legal advice. There is an easy way to calculate the fee. Simply determine the average gross income you bring in each day. Charge approximately that fee. Your rationale is that are not being paid to testify. You are merely being compensated for lost income. It is irrelevant whether this a malpractice, disability, or accident case.

Query: Study Info for Part 3 Lexis Exam

Where I can obtain test question information and study materials for the Part 3 PM Lexis exam?

Frank DiPalma, DPM, Athens, GA Fivetoes1946@aol.com

Query: Down-coding Orthotic Codes

I was reading in Codingline about Cigna orthotic denials. Has anyone experienced Blue Cross Blue Shield down-coding or modifying the codes for orthotics?

We have had many of our L3000 orthotic codes switched by Blue Cross Blue Shield, without notification, to L3020 (foot, insert, removable, molded to patient model, longitudinal/metatarsal support, each) - a lesser paying code. We have also had Blue Cross of Maryland, National Capital Area, and Federal Blue Cross pay for only a single orthotic stating that we are not treating the other foot so it is not medically necessary for them to pay for 2 (a pair of) foot orthotics.

Are we the only ones experiencing this frustration? Is this a trend we should be aware of? How are people dealing with this situation?

Amy Meehan, Billing Manager, Office of Franklin Polun, DPM, Potomac, MD

Response: If your orthotic devices truly meet the definition of an L3000, then down-coding of what you had fabricated to an L3020 should be contested.

What differentiates a UCBL-type device from an L3020 is that a UCBL-type of device stabilizes the foot using heel cup depth and medial and lateral wall height extending distally to the metatarsal bases.

My suggestions would include sending a photo of the device, a lab description of the device you ordered, and a copy of your prescription or order for the device to the insurance company.

If this fails to resolve the problem, perhaps an external review or a letter to the Maryland Insurance Commissioner or Attorney General's Health Care Bureau would hep resolve the problem, especially if these payers altered or down-coded the coding for the devices WITHOUT review of your records to validate their action.

Paul Kesselman, DPM, Woodside, NY

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

RE: Returning for Residency Training
From: David Gottlieb, DPM

In answer to all the questions I've gotten regarding my earlier posting about going back for a surgical residency after years of practice all I can say is that it's been the best decision I've ever made. Spending two years [often the first year of a 3-year program can be waived for someone who's been in practice] of hard work, intense training and learning will allow me to spend the next 15 to 20 years really enjoying performing state-of-the-art foot care and wound care.

The exposure I've gotten to world-class facilities on a daily basis and the employment opportunities that will be available to me upon the completion of my program next June are unbelievable. The exposure and guidance of many excellent surgeons and clinicians has been an incredible experience.

To all who are wondering if they should go back and be trained for today's practice style I can only say: GO!! The two years now may be financially tight and short on free time but the payoff in the end is immeasurable both in personal happiness and growth and financial reward.

H. David Gottlieb, DPM, VA Podiatric Surgical Resident, Baltimore, MD, hdavidgottliebdpm@gmail.com

RE: Severe Cramping of Feet & Legs (Jean Bainbridge, DPM)
From: Multiple Respondents

High on the list of possible causes is a reaction to statins. Is the patient taking Zocor, Lipitor, Crestor or one of the others? These are life saving medications but they are myotoxic. Other things to look are low potassium level or abnormal electrolytes. Order the proper blood tests. Is the patient taking a diuretic could he or she have a low potassium level? Of course do a Doppler study to rule out peripheral vascular disease. A rare possibility is a reaction to coffee and I not mean caffeine. Some people get muscle cramps and spasms from some element in the coffee bean and when I have taken them off of coffee entirely the spasms and cramps go away.

If all is ruled out you might want to treat this patient with in office infrared heat therapy and light massage. The former is very effective in treating muscle cramps and spasms. .

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

When and under what circumstances does he get these? Has he had a good vascular and neuro workup? For typical night cramps of the calf, I've found that stretching the gastroc/soleus group at bed time makes a huge improvement.

Paul Busman DPM, Troy, NY, BREWERPAUL@aol.com

A long time ago the medical director at a facility where I was working suggested that a good safe antispasmodic, mostly for night cramps, is Benadryl. It is safe and very effective for cramping. I usually start at the 25 mg dose and will go up to the 50 mg if necessary. Since it is so safe, the least it will do is help the patient to sleep. It certainly is worth a try.

Gene Feinberg, DPM, Annandale, VA, feinberg@cox.net

TEMPORARY POSITION – LONG ISLAND

Doctor broke arm and needs a NY-Licensed DPM to cover for a period of time. (516) 637-3672 Mel2222@peoplepc.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 POSITION - NAPLES- FLORIDA

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills. Hospital privileges available at 548 bed hospital system and multiple surgical centers. Candidate should want to perform rearfoot surgery including Charcot reconstruction. Candidate needs to be ethical and motivated and have a current Florida license. Established practitioner or new practitioner OK. Base, percentage, benefits including insurance and 401K. Fax CV to (239) 566-8778.

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901.

ASSOCIATE POSITION – MIAMI DADE COUNTY FLORIDA

Part time work available. Clinic sessions-nice environment / assistants supplied 8am-12pm / 1pm-5pm. Miami Dade County. Hourly Salary. E-mail response to: podoffice@aol.com

PRACTICE FOR SALE - NORTHWESTERN US

Selling 3 well developed satellite offices with substantial potential of continued growth. All offices in areas of abundant outdoor recreational activities including skiing, fishing, hiking, etc. These offices are priced to sell quickly! Please only serious inquires only and contact via e-mail: offmgr4464@hotmail.com

RESIDENCY POSITION – VIRGINIA

One Year Foot and Ankle/Rearfoot Surgical Fellowship with excellent salary/benefits available July 1, 2006. If you are finishing a PSR-24 and don't have a job yet, this is an excellent way to learn additional surgical and business skills. Please fax resume to 703-
491-9994.

ASSOCIATE POSITION - PITTSBURGH, PA AREA

Excellent opportunity for a hard working, surgically trained podiatrist to join a well-established, high volume, multi/location practice in the suburbs of Pittsburgh. Must be willing to perform all aspects of podiatry. Incentive-based salary, compensation package, with potential for partnership. Must presently have Pennsylvania license. Would like to fill position asap. Fax resume to 412-831-2115.

ASSOCIATE POSITION - 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.

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)

PRACTICE FOR SALE - COLUMBUS, OHIO AREA

Fully furnished practice, open ONLY 14 hours a week with an average yearly gross of 235K. 75% primary care, 20% surgical, 5% Nails. Plenty of opportunity for growth and surgery. Changing locations. Financials available upon request. Kyle_DPM@Yahoo.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

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