The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

June 27, 2009 #3,582 Publisher-Barry Block, DPM, JD

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MO Podiatrist Discusses Flatfoot Surgery

John Dailey, DPM, a podiatrist with The Missouri Foot & Ankle Institute in Washington, MO, performs a type of surgical flat foot correction known as “subtalar joint arthroereisis,” that focuses on repairing the sinus tarsi, an opening on the outside of the foot between the ankle and heel bone. “This canal collapses in people who have flexible flat feet, and it can cause a number of other foot problems down the road,” he says.

Dr. John Dailey

Dailey uses a HyProCure sinus implant to ensure the sinus tarsi remains open. “By using this small stent, which is the exact shape of the natural opening, to hold the sinus tarsi open, we can allow for normal joint rotation and proper alignment of the entire leg,” he says. The outpatient procedure requires only a small incision, and patients are able to walk the same day, wearing a post-surgical boot for about a week.

“We follow the procedure with some physical therapy, and many patients don’t even need an orthotic afterward,” he adds. Dailey says he has performed countless such procedures during the past three years and reports it has provided a permanent solution for people of all ages. “If orthotics haven’t worked, this is an option, and we’re glad to have something like this finally available for our patients.”

Source: Connie Mitchell, LaDue News [6/11/09]

APMSA and FIP to Host International Student Forum

In conjunction with the activities of the 2009 APMA Annual Scientific Meeting, the American Podiatric Medical Students' Association (APMSA) and the International Podiatry Federation (FIP) have joined forces to host a free student-led forum for podiatry students to discuss global interests, perspectives and needs in education, practices, and work opportunities for student podiatrists in many countries around the world.

Podiatry students interested in learning and sharing perspectives about podiatry from around the world can join fellow students from around the globe and attend the APMSA/FIP International Student Affairs Forum on July 30, 2009, in Toronto, Ontario Canada, from 1:45 – 3:15 pm in the Fairmont Hotel/Quebec Room. Seating is limited and will be first come, first served.

Offer Help Sincerely, or Not at All

Do not end correspondences with a vague boilerplate phrase like “Please don’t hesitate to call if you need further assistance.” Instead, reference the patient’s query and say “If you have more questions about ____, please call me at _____.”

Source: Adapted from “Increase Rapport in Your Closing,” Ann Block, B.Clear, Brody Professional Development via Communication Briefings

Query: Melanoma in Situ

I took a punch biopsy of the lesion below. The pathology report came back "Lentiginous and nested melanocytic proliferation with moderate atypia. Note: This lesion has features of early evolving malignant melanoma in situ."

Melanoma in Situ

So, it is time to excise. I have received different answers from many dermatologists as whether the margins should be 1.0 cm., 0.5 cm., or no margins are needed. I was planning on taking the 1. cm margins just to be safe.  Am I doing the correct thing?

Bret Ribotsky, DPM, Boca Raton, FL
 

Query: Answering Service For Emergency Calls
 
I'd like to know how others are handling after hours "emergency" phone calls. I currently have my voicemail set up where patients can leave messages, and if it is a "true medical emergency", they can enter a sequence after their message, and their message will be delivered to my cell phone. I would say 1 out of 100 messages is an "emergency." Most of the time, the messages are regarding patients' appointments, refilling prescriptions, etc. I know that I'm asking for trouble by leaving it up to the patient to determine what is an emergency, but I don't know of an alternative.

I was wondering if anyone had success with answering services where they could screen calls after hours and then notify you if it is an emergency; but again, you're relying on that operator to make that decision. I know some podiatrists who do not have a way for their patients to contact them after hours unless the patient goes to the emergency room and then the ER contacts the podiatrist.Their after hours message instructs patients to call back during regular business hours, and if it's an emergency, go to the ER. 
 
Anas Khoury, DPM, Passaic, NJ

Query: Treating Gout-Like Symptoms

I saw an established patient today with a new complaint of severe gout-like triamcinolone acetonide symptoms at the 1st metatarsal-phalangeal joint. I performed a nerve block, aspirated joint fluid for analysis, and injected joint with dexamethasone phosphate. How would I bill the above?

Gary Hoberman, DPM, Chicago, IL

Response: Depending upon the quality of your medical documentation, appropriate coding would be:

CPT 99213-25 (with really good documentation to support medical necessity, you might be able to support CPT 99214-25)

CPT 20600 (injection, small joint)

The steroid supply is separately billable with applicable HCPCS code. The nerve block is NOT billable.

Rick Horsman, DPM, Olympia, WA 

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

RE: Heel Pain in Runner (David E. Gurvis, DPM)
From: Jeffrey Kass, DPM

I would consider a diagnosis of medial and or lateral calcaneal neuritis. It is plausible that, at the 5 mile mark, the constant heel strike against the ground induces the neuritis. I don't know if the skin peeling is coincidental or the constant pounding is having a similar effect on the skin. I think an accommodative heel cushion to help absorb heel strike may be a good start. While, I initially think of neuritis because you mention burning - a calcaneal stress fracture does sit in the back of my mind due to amount of pain you report. A 74 year old woman does fit into an osteoporotic age. Let us know how she fairs.
 
Jeffrey Kass, DPM, Forest Hills, NY JeffcKass@aol.com
 

RE: Drop Foot (Richard Hofacker, DPM)
From: Multiple Respondents

This patient has a compression neuropathy of the common peroneal nerve, caused by a drunken stupor and sleeping on his side and not rolling over. Some form of bracing like a simple CAM walker, or even an inexpensive pre-fab AFO, will help prevent any posterior leg muscle tendon contracture while tincture of time will usually resolve the injury to the nerve. Physical therapy to include range of motion and muscle rehabilitation, either by a real physical therapist or "at home" exercises, also will be helpful. This should improve or resolve over time.

Keith Gurnick, DPM, Los Angeles, CA, e-mail keithgrnk@aol.com

Unfortunately, I have had first-hand experience with this condition during my wild and crazy college days. Fatigue combined with intoxication caused me to fall alseep crammed into the back seat of my VW bug, and so all through the night my knee was pressed against the door handle, compressing the common peroneal nerve. When I awoke, I got out of the car and fell flat on my face, because my left foot wouldn't work. After neuro-consult and NCV confirmation of common peroneal nerve palsy, my dropfoot gradually went away after 6-9 months. The dropfoot can be supported with an AFO in the meantime. I recommend you refer your patient to neuro and AA.
 
John Chisholm, DPM, Chula Vista, CA, dr_triguy@yahoo.com

I agree with the common peroneal palsy. Recently, I  had two cases of this and both were resolved within days with surgical decompression.  

I definitely agree that a good neurology consult with EMG and NCV is warranted. While AFO's, etc. are a good idea, if the foot drop is caused by compression of the common peroneal nerve either through acute trauma or chronic compartment syndrome (such as my case of a police officer), we are not doing the patients any favors by ignoring the cause. This is especially true when a problem can be easily solved with a simple surgical procedure; you can spare the patient from a lifetime of AFO's, etc.
 
Kevin Lam, DPM, Naples, FL, klamdpm@hotmail.com

RE: Platelet Gel (Sloan Gordon, DPM)
From: Jeffrey Kass, DPM

Harvest is a company that is seen at many podiatry conventions. Smith and Nephew makes a disposable unit. I suggest the website harvesttech.com as a resource.
 
Jeffrey Kass, DPM, Forest Hills, NY  JeffcKass @aol.com

RE: Time Clock/ Management Software (Stuart W Kushel, DPM)
From: Multiple Respondents

Our practice purchased TimeForce. The website is mytimeforce.com.  The costs vary, depending on if you want a computer-based clock-in or time clocks. Time clocks cost more, averaging $300-$500, but you may need additional computer equipment if you have a multi-site network environment. It is easy-to-use, but time intensive to set up. I highly recommend the additional cost for assisted set-up. Our staff loves it!

Howard Stone, DPM, Glenview, IL, justus313@comcast.net

We use the single PC version of AttendanceRx and it has been very simple and straightforward. I purchased it here: tinyurl.com/ndhkys for about a hundred dollars. It can run on the PC only, no ID cards, fingerprint scanners, etc. Our employees clock in/out on a PC in a central location. We print totaled and calculated "time cards" each pay period. It has saved a ton of time in calculating hours worked.

Michael Hodos, DPM, Wake Forest, NC, mike@mikehodos.com

We use ontheclock.com.  It is an online program and is very helpful for our payroll as there is no paper to follow and they add up all the times for you. It is easier for our staff to use than even the old paper stampers. 
 
Kevin Lam, DPM, Naples, FL, klamdpm@hotmail.com

PRACTICE FOR SALE - FLORIDA

PRACTICE FOR SALE - ALABAMA, GULF COAST

Established 26 year old practice. Owner desires to sell and relocate. Operated 25 hours per week. Mixture of surgery and general podiatry. MD referrals. Surgery center and hospitals in close proximity. Highly profitable. Priced to sell.  Will lease office to buyer. Call Mike Crosby at 888-776-2430 or email mcrosby@providerresources.com

ASSOCIATE POSITION – MARYLAND

Maryland Eastern Shore Practice has opening for associate with ownership interest. MCR approved ASC, EMR, Ultrasound, Flouro, with Hospital Privileges available. E-mail CV to: patimmons@comcast.net  

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS 

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

CASE CONSULTING

Dennis Shavelson, DPM is accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds, pigmented & derm lesions, PRP and diagnostic dilemma’s from DPM’S. Full reporting with second opinion only and rapid return after care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

ASSOCIATE POSITION AVAILABLE-MIDTOWN MANHATTAN 
 
Looking for Full-time associate to work in well established practices in midtown Manhattan and Forest Hills. Immediate opening for PSR 24-36 surgically trained Podiatrist. Great opportunity with competitive salary along with malpractice benefits. Position includes Saturday office hours. Please send CV to slurie@papapc.net

PRACTICE FOR SALE – NEW YORK CITY

NY Manhattan, prime location. Upper East Side, 23. Y.O. practice, high visibility-traffic area next to post office, street level, All phases of Podiatry, NO surgery, retiring due to disability. call 516-759-4062 or Paulfxfeet@aol.com

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

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