July 06, 2006 #2,623 Editor-Barry Block, DPM, JD

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FL Podiatrist Discusses Risks of Barefoot Walking

Dr. Roberta Guidice-Teller, a Gainesville, FL podiatrist, said she'd seen two cases in recent days where someone had cut open the sole of their foot by stepping on something sharp while barefoot. "You can also pick up a foot fungus, if you have some micro-opening or an infected place on your foot," Guidice-Teller warned. "That opening gives the fungus a point of entry."

You also can pick up a virus that can create a wart by going barefoot, but that is more of a risk in the moist environment of a gym or shower area.

Larva migrans, or ground itch, is something you can certainly pick up here in the South. It's a type of parasite that burrows into the skin. The life cycle of the parasite begins when eggs are passed from animal feces into warm, moist, sandy soil, where the larvae hatch. Once it gains access beneath your skin, the parasite will form long burrows as it moves about your foot. It can be treated with a topical cream or spray, Guidice-Teller said.

Source: Diane Chun, Gainesville Sun (FL) [7/2/06]

After 20 Years SC Podiatrist Finds Practice Rewarding, Yet Paperwork Intensive

For Dr. Bruce Wellmon, success can be measured not only in dollars, but in time as well. And on July 4th the Gaffney, SC podiatrist celebrated 20 years of success. As a podiatrist, Wellmon has always operated as a bit of a specialist, even before the term was en vogue for the medical community.

Dr. Bruce Wellmon

“I wanted to be a podiatrist first and foremost as it related to sports medicine,” he said. “I spend a lot of time around the team and team doctors at Wake Forest. The more I investigated podiatry, the more it interested me. There are so many things I can do – from surgery to helping care for diabetes-related foot ailments.”

Twenty years has brought significant change to the field of podiatry. “The biggest change I see is the sheer amount of paperwork I have to fill out now for insurance companies,” Wellmon explained. “I like the surgery aspect of the job. It is the most challenging but the most rewarding. But the deluge of paperwork is incredible.”

Source: Scott Baughman, Gaffney Ledger [7/1/06]

Tuning Fork More Aggressive Screening Tool for Neuropathy Than Monofilament

Results of a tuning fork test to identify neuropathy appear to be reproducible in a non-diabetic population, according to findings from a blinded, observational study.

Dr. David S. Oyer of Northwestern University, Chicago, IL, described how he used a tuning fork test to evaluate 147 patients aged 40 years and older. To perform the test, a C128 tuning fork was struck to make the ends clang together, and then patients were shown the difference between the vibration sensation and pressure on the patient's toe, malleolus, knee, or sternum. The tuning fork test was performed again at the end of the dorsal bony prominence of the patient's big toe proximal to the nail. Blinded, the patients then indicated when they could no longer feel the vibration.

Vibration sensation duration was measured in both feet twice. Average scores were then analyzed for correlations between the right versus left foot, statin versus nonstatin use, and overall difference in sensation by age-group decade. Overall, 80% of patients were within 2 seconds between the right and left feet, suggesting the test's consistency.

The findings dovetail with those from a previous investigation in which Dr. Oyer found that the tuning fork test was far more effective than the more widely used monofilament test in detecting distal polyneuropathy. That study involved 45 diabetes patients who had vibration test scores of 0–8 seconds, indicating some level of neuropathy. Of those 45 patients, only 16 had abnormal monofilament test results (Endocr. Pract. 2004;10[Suppl. 1]:20).

Presented at the annual meeting of the American Association of Clinical Endocrinologists

Source: Diabetes in Control [7/4/06]

Query: Discharging a Difficult Patient

In nearly 25 years of practice, I've never "fired" a patient. But I've got one now who has cost my office staff hours of time on the phone and doing paperwork to appeal non-covered [due to time] Medicare services. The patient understands it is not covered. He's just decided it's not fair and is torturing me and my staff in an attempt to get Medicare to change their policies. I've had enough but I want to make sure that I "fire" him correctly. Does anyone have an appropriate form letter/ protocol to make sure that there are no mistakes as I begin the process to terminate a very difficult patient?

Deborah A. DeRose, DPM, Fairfield, CT, debbyd@optonline.net

Previous Response Published in PM News

I use this or a variant of the same, depending on the individual circumstances:

Dear Mr/Mrs. Patient:

During the course of my treatment for your condition, it has become obvious you do not have faith in either myself or my office, as evidenced by your failure/refusal to follow my instructions as to your care. [or some variant of the above, such as "You have consistently refused to follow my office policy" or "You have repeated, after having been warned, failed to keep your appointments"] Because of this, I feel it would be in both our best interests if I was no longer your podiatrist. I will continue treating your present condition [only if not seeing the patient for the current condition could or would cause worsening of that condition] or see you in emergencies for 30 days. After that time, I will no longer be able to see you as a patient. I would recommend any of the following three podiatrists for your future care: [enclose three names, numbers, and addresses].

I send this letter certified, and keep a copy. If the patient refuses to accept and sign for the letter, I keep the returned unopened letter in my files next to the copy. You should check your state laws regarding this, but I have used it for 25 years without a problem.

David E. Gurvis DPM, Avon, IN

Editor’s comment: PM News does not provide legal advice. It is not necessary to recommend colleagues for a discharged patient. In fact, it’s a bit of a left-handed compliment.

Query: Excision of Sural Nerve Lesion

How would I bill an excision of a sural nerve lesion from the posterior-lateral aspect right ankle? We billed out CPT 64784 (excision of neuroma; major peripheral nerve), but our Medicare carrier rejected the claim stating not payable to a DPM.

Mary Nyssen, Grand Rapids, MI

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Response: Your claim appears to have fallen outside of the range of established for procedures performed by a podiatrist that have been established by your carrier.

You have two options as I see it. Consider re-billing this procedure using the CPT 64782 (excision of nerve lesion, foot) which is probably closer to what was done than the excision of a nerve lesion (neuroma) of a major peripheral nerve of the limb. The CPT 64782 code should go through without denial. A second choice would be to resubmit the procedure as "unlisted" (CPT 28899) with a paper claim and operative report. Be sure to request peer review to determine reasonable payment.

Long term, you may want to contact your state association and see if there is potential to dialogue with this carrier to be more inclusive of procedures that podiatrists can be paid especially if they are licensed in your state to perform those procedures.

Howard Zlotoff, DPM, Camp Hill, PA

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RE: DMAC Jurisdictional Changes

Effective July 1, 2006 all claims for DMERC Region A are NO LONGER to be sent To Health Now. They should be sent to National Heritage Insurance at the following address:

DME – Specialty Claims
P.O. Box 9165
Hingham, MA 02043-9165

For those sending their claims electronically, the electronic address used prior to June 30th is incorrect. You are urged to contact your software vendors who should be able to provide an update for your electronic submission systems.

The jurisdictional map has also changed. Anyone previous in DMERC A is still there. Those readers in Washington DC and Maryland, you are now part of DMERC A.

I would urge all readers in the Northeast to view their new carriers website at: http://www.medicarenhic.com/dme/index.shtml

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

RE: Residency Positions
From: Bryan C. Markinson, DPM

In the past few days, some writers discussed the loss of Federal funding of residency positions. We are now seeing large numbers of ads for filling of empty residency positions. It was just twenty years ago where there were not enough positions. The quickest way to go broke in terms of federal funding is demonstrating that there is no need for the funds. There can only be one reason for this.....too few people are interested in entering our profession. I make this to be at crisis levels. Several people who I have considered "in the know" tell me that there is no such crisis. Others tell me there are only 500 legitimate applications to our schools.

Dr. Mullen talks about the worth of our practices plummeting if we cannot find trained younger practitioners to buy them. The worth of practices went from a years gross thirty years ago to who knows what now, due to managed care and the ability of such new practitioners to get on the plans of the practices that they would like to purchase. The days of the practice as a retirement vehicle are over.

APMA cannot be blamed for every bad turn. It is not enough to just call ourselves the "guardians of foot health." We finally have smaller classes in our schools, (something many of us have desired for years), yet the pain out there in practice is greater than ever.

We need to increase interest in the field. Tens of millions of dollars of funding is at risk.

Bryan C. Markinson, DPM, New York, profpod@aol.com

HOUSE CALL PRACTICE FOR SALE – SOUTHERN CALIFORNIA

House Call practice for sale which includes approx. 400 patients and continued referrals. erfect for solo practitioner. Extremely easy and profitable practice to run. Yearly gross of over $200K. Current DPM is retiring. Financials will also be provided. Please contact
ccipinc@ccipinc.net

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- 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

PRACTICE FOR SALE - WALLA WALLA, WASHINGTON

32 year old established podiatry practice for sale immediately. 2 treatment rooms, 1 surgical suite, x-ray room, sterilization equipment, and private office area. Located at busy intersection, only 2 blocks from major hospital. $50,000 or Best Offer. Please call 509-525-2863 or email darcycharlesDPM@charter.net , if you are interested.

EQUIPMENT FOR SALE - ESWT - BEST OFFER CONSIDERED NOW!!!!

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.

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.

PRACTICE FOR SALE - NEW JERSEY

Well established practice with modern equipment for sale. Two main offices and two satellite offices included. One podiatrist has been able to make very comfortable living, but also great for two docs looking to start up. Willing to transition over 1 year. This is a great opportunity! contact DOCCAPO@YAHOO.COM

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.

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