The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

July 13, 2009 #3,594 Publisher-Barry Block, DPM, JD

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Flip-Flops Can Lead to Wider Feet: IL Podiatrist

Stephanie Wu, DPM explains that your foot bones are held together by ligaments, which lose elasticity "resulting in the foot becoming splayed out and wider as we age."

Dr. Stephanie Wu

"Because flip-flops offer no support, long, continuous wear will accelerate the ligaments losing their elasticity, resulting in a wider foot in a shorter period of time," says Wu, a foot surgeon and associate professor at Chicago's Rosalind Franklin University.

Sandals that offer more support to the feet, including those that come with a comfortable arch support, will help avoid this accelerated widening process, she says. "It's also helpful to not wear the same pair of shoes every day."

Source: Ellen Warren, Chicago Tribune [7/10/09]

Vilex Sponsors Mini-Fellowship at NYCPM

The New York College of Podiatric Medicine has announced a mini-fellowship program for surgical training of podiatry residents in the New York Metro Hospitals. Vilex, Inc., a well-known manufacturer of foot & ankle implants and surgical products, is sponsoring the entire program.

Dr. Abraham “Abe” Lavi, Founder of Vilex, Inc., speaking with participants in a CME workshop being held in the NYCPM Skills Lab.

The multi-year program will consist of two tracks: Basic, for first-year residents, and  Advanced, for second-year residents. Each track will enroll about 25 residents, selected by the residency directors of the participating hospitals. A few positions in the advanced track will be made available to practicing surgeons. There will be three two-day sessions during each academic year. Faculty will be drawn from NYCPM, residency directors, and practicing surgeons with national reputation. All sessions will take place at the Skills Lab and the Anatomy Lab of the College.

Each participant will perform a series of surgical procedures using sawbones and cadaver as applicable. The sessions are structured beginning with basic procedures in forefoot surgery and culminating in advanced rear foot construction and limb salvage. Upon completion of the two-year program, the residents will participate in a symposium. 

AZ Podiatrist Skepical About Kiosk Scanning System

A Scottsdale insole manufacturer is running high after landing a lucrative licensing agreement with the PGA Tour, and the company this week will begin testing a kiosk scanning system inside a Sam’s Club in Gilbert as it tries to expand its footprint in the consumer space.

Dr. Kerry Zang

Although the product was developed with several technology companies and medical experts and implemented by world-class athletes, Dr. Kerry Zang is skeptical. He said the reading may not be accurate because of the foot’s position or the varying pressure it creates when walking or running across the mat.

“It’s not a dynamic picture,” said Zang, a veteran podiatrist who practices at the Arizona Institute of Footcare Physicians in Mesa. “They don’t have anybody that’s qualified to interpret the machine.”

Source: Chris Casacchia, Phoenix Business Journal [7/10/09]

Part 6 -  The Importance of Timely Filing -  By David Mullens, DPM, JD 

As previously discussed, you can stop the repayment of overpayment collection process in its tracks by timely starting the process of appealing all of the claims that are the subject of the overpayment demand.  However, you won’t win at the contractor Redetermination level unless the claims at issue have minor typographical errors that can be corrected, and you won’t win at the QIC Reconsideration level unless the Medicare contractor’s mistake is outrageous and obvious. Your first and only real chance of prevailing is at the ALJ Hearing level of appeal. 

If you are losing at the ALJ Hearing level of appeal, chances are you are losing because you did not submit the relevant evidence at the time you requested the QIC review. This is how the Federal government tricks Medicare providers. If the ALJ served as a straight forward finder of fact, and all relevant evidence were allowed to be submitted at the time of the ALJ Hearing, the Medicare providers would almost always win. That’s how it used to be and that is why the government changed the rules as of March 2005. 

Now, you have to have all necessary evidence submitted by the time you request the Reconsideration (QIC) appeal. Any evidence submitted after the QIC decision must be accompanied by a “good cause” statement as to why the late-submitted evidence should be admitted into evidence. This evidentiary barrier effectively prevents most late-submitted evidence from being admitted into evidence, and without that late-submitted evidence the provider will not prevail.

To get an idea how difficult it is to pass the “good cause” test, put ‘42 CFR Section 405.1028’ into the Google search bar and see for yourself. Here is the point: You must submit ALL of your evidence before, or at the time, you request the QIC appeal review.

Query: Fluid-Filled Mass

I have a 60 y/o well controlled non-neuropathic diabetic female with an ovoid anechoic mass plantar midfoot measuring 1.5 x 1.7 cm. on ultrasound exam. An aspirate obtained was yellow-brown in color. It was sent to pathology and it was read as: "Blood, scant amorphous debris, and few atypical mononuclear cells of indeterminate significance. Features of a common ganglion are not seen."
 
If this were a solid mass, I would send a piece for an intra-operative frozen section as Dr. Markinson has advocated. How should one proceed, as this is a fluid-filled mass of suspicious nature? If I attempt to get a frozen section, I suspect I will rupture the capsule and possibly find it difficult to remove in toto.

Calvin Britton, DPM, Little Rock, AR

Query: Transcription Services

Any references for transcription services on-line? What is the going rate? What are the pro and cons of using someone local?

Gary Friedlander, DPM, Glendale, AZ

Query: Charcot Code Arthropathy ICD-9 Coding

What is the ICD-9 code for Charcot arthropathy?

ICD-9 713.57 is the code I have had for the Charcot joint diagnosis, but I have recently been getting denials.

Charles Morelli, DPM, Mamaroneck, NY

Response: The correct code for Charcot arthropathy is ICD-9 713.5. There is no fifth digit for this code, which is likely the reason you are getting denials.

Stacey Hernandez, CCS-P, Long Beach, CA 
 

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

RE: Bone Lesion (Judd Davis, DPM)
From: Multiple Respondents

More diagnostic information should be obtained before definitive surgical intervention is performed. An MRI would be helpful in determining the nature of the cyst. A bone biopsy would be more definitive. The cyst appears consistent with an osteoid osteoma with the calcified central nidus. Other possibilities might include a unicameral bone cyst or intraosseous lipoma. I would review the case with a radiologist prior to gettting the MRI and provide or order plain film x-rays to allow for correlation with the MRI findings. This will provide information on the nature and full extent of the cyst. 

If the lesion is benign, then curettage with bone grafting could be performed. This can be either with cancellous bone chips or an injectable bone void filler. A bone graft can be obtained from the heel or tibia to fill the defect and facilitate healing. Fusion of the interphalangeal joint of the toe should be considered to stabilize the repair. There is not much bone remaining in the distal phalanx that does not involve the cyst, so non-union of any fusion and/or curettage with bone graft is a possible complication. Primary disarticulation of the distal phalanx should be presented as an option to the patient.

If the cyst appears to be malignant on the MRI and/or biopsy, then amputation level appropriate for the lesion would need to be considered. Intra-operative frozen section can also be performed in such a case, with the patient consented for possible amputation of the toe. 

Palmer Branch, DPM, Cumming, GA, DrCuboid@aol.com

I would give strong consideration to an osteoid osteoma or enchondroma. There is a central nidus in the lesion. If aspirin improves the symptoms, it may well be the former. Biopsy is in order.

Donald Arenson, DPM,  Elmhurst, IL, darenson@pol.net

The AP/DP view shows a destructive lesion of more than 50% of the distal phalanx. You could do a percutaneus bone biopsy or a partial excisional biopsy and refer the patient to a musculoskeletal surgical oncologist as this may be worse than a benign lesion (osteoid osteoma vs. osteosarcoma). The distal phalanx, with this much destruction, would be very difficult to graft or repair even with a benign process. Inform the patient of the high risk of a partial or total loss of the digit.

Narmo L. Ortiz, Jr., DPM, Cape Coral, FL, nlortizdpm@embarqmail.com

RE: Recurrent Bunion (Richard Frost, DPM)
From: Multiple Respondents

Try a rocker bottom shoe first. If this does not help, then do a modified Keller procedure with a soft tissue interposition flap from the joint capsule. I have had this procedure on my own foot with excellent results.  

Dwight L. Bates, DPM, Dallas, TX, dlbates04@yahoo.com

The original procedure appears to have been a McBride / combined with a distal Akin and it looks like the patient, now age 70 and 16 years post-op has progression of the hallux adductus and also an osteoarthritic 1st metatarsal phalangeal joint with marked narrowing of the joint space and hallux limitis.

Although this would leave a stiff toe, a 1st MPJ arthrodesis is an option that will leave a stable, predictable, and well-positioned hallux as well. Other options could include a joint replacement or even a distal chevron osteotomy bunionectomy, however, these procedures will require good capsular tissue to close and for  maintaining toe positioning, and you do not know what these tissues are like at this time since there was a prior surgery and the patient is now age 70. For the hypermobile foot, fusion may just be the best choice for this patient. Whatever you do, don't leave her requiring a 3rd surgery when she turns 84 years old. If you do, the next one will be a Keller.

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

This is probably a good case for a first MPJ fusion. The result will be very predictable in a 70 year old female with no chance for return of the bunion. Unless she likes to wear a very high-heeled shoe, she should have good function and be happy with the cosmesis.
 
Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

RE: Sign of the Times (Peter Bregman, DPM, Allen Jacobs, DPM)
From: John V. Guiliana, DPM, MS, Marc Mizrachy, DPM

Dr. Bregman - you apparently "get it" and it sounds as though you practice in a manner that is conducive to patient "rapport". That rapport is critical for patient acceptance and compliance with our proposed treatment plans. Every word that you speak and every movement of your body either adds to or subtracts from that rapport. Perhaps it comes naturally to you. Perhaps it does not come naturally to your associate. This might be an isolated situation or you might have fortunately stumbled upon a silent "practice killer" that is often  more elusive.   

Dr. Jacob's reply precisely defines the teachings of the American Academy of Podiatric Practice Management. I could not agree with him more. Give your associate this important feedback and help him/her grow professionally by attending the seminars produced by the AAPPM (aappm.org).

John V. Guiliana, DPM, MS, Hackettstown, NJ, footmds@aol.com
 
The issue may be less about the "Sign of the Times" and more about the fact that the associate may have felt that doing a partial matrixectomy on a elderly diabetic was too much of a risk. Just because the patient was willing to pay extra for the procedure doesn't necessarily make it the correct procedure. Of course, I don't know anything about the patient's circulation, diabetic control, previous frostbite/trenchfoot, etc., but the associate may have felt diabetic routine care was what was best for the patient.

Marc Mizrachy, DPM, Hillsborough, NJ, marcmiz@optonline.net

RE: OIG's Targeting Podiatrists (David Mullens, DPM, Bryan Markinson, DPM)
From: Michael M. Rosenblatt, DPM

There is an interesting discussion going on between these two doctors on this issue. Dr. Mullens says that CMS intends to “intimidate” doctors to deliberately “down-code,” thus saving millions. Dr. Markinson says that Medicare is also concerned about deliberate down-coding, because in a sense it is a type of “Medicare fraud.” (You are under-charging for services to get patients fraudulently.) Actually, both are correct.
 
I think the problem is temporal. There are times when Government is “your friend” and wants to educate you to code properly. They “exude cooperation” and friendly intent. Other times, Government is your enemy, holding the Sword of Damocles over you, threatening your professional existence with their gargantuan power. Since Medicare enforcement is political in nature, it is easy to understand this.  If you doubt it, just look at the recent battle between Congress and the Administration, which intends to significantly cut Medicare payments.
 
What to do? Follow the advice of both doctors. Never pay a demand for recoupment by first writing a check, even for a small amount. Always fight it, using the procedures in place, ending with an ALJ. It is an open secret that insurers and government share recoupment data. Neither side will ever openly admit it. If you cave in, you become open season for both.
 
Dr. Markinson’s advice to “document, document, document” is still on-target. You never know “which phase” Government is in (friend or foe) from one time to another. By  documenting, you are protecting yourself during each phase.  
 
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

PRACTICE FOR SALE – WESTCHESTER COUNTY, NY

Established 30+ year old practice. Well respected podiatrist in beautiful Westchester County Owner ill and needs a quick sale. Mixture of surgery and general podiatry. Hospitals in close proximity. Will lease office to buyer. Call Mali McGrinder at 914-434-1663.

PRACTICE FOR SALE-VIRGINIA (SOUTHEAST)

Very busy office near Williamsburg. Currently, a satellite office 2 days a week. Great opportunity to make office full-time. Grosses approx. 150,000/year. The office has everything needed to start practicing. All included. Must sell. If interested, e-mail
totalfootcareva@hotmail.com

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

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

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

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to .comf-massuda@footexperts

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.

OFFICE SPACE/ MRI RENTAL – NYC, LI  
 
Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, Hicksville and/or Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

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 

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