The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

July 16, 2009 #3,597 Publisher-Barry Block, DPM, JD

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Diabetics Need Annual Foot and Ankle Exam: FL Podiatrist

“Every diabetic is recommended to see a podiatrist once a year,” Dr. Felix Esarey said, explaining that diabetics are more prone to getting PAD and developing neuropathy, where the nerves in the legs aren’t functioning properly, creating numbness, tingling or burning in the feet.

Dr. Felix Esarey

The danger comes when patients don’t realize they have a wound or problem with their foot because they can’t feel anything wrong. Even an untreated blister can lead to infection and worse problems. “Diabetics are 10 times more likely to experience amputation than a non-diabetic,” Esarey said.

Source: Caroline Klapper, Daily Sun

PA Podiatrist Appointed to Chesson Labs Advisory Board

Chesson Labs, a Durham-based healthcare products company, announced the appointment of Dr. Warren S. Joseph to their Scientific Advisory Board. An internationally recognized podiatrist, Dr. Joseph lectures extensively and his presentations have focused on the treatment of bacterial and fungal infections of the lower extremity.

Dr. Warren Joseph

Dr. Joseph is a podiatric attending at Roxborough Memorial Hospital in Philadelphia, PA and at the Coatesville VA Medical Center, and a consultant in the treatment of lower extremity infectious diseases. He received his podiatric degree, magna cum laude, from W.M. Scholl College of Podiatric Medicine in Chicago. Dr. Joseph is a fellow of the Infectious Diseases Society of America and sits on the IDSA Diabetic Foot Infection Guidelines Committee. He is also certified by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, and currently serves as Editor of the Journal of the American Podiatric Medical Association.

Source: Business Leader (NC) [7/14/09]

Part 9- Beginning Your Presention to The ALJ - By David Mullens, DPM, JD

At the time of the ALJ Hearing, and before you read from a particular patient care document, identify the document to the ALJ. For example: “Your Honor, I would like to direct the Court’s attention to the hand-written progress note for Mary Jones dated 05-01-08. There is also an accompanying typed version of that progress note, and the typed version exactly duplicates what was written in the original progress note. Both the hand-written progress note and the typed version were submitted to the QIC at the time the QIC appeal was requested.”

Then make the point you want to make - from that document - to the judge and move on to the next document. When you complete the presentation of evidence from the patient care documents, give the judge a brief - and I mean brief - summary of what you did and why you did it, as supported by the patient care documents.  

Remember, everything you say should be in plain-speak English. You are not an attorney, and you will look stupid pretending you are. The ALJ is not a doctor, but will not admit he/she does not understand what you are saying. So keep it simple.

Query: On-Line Back-up

Currently, I back up my server with daily tapes. Does anyone have experience with online back-ups?

Lynn LeBlanc, DPM, Bloomfield, CT

Query: GraftJacket Removal ICD-9 Code

I performed a fat pad augmentation procedure using GraftJacket. The graft did not take and incorporate, and I have to remove it. Is there a specific "V" code that would be appropriate, or should I use the foreign body ICD-9 code?

David Sands, DPM, Great Neck,  NY

Response: Actually, it looks like a mechanical complication of the graft, which wouldn't be a "V" code, but one from the ICD-9 99.xx category.

From ICD-9:

ICD-9 996.5x (5th digit needed here)
Includes the following: Mechanical complications involving prosthetic implant in:
nonabsorbable surgical material NOS, other graft, implant, and internal device, or not elsewhere classified

ICD-9 996.55 Due to artificial skin graft and decellularized allodermis, dislodgement, displacement, failure, non-adherence poor incorporation, or shearing.

I suppose to round out the picture well, you could use V43.83 to explain the status post skin tissue replacement/graft.

Leslie Johnson, CPC, Raleigh/Durham, NC

Codingline subscription information can be found at:
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RE: Foot Surgery on Patient with a History of CRPS (Doug Mason, DPM)
From: Multiple Respondents

The problem with operating on patients who have a definite history of complex regional pain syndrome is that we really don't know what triggers CRPS. Is it a single traumatic episode that caused the sympathetic nervous system to go haywire, or do these patients have peripheral nervous systems that display idiosyncratic reactions to any trauma? If the answer is the latter, and we don't know for sure, then it would be best to error on the side of caution and not do elective surgery. On the other hand, some of the latest treatments for CRPS involve surgical placement of spinal cord stimulators and most of these patients do not over-react to that minor surgery.
 
Another way of looking at the situation is that if there is a painful neuroma that is not responding to injections and other types of conservative care, removing the neuroma might indeed remove a source of trauma that might be contributing to some of the CRPS symptoms.
 
So, in the absence of definitive knowledge about CRPS and a sea of theories as to its etiology, I would recommend being as conservative as possible until all conservative measures have failed, and then discuss the risks and benefits with the patient of more aggressive treatment. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

I have been treating a CRPS patient for the last 25 years. Before any surgery, I highly recommend that the patient be treated by any and all persons you can find to give her relief. Use anesthesiologists, neurologists, physiatrists, special pain clinics, acupuncture, whatever, because the surgery "will not" fix the symptoms. It only gives temporary relief.

I have removed several "hot spots" of nerve pain (e.g., entrapments, neuromas). You can expect up to one year of pain relief, if successful. The pain will come back in some form. You can expect to repeat the same procedure at a later date.  I have learned that removing ALL nerves in the foot, except the posterior tibial nerve, doesn't provide pain relief.

Do not amputate any parts, unless it is to manage a non-healing ulceration. You will just end up chasing the pain proximally. I found that alcohol solution injections to the nerves give the best pain relief when performed at 2-week intervals. The alcohol will have to be 25-50% for the most effective results. These injections are not fun! A CRPS patient is the most difficult case you can have in practice. Their care is a one-way road that gets more difficult. 
 
Darryl Burns, DPM, Monterey, CA, darrylburns@msn.com

This patient is best dealt with using an eleven foot pole, because ordinarily you wouldn't want to touch him with a 'ten foot pole.' We have to be podiatrists, not heroes.
 
R D Teitelbaum, DPM, Naples, FL, mfvandange@aol.com

RE: Femoral Anteversion with In-toe (Andrew Warner, DPM)
From: Mr. Jeff Root

In response to Dr. Warner’s question concerning specific orthotic modifications to treat an 18 y.o. female with pes planus, calcaneal valgus and in-toeing secondary to femoral anteversion, it is difficult to give specific recommendations for a general question like this. Ideally, the orthotic prescription should be...

Editor's Note: Mr. Root's extended-length note can be read at: http://www.podiatrym.com/letters2.cfm?id=27454&start=1
 

RE: After 15 Years,  Albright to Retire from Scholl
From: David G. Armstrong, DPM, PhD, Harold B. Glickman, DPM

I heard yesterday about Dean Albright's announcement. His strength of character, credibility, and vision have made him, in many cases, single-handedly, a force for positive change in our profession. His leadership and guidance have integrated podiatric medical education in academia at a level never dreamed of a generation ago. When the history of podiatric medicine and surgery is written, I know that the Albright chapter will be a prominent one.

David G. Armstrong, DPM, PhD, Tucson, AZ, armstrong@usa.net

Let me take this opportunity to congratulate Terry Albright, DPM on his retirement as Dean of the Scholl College of Podiatric Medicine. I have had the honor and pleasure of working with Terry both on and off the APMA Board of Trustees and he is a true leader and visionary of our profession, not to mention his accomplishments as an educator of podiatric medicine. In my visits to Rosalind Franklin University, I have also had the pleasure of meeting Dr. Welch, who had foresight to choose Terry to lead the Scholl College to prominence in podiatric medical education. I want to wish both Terry and his lovely wife Jan, the best in the future, and I know that Terry will always continue to give back to podiatric medicine.  

Harold B. Glickman, DPM, Washington, DC, hbgapma@aol.com

RE: PDR Website (George F Jacobson, DPM)
From: Multiple Respondents

I routinely use RxList.com. It is quick and free. You can always find the "how supplied" information if you click on the "Indications & Dosage" tab.

Amy Miller, DPM, Bay City, MI, ajmdpm@yahoo.com

PDR has a website with medication description. However, the best I have found is Epocrates. I use it on my main computer and my iPhone. The iPhone updates automatically. The site not only shows an image of the various dosage forms but also supplies the approximate cost of the medication. Very handy.

Pete Harvey, DPM, Wichita Falls, TX, pmh@wffeet.com

I like medscape.com/druginfo/druginterchecker
 
Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Insurance and Your Reputation
From: Greg Cohen, DPM

I had a humbling experience today in the office which I would like to share. A patient came in to see me for routine diabetic foot care, for which she comes in every few months. During our visit, she proceeded to tell me about some new onset knee and hip pain and asked if I knew of a good rheumatologist in the area. I gave her the name of a good doctor down the street which many of my patients have had a good experience with. As soon as she heard the name, she said "Oh, that doctor is a money hungry a--hole". Upon asking her why she thought that, thinking the worst, she proceeded to say that she used to see him and was happy with him and his care but he simply stopped taking her insurance. 

It is shocking, but perhaps not surprising how little our patients understand the economics of practicing medicine. In all likelihood, this doctor figured that the amount of time he spent with his patients, which I hear was usually generous, versus the reimbursement from this plan (which is actually one of the lowest payors in the area), he was losing money.  I too am thinking about dropping this plan, but if this is the reputation that I will unfairly be left with, I'm not sure it's worth it. 

Greg Cohen, DPM, Brooklyn Heights, NY, gcohen428@yahoo.com

RE: Sign of the Times (Eliot Udell, DPM)
From: Kenneth L. James, DPM, MPA

Our esteemed colleague, Dr. Eliot Udell laments the recent changes that local physicians have experienced in response to present economic conditions. I pose that two factors played large in their decisions: courage and organizational/management skills. All economies run in cycles. In 1952, the average physician in America earned 2.5 times what the average worker did; in 1992, the difference was six-fold. Continual sustainability at this rate was impossible; hence, we are now cycling back, and those who have not positioned themselves for this change will have to make similar decisions.
 
Few in the medical field realize that wealth is defined as the ownership of the means of production, and learn too late that they have squandered their opportunity, money, and time to weather bad economy (often on the “trappings“ of wealth, as described by Dr. Hultman). It takes great management skills to change quickly, and greater courage to withstand pressures. Those who lack either will have to be successful in other ventures, or continue dreaming. Do not be discouraged in their mis-adventures; they are given to you as a learning tool. Evolve rapidly, hone your skills, and above all, maintain a positive view and a passion for life. In sum, “Earn, Learn, and Burn.” 

Kenneth L. James, DPM, MPA, Fort Worth, TX, docjammin@sbcglobal.net

PRACTICE FOR SALE – NEW YORK CITY

ASSOCIATE POSITIONS - CALIFORNIA

Podiatrist needed for busy North Hollywood office. Part-time Monday-Friday 8am-2:30pm. No weekends and no call. Pay negotiable. New podiatrists are encouraged to apply. Please email resume and salary request to Coasttocoastpodiatry@yahoo.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.

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 

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

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