The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

July 17, 2010 #3,912 Publisher-Barry Block, DPM, JD

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PM News Goes on a Cruise  -  July 18-25th

There will be NO issues of PM News from July 18 - July 25th. Readers can still send in queries and comments. We will resume publication on July 26, 2010. 

IL Podiatrist Questions Heel Pain Study's Conclusions

Women who habitually wear high heels have shorter muscle fibers in their calves and thicker Achilles' tendons than those who walk in flat shoes, researchers say. The result? The heel lovers’ tendons stiffen and become harder to stretch, which could explain why walking hurts after kicking off the Jimmy Choos, according to a small study published in the Journal of Experimental Biology. The researchers  found that wearing heels affected muscle fiber length--the high heel wearers' muscle fibers were 13 percent shorter than those who wore flat shoes. For some women, once the heels come off, the pain starts because the muscles can't stretch enough, the researchers said.

Dr. Stephen Weinberg

Wearing a variety of different types of shoes and stretching may help alleviate the pain, according to the study authors.  But Chicago podiatrist Steve Weinberg, who was not involved with the study, questioned whether it's possible to stretch the Achilles tendon enough to make a clinical difference. "If women are going to wear high heels, they should be prudent—stand or walk in them for a short time,” said Weinberg, a podiatrist at the Weil Foot & Ankle Institute and the longtime chief podiatrist for the Chicago Marathon.

Source: Julie Deardorff, Chicago Tribune [7/16/10]

Barry Professor Serves Migrant Farm Workers

Every Tuesday afternoon, Dr. Steve Maynard drives 100 miles to The Open Door Health Center in Homestead where he is known as "the doctor who doesn't say too much but likes to whistle." Open Door Health Center provides care to as many as 3,500 uninsured, the majority of them migrant farm workers. Largely Hispanic and poor, his patients at Open Door are at a particularly high risk for developing Type 2 diabetes with its ensuing complications.

Dr. Steve Maynard

Maynard, an adjunct professor in the School of Podiatric Medicine, manages all foot traumas at Open Door as well as all disorders of the feet - especially  ulcers, infections, and even gangrene, resulting from diabetes and its concomitant numbing of nerves in the lower extremities.

Source: Elizabeth Hanley, Barry Magazine

APMA National Meeting One of Largest Ever

Nearly 1,400 podiatrists convened in Seattle this week, making it the second largest meeting ever held in the West Coast and nearly eclipsing the Las Vegas event held in 2006. Even the weather cooperated, with sunny skies and temperatures in the 70's.

Crowded Exhibition Hall During APMA National Scientific Meeting

Attendees enjoyed APMA's state-of-the art lectures and roamed through the well-designed exhibit hall packed with 225 podiatric suppliers. Kudos to APMA leadership and its hard-working staff for presenting another first-class event. 

Lynn Homisak and Allen Jacobs Inducted into PM Podiatry Hall of Fame

In what has been a must-attend event at the APMA National Scientific Meeting, Lynn Homisak, PRT and Allen Jacobs, DPM became the latest inductees into the PM Podiatry Hall of Fame.  Over 250 attendees enjoyed a delicious luncheon along with a hilarious roasting of the honorees.

Lynn Homisak Receives Lifetime Achievement Award from PM Editor, Dr. Barry Block

Lynn Homisak, Podiatry's best known podiatric assistant  was roasted by Jason Kraus of Langer Biomechanics and her former boss, Dr. Roy LaBarbera.  The funniest parts included out-takes of some of Ms. Homisak's practice management videos. 

Dr. Allen Jacobs Receiving PM Lifetime Achievement Award

Dr. Jacobs was roasted by long-time friend and colleague, Dr. Joseph Crisafulli, but turned the tables of the roast by hilariously slinging barbs at many of the Hall of Fame members on the dais, as well as many podiatric celebrities in the audience. The often-controversial Jacobs pulled no punches, even telling the audience, "Dr. Barry Block's Podiatry Management Magazine is best-suited for those who are beyond reading comic books, but not quite ready for peer-reviewed literature."     

Expanding RAC will be a Stretch: Official

The CMS faces some challenges ahead in expanding the Recovery Audit Contractor program to all of Medicare and to Medicaid by the end of the year, an agency representative told a Senate panel. The RAC program allows third-party auditors hired by the CMS to keep 9% to 12.5% of provider payments they identify as improper. Currently, it conducts audits only in fee-for-service Medicare, but provisions in the new reform law call for an expansion of the RAC program to Medicare Parts C and D and Medicaid by Dec. 31.

Such a task will not be easy, admitted Deborah Taylor, director and chief financial officer of the CMS' Office of Financial Management, who testified before the Senate Homeland Security and Governmental Affairs' Subcommittee on Federal Financial Management, Government Information, Federal Services and International Security. Phasing in RAC audits for Medicare Advantage “is going to be tougher for us,” given that the CMS already has a contractor that gets paid to conduct audits for Medicare Part C, she said. “We don't want to duplicate our efforts.”

Source: Jennifer Lubell, Modern Healthcare [7/15/10]

Query: Multiple Fractures vs. Charcot Foot?

I have a 40 y.o male diabetic patient with neuropathy. I was seeing him for an ulcer on his right lateral malleolus. He came in for follow-up and told me that his left foot was killing him, more than his right ankle. The foot was red, hot, and swollen. My differential included: gout, cellulitis, and Charcot foot. The patient had no pain at all on palpation around the 5th met base, but did have pain in the medial longitudinal arch. He was placed on oral antibiotics and NSAIDs and dispensed crutches.

The patient has a normal white count, but elevated uric acid. MRI revealed a vertical fracture of the navicular (non-displaced) and fractures of the second and third met bases, as well as the 5th met base fracture. How does one differentiate between multiple fractures and a Charcot foot?

Jeffrey Kass, DPM, Forest Hills, NY  

Query: Non-Partipating vs. Opting Out

Can anybody explain the difference between opting out of Medicare and being a non-participating provider? Which would be best?

John Swangim, DPM, LaPorte, IN

Editor's comment: PM News does not provide legal advice. Non-participation merely means that, instead of accepting payment directly from Medicare, you collect your full payment (at non-partipating rates) from the patient. The patient then receives payment from Medicare, less any deductible or co-payment.

Opting out is a complex process where both you and all your patients execute bi-annual contracts in which all parties agree to neither bill nor accept payment from Medicare. Opting out means that you can charge patients any fee that you wish. It also eliminates the possibility of a Medicare audit, since you are no longer part of the system. Opting out works best for podiatrists with so-called "boutique" or "concierge" practices. 

Query: Plantar Fasciitis and Ultrasound Guidance

When billing for an ultrasound-guided needle injection to treat plantar fasciitis, do I bill CPT 76942 alone? Should I bill CPT 76942 in combination with CPT 20550?

John Jurcisin, DPM, New York, NY

Response: The CPT code descriptor for these two codes reads: "CPT Code 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation" and  "CPT Code 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar 'fascia')".

Breaking these two CPT codes down, CPT 76942 is an imaging code that lets you visualize what you are injecting. It is important to document why the imaging was necessary for this type of injection. Typically, a plantar fascia injection does not require ultrasound guidance.

CPT 20550 is a procedure code. When medically necessary, you can bill both in combination. I would document why an infiltrative injection requires imaging guidance (medical necessity).

David J. Freedman, DPM, CPC, Silver Spring, MD

Codingline subscription information can be found here
APMA Members: Click here for your free Codingline Silver subscription

RE: Coumadin Patient and Phenol Alcohol Matrixectomy (Elliot Udell, DPM)
From: Multiple Respondents

I have been in practice for 27 years and have done nail surgery on numerous patients on Coumadin. I have always told then about the potential bleeding and additional aftercare that may be necessary. I have had no problem with this treatment plan; in fact, I tell the patients, for a nail procedure, it will probably be more risky if they go off the medication. Some of the patients will elect not to do the procedure, but many, due to the pain and difficulty with shoes, will complete the surgery.

Gene Sherwood, DPM, Fairfield, OH, gsherwood1@cinci.rr.com

"High doses" of Coumadin, I believe, is irrelevant, Coumadin has a very narrow therapeutic range, and some patients reach that level with low doses and others with higher doses. Whatever is needed to achieve that therapeutic level, it's all about the INR. That being said, I do not hesitate doing a chemical nail matrixectomy (I use NaOH) on Coumadin patients; without stopping the Coumadin, I instruct them to leave the dressing on longer than normal, usually 24 hours. My concern with Coumadin patients is not the medication but the medical reason they are on Coumadin, with A-Fib as the reason. I would not hesitate to do the procedure if all other parameters are normal.

Angelo J. Bigelli DPM, N. Providence, RI, toedocri@aol.com
  
I have done many chemical or surgical matrixectomies on patients receiving Coumadin or Plavix. I do NOT take them off those medications. Risk of hemorrhage is minimal, especially with phenol which helps cauterize. Any hemorrhage can be controlled with dressings. I generally apply a moderately compressive dressing and have the patient return the next day for a dressing change. I would rather deal with the highly unlikely complication of hemorrhage than with DVT or pulmonary embolism.

Kathleen Neuhoff, DPM, North Bend, IN, vetpod@aol.com

RE: Coumadin Patient and Phenol Alcohol Matrixectomy (Elliot Udell, DPM)
From: Multiple Respondents

I have done hundreds P&A's on patients on Coumadin therapy without any complications at all. In fact, I have never had a "bleeder" after the procedure. I would not hesitate at all to do this. I do use NaOH instead of phenol, simply because it's far cheaper (our local compounder charges me about $10 for a 30 mL bottle of 10%). I do think NaOH coagulates the tissues/capillaries better than phenol.

R. Alex Dellinger, DPM, Little Rock, AR, raddpm@yahoo.com

Editor's note: Additional notes by Drs. Paul Kesselman and John Swaim can be read here.

RE: HITECH HIPAA Regulations
From: Michael L Brody, DPM

Regarding the recent comments on HIPAA regulations. HIPAA does require that all workstations be password-protected, but it does not require that all applications be password-protected. We can all continue to use our word processing software to generate letters to patients, referral letters to other doctors, or even create our chart notes with no concern about being in violation of HIPAA.

HIPAA also specifies rules regarding encryption of data, especially data that is stored on removable media such as thumb drives. So, if you wish to utilize a word processor to store patient data, when you back up your word processor data, you will need to configure the encryption of your removable media yourself.

There are additional rules regarding security and passwords for software to be certified for the incentive payments. But, if you are using a word processor as your EMR, you are not eligible for the incentive; so in this case, these rules are moot.

Michael L Brody, DPM, Commack, NY, mbrody@cmeonline.com

RE: Patient Who Brings in Wild Child (Jon Purdy, DPM)
From: Pat Caputo, DPM, Frank J. Lattarulo, DPM

My favorite story regarding a solution to the problem of an unruly child was when my (ex)-partner told the 5 year-old patient, “If you don’t behave, the Easter Bunny isn’t going to come to your house.”  The kid cried and carried on even more, and the mother was mortified. She later said to me, "He doesn't have any kids, does he?"
 
Pat Caputo, DPM, Holmdel, NJ, capstops@aol.com

As a parent (and a proud one) of a child who has suffered and battled with ADD, I take extreme offense to Dr. Purdy’s remarks. My son's pediatrician, along with his child psychologist, have struggled for two years to find the correct dosing of his medication. Although my child struggled for several years without a correct diagnosis as well as correct dosing of medication, he always knew right from wrong.

If, in fact, these children do have a disease process, try to find it in your heart to have a little more patience, and a better understanding of what these children and parents are trying to cope with. Maybe Dr. Purdy needs to be educated a little more, and no, the parents do not need medication. They need your support and understanding. You, as a doctor, should know this, but alas you obviously don't. No, these parents do NOT need medication, just a little understanding and compassion.

Frank J. Lattarulo, DPM, NY, NY, DOCLATT@aol.com

RE: FL Podiatrist Survives First Cut on Big Brother (Barry Blass, DPM)
From: Shari Lee, PMAC

I agree that Andrew has a chance to talk about podiatrists, what we do and the battles we face. He also can explain that podiatry has just as big schooling bills as other doctors, yet we are not on the top of the pay list. Maybe, he could dispel the misconception that just because someone is a doctor, that means they don't need money. He could have also taken this time to educate the public about the Medicare pay issue. I guess he had the game only on his mind, and not what he could have done with the opportunity.

Shari Lee, PMAC, Columbia, SC, midlandspodiatry@bellsouth.net

PRACTICE & STATE LICENSED ASC FOR SALE (MARYLAND, DC SUBURB)

38 yr old general podiatry practice grossing over $550K. Fully equipped with digital x-ray, diagnostic ultrasound, 2 orthotic scanners, computer network and well-equipped surgical suite. Retiring owner will stay on as needed. Email - dpmpracticeforsale@yahoo.com

PODIATRY ON CALL - MIAMI-DADE & BROWARD COUNTIES, FLORIDA

Call us for vacations, "unexpected emergencies" and playing hooky. Part-time or Per Diem Basis! Extensive surgical and non-surgical training with Dr. Stanley R. Kalish in Atlanta, Georgia. On call everyday to meet your office needs! Contact: podiatryoncall@gmail.com or 305-342-9797.

ASSOCIATE POSITION - SOUTHEAST GEORGIA

Beautiful weather year round & near the Coast. Opportunity for Early Buy-in. Seeking associate or new residency graduate to join practice. Must be PSR-24/36 trained. Multiple locations. Full range of services with new facilities. E-mail cover letter & CV to melissafoot@pol.net

PART-TIME, LICENSED PODIATRIST - WEST BLOOMFIELD, MICHIGAN

Immediate opening for treating patients in a nursing facility setting.  If interested, please email drteetime@aol.com

PART-TIME ASSOCIATE - NY LOWER HUDSON VALLEY (PUTNAM COUNTY)

Wednesday's & Saturdays  compensation dependent on collections. Hospital privileges & wound care center available. Excellent relationship with local Drs. including orthopedists- References required. Great opportunity for recent resident to gather cases for ABPS. Reply to PodAssociate@aol.com

ASSOCIATE POSITION - FREDERICK, MARYLAND

Fredericks premier group practice is located only 45 minutes from both DC and Baltimore. Immediate opening for a minimum PSR 36 Podiatrist for full time position. We have it all: EMR, digital x-ray, ultrasound, ASC, etc. Excellent salary with bonus structure and benefits. Please email resume to docsbnb@aol.com

POSITION AVAILABLE - SOUTHERN CALIFORNIA

Very well established, multiple location group practice has immediate opening for associate doctor. Attractive compensation and benefit package offered. E-mail resume to mrsmcmackin@aol.com

PODIATRISTS NEEDED NATIONWIDE

Podiatry referral company has thousands of diabetic patients nationwide in need of immediate service. We are looking for podiatry practices interested in joining our network to receive referrals. Email coasttocoastpodiatry@yahoo.com

ASSOCIATE POSITION - VIRGINIA IS FOR LOVERS

TN PRACTICE FOR SALE (SOUTH OF NASHVILLE)

Active, established practice with new equipment (digital x-ray, ultrasound, computer network, etc.). Great referral network with an excellent scope of practice. Turn-key operation with seamless transition. Grossed over $350K last year. Call 931-446-5724 or e-mail mchad500@gmail.com

PRACTICE FOR SALE – MAINE

25 year full scope in medical building, podiatrist friendly hospitals, appreciative and cooperative patients, excellent expansion potential, physician referrals. Wonderful place to raise a family. Retiring seller will stay for transition. mainefootdoc@yahoo.com

MANHATTAN MEDICAL SPACE AVAILABLE

Multispecialty Medical Building with 24/7 doorman. Prime Luxury Building and Location, Gramercy, Stuyvesant, Peter Cooper Area. 305 Second Avenue (17th-18th). Prior tenants past 23 years; podiatrist, dentist (plumbing/electric intact), internist. Ideal for podiatry, co-share with dentist, MD, etc. (flexible lease terms). E-Mail; jbdrun@aol.com Phone; 480-951-2480.

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