July 26, 2006 #2,639 Editor-Barry Block, DPM, JD

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IL Podiatrist Provides Advice on Plantar Fasciitis

Marlene Reid, DPM, a podiatrist in private practice in Westmont, IL, and past president of the American Association for Women Podiatrists, tells WebMD plantar fasciitis can best be prevented by walking in sturdy shoes, with good stability and arch support, rather than flimsy sandals or flip-flops. Once it starts panging, the disorder -- which usually hurts worst right after taking the first steps in the morning -- can go on for months, gradually getting worse rather than better.

Dr. Marlene Reid

If the pain lasts more than two months, Reid recommends seeing a doctor. "You could stretch gently in the morning before walking," she says. "There also are different types of heel cups you can buy. "The doctor might also recommend physical therapy or night splints," Reid says. "Cortisone can be injected, and there are shockwave and cryogenic treatments available to destroy the inflamed tissue and promote normal healing."

Source: WebMD [7/24/06]

Lower Payments Do Not Decrease Access, GAO Finds

Reductions in Medicare payments to physicians have not resulted in a decrease in the number of providers accepting Medicare beneficiaries or made it difficult for beneficiaries to find providers, according to a Government Accountability Office report released on Friday, Reuters/Arizona Daily Star reports (Reuters/Arizona Daily Star, 7/22).

Since the early 1990s, some lawmakers, health policy analysts and physician groups such as the American Medical Association have raised concerns that reductions in Medicare physician payments will lead some providers to stop accepting beneficiaries as patients, CQ HealthBeat reports.

According to the report, which analyzes CMS data, concerns about decreased access to providers "were heightened in 2002" when Medicare physician payments were reduced 5.4% to lower spending increases. However, the report finds that no more than about 7% of beneficiaries have experienced "a major access difficulty." In addition, the report states, "Only a small fraction -- less than 4% -- of physicians responded that they did not accept any new Medicare patients" (Washington Post, 7/22). Overall, from April 2000 to April 2005, the percentage of beneficiaries who received physician services and the number of physician services that were provided both increased, the report finds. "These increases suggest that there was no reduction in the predominant tendency of physicians to accept Medicare patients and payments," according to the report.

Source: American Healthline [7/24/06]

Query: CPT 97032 - Reversing Neuropathy Tx

My client, a podiatrist, is considering leasing a machine that "reverses neuropathy" - according to the vendor. The vendor tells me the code they use is CPT 97032 (physical therapy, electric stimulation) x 3-6 units. They are saying that it should be used with a diagnosis of pain, reflex sympathetic dystrophy of the lower limb, and/or edema, as appropriate. The vendor is telling my podiatrist client that the patient can come in a few times a week, and that he can additionally bill an E/M service each month.

Has anyone successfully used code, CPT 97032, with a treatment that "reverses neuropathy?" And while I don't want to mention the product, is there any information out there supporting or refuting a procedure/therapy using a machine that "reverses neuropathy?"

Denise Merrick, North Las Vegas, NV

Response: Before any major purchase whether the item is a piece of diagnostic equipment or a treatment modality, the provider should perform a due diligence - standard business practice - on the item and company in question.

The research should include:
- A check to see if the device is FDA-approved; if so, for what treatments?

- Economic projections (profit/loss) to your practice with the addition of such a device - is it cost effective, or will it be an economic drain taking up doctor and/or staff time?

- A check with existing owners of the unit (references) to see if it lived up to its billing, both clinically and economically for their practices; ask them if they had to do it again, would they purchase the device today? [By the way, if they want to sell you theirs, that's a bad sign]

- Ask existing owners what code(s) they use to bill the treatment/service; and if payers universally approve claims submitted with the codes.

- Check with payers you regularly deal with to confirm that the treatment code(s) given you by the vendor and/or practitioners utilizing the units are accurate and appropriate; does Medicare reimburse the treatments? Ask if the payers have any guidelines or limitations associated with the use of the device.

- Request the vendor provide you with published articles regarding the efficacy and superiority of their treatment (or testing device), and

- Examine the reliability of the vendor/manufacturer in terms of product quality and service.

Keep in mind that many reps will talk the big talk - after all, their job is to sell you the machine/device/item. "Reverses neuropathy" - hmmm, sounds almost too good to be true...

Tony Poggio, DPM, Alameda, CA

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

RE: Bruce Frankel, DPM
From: Multiple Respondents

September 2007 would have marked 31 years that I have known Bruce Frankel. We met fortuitously, as prior to entering NYCPM, he and his wife Bobbi used a pediatrician for whom my mother was practice manager. As soon as my interest in podiatry was known, Bruce could not do enough to make sure I was fully informed. His storied family and professional life were literally an open book to all who would avail themselves of their magnanimity. What would endear Bruce to many was his enormous pride in his becoming a doctor, in successfully joining and eventually taking over a Brooklyn private practice, and in doing it all over again in New Jersey. When Bruce spoke of his successes, it was never about "largesse." Rather, it was always with the tone of "If I can do it, you can do it." Indubitably, across all sorts of distracting issues, Bruce loved his profession. Bobbi for sure, has been the essence of the super-supportive partner, who maintained a warm, loving home while virtually always being at Bruce's side, be it in the office or even behind the scenes at NYCPM fundraising and other activities.

Personally, Bruce was one of my biggest supporters, both as my teacher, and even more so as my career has developed over the years. He was always fair, always striving to do the "right" thing for all parties. I could always count on pleasantness from him. He affectionately called me "Big B." That we all encourage and teach our younger practitioners to maintain enthusiasm and lend support in any way would be a very fitting legacy for our departed colleague and friend.

Bryan C. Markinson, DPM, NYC, NY

I am shocked at the untimely passing of one of our most dedicated colleagues. Bruce Frankel was a man who made a difference in the lives of all podiatric practitioners, students and educators. He will be missed by all who knew him. His lived his life in the realm of "we" and not the all too familiar "me."

A way in which can bring honor to his memory is to devote time to devote some time to the betterment of our professional community. If everyone one of us does a little more than we have already been doing there is no limit to what we can accomplish for our professional community and well as for humanity.

Elliot Udell, DPM, Hicksville, NY

I was saddened to learn of the passing of Bruce Frankel, one of the real "givers" in our profession. I would like to relate a brief story demonstrating the dedication and pride that this gentlemen took in sharing and giving back to podiatry.

When I was a sophomore at NYCPM in 1978, Bruce was a clinician. In those years, minimal incision surgery was coming into vogue. MIS was not taught at the school, but Bruce thought it was important for students to see "everything" podiatry had to offer. He invited a few students to his office to spend a day and see some small procedures being performed.

About four of us showed up on the same day. While that was too many to cram into a small surgical room without risking infection and patient anxiety, Bruce would not think of leaving someone out. So he instructed his secretary to go to the hardware store and buy a 2-way mirror. He then proceeded to knock a hole in his wall, insert the mirror, and have the 4 of us observe his surgery form the next room looking through the mirror!. He got a real kick out of teaching others, and he was a mensch. He will be missed by many.

Brian Kashan, DPM, Baltimore, MD

I was deeply saddened to learn of Dr. Frankel's passing. He was a wonderful teacher and most caring person. He will be sorely missed by our profession. My heartfelt condolences go out to his wife Bobbi and family.

Michael J. Schneider, DPM, Vail, CO

RE: Dragon Software (Gary Bjarnason, DPM)
From: Multiple Respondents

Our office has used the Pro version for several years. It allows you to create macros which will speed the process of dictating enormously. So yes, it is worth it. We have not found it necessary to add the medical dictionary. If you have Word versions or Text files of some existing transcriptions, they can be fed into the software for analysis and Dragon will learn your style much more quickly from those documents.

The new version 9 is just coming out and is reportedly faster and more accurate than ever. I have found the Dragon "phorum"

(http://forum.knowbrainer.com/list.php?f=2) very helpful in learning the ways of the Dragon and in finding the right equipment. The right hardware and microphone can make a huge difference.

We have multiple users in our office. Most now find they get fairly good recognition and the software easy to use while others have struggled to get the Dragon to understand them. Mumblers have a tougher time. The Knowbrainer software sold at the site noted above has also been helpful in speeding the dictation process as there are many useful prewritten macros.

Alan Kalker, DPM, Middleton, WI, ajkalker@facstaff.wisc.edu

Version 9, the brand new version of Dragon from Nuance (bought out ScanSoft) is just being put on the shelves as we speak. The standard and preferred version should be out now and Professional and Medical in a few weeks. Unless you are doing a high school paper forget standard. Preferred will not get you command and control that once you get the hang of this you will want. So you are left with Professional and Medical. Unless you have a long list of words that pertain to podiatry then I would go with medical.

Since version 8, the vocabulary like orthopedic had been greatly improved and even the drug lists are expanded, (none of this is in Professional to any degree). Version 9 does not require training ( i.e. reading a 10 minute text to learn your speech pattern) but anyone serious will take the time to read the training. The accuracy has improved also over version 8 and beta testers and ones with early releases are stating that this is the best version ever.

Just so you know you need the correct microphone (the one that is comes with is a cheap $8.00 microphone) sound card and computer setup to make this program fly......

If you contact Nuance it is like $26.00 a call to stay on the phone for 30 minutes and their tech support usually gets the reason for the call wrong!!!. You should contact a Var to train you and give you pointers and answer your questions. I only use this product with a speech EMR and once you "hire" someone to professionally teach you and give you tips etc you would be better off getting an EMR with this built in since you can catalog your patients, notes, demographics and recall them quickly for your staff but that is another question.

Larry Kosova, DPM, Chicago, IL, lkosova@yahoo.com

I bought the preferred version 8 on Ebay with the intent of only learning it, and assumed I'd then upgrade to the medical version. I never found it necessary to do that. The single most reason for that conclusion is the really cool way Dragon Preferred (and presumably Ver 9) will train your vocabulary.

Dragon will scan a folder of your previously transcribed documents. (If you don't have documents on your disk, have your transcriptionist give you a CD with a good sampling of your documents) It then grabs every word it doesn't recognize, puts them on a list, and prompts you to pronounce them one at a time. From that time on, it will recognize and properly spell them. Even if it may take a couple hours to say a bunch of words, once the program has learned them, it will have no more difficulty with "osteomyelitis" than "cat." Most importantly, it will know your own words, rather than those which the author of a medical vocabulary list thinks you want it to know.

As you use the program, it's easy to correct it and add more words. Also there's a program (can't remember the name) which uses Dragon as a voice recognition engine and comes up occasionally on this forum - they offer podiatry-specific macros and have a Yahoo group. I've not used that, as the ability of creating your own macros/templates in Dragon has been so easy. I was able to install and use it given the information straight out of the manual, and it didn't require any other support. It's almost scary how well this works! Given the current climate of our need for documentation, would it be an overstatement to wonder why everybody doesn't use this program?

Carl Solomon, DPM, Dallas TX, cdsol@swbell.net

If you really want to go that route you would be best off using a product called TexTalk MD which incorporates Dragon. You get what you pay for and TexTalk is amazing. I tried all of the Dragon products alone and wouldn't waste time with them. TexTalk is a compelte EMR. I do all of my dictation and have all of my "charts" within the program.
tkmd-subscribe@yahoogroups.com subscribe to this TexTalk site, which is mostly podiatrists, and ask any questions.

I would also contact Larry Kosova, a podiatrist that distributes the product. lkosova@yahoo.com

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

RE: Medial Calcaneal Nerve Entrapment (David Gutierrez, DPM)
From: Francisco J. Oliva, DPM, Will Godfrey, DPM

I have had a few patients with similar entrapment conditions. One was a teenage boy who was electrocuted with a power line and had exit injures to the fifth digits. I injected him with a celestone / lidocaine injection with an added.2cc of Hyaluronidase. I do not know if some local Pharmaceutical lab can prepare this solution for you but it worked for my patient with 100% resolution of the symptoms.

Francisco J. Oliva, DPM, Coral Gables, FL, Fyoliva@cs.com

I've done alcohol sclerosing injection here but only after corticosteroid injections have failed. However, I've done Solumedrol (40 or 80 mg/ml strength in 3 cc of 1:1 of 1% lidocaine and 0.5% Marcaine, either one of these locals w/ 1:100K or 200k epinephrine ) injections through several needle sticks about the area of scar and pain (which likely involves underlying fibrosis and nerve entrapment scarring); I've usually had to repeat this 2-3 times and have known cases where other podiatrists have done up to 5-7 treatments.

In doing these, I now also try to have it set up so the patient can go immediately for ultrasound therapy at physical therapy which seems to help. I started this after finding some support in the literature for ultrsound following steroid injection and getting similar advice from PM News readers in the past. This has worked very well here and in other places in the foot for me in my patients (and when I did resort to dilute absolute alcohol injections, in a few, I've had to go up to 6% strength after 3-4 treatments once we realized we weren't getting the desired result or only partial response).

In approximately 12 cases in 6 years, I've only had one fail one of these two protocols. After two years of intensive and exhaustive modalities, including topical and oral pharmacotherapy, physical therapy, and her going "outside the box" for acupuncture, she ended up succeeding with the Whitee Patch--which was sent to me by chance from Wei Labs.

Will Godfrey, DPM, Leesville, LA, williamtrekkie@earthlink.net

RE: Long-Term Studies on Efficacy of Orthotics (Tip Sullivan, DPM)
From: Dennis Shavelson, DPM

To understand the lack of orthotic research, one needs an historical perspective. Root presented his work from 1971-1977. Contemporary chiropodists/DPM's made arch supports and the thought of posts, cupped heels, measurements and pathology related treatment was more than they could acculturate to. Dr. Root's mantra was "I don't make arch supports, I make orthotics."

The laboratories gained control of biomechanics education. To this day, their owners/consultants are professors and department heads at the colleges. The labs are with rare exception, self-serving, so the education into podiatry allows the labs to produce devices inexpensively as patients pay the price of reduced orthotic quality. Labor is the most expensive category to a lab. When a DPM takes a foam or scanned cast, posts every rearfoot 3 degrees, doesn't ask for forefoot posting or ray cutouts, doesn't make heel lifts for short limbs, allows plaster arch fill to the positive cast to reduce returns to the lab, this makes for an inferior custom orthotic that in today’s marketplace isn't better than high tech OTC devices. There is no incentive for labs or the schools to fund research that would prove the podiatry device less effective than perceived.

Even worse, Dr. Root gifted podiatry with the branding that our devices sit at the top of the biomechanical pyramid. Yet, complacency, time constraints due to "HMOitis", the surgical focus of our training programs and the reduction in orthotic reimbursement prevent the average podiatrist from upgrading biomechanics and "less mess" and "even tissue paper works" remain part of our vocabulary.

I ask the readers, how much are you willing to invest to fund Dr. Payne’s research? Waiting for the schools and the labs for research is like repeating the same task and expecting a different result.

Dennis Shavelson, DPM, The FootHelpers Lab, drsha@footworldusa.com

HOUSE CALL PRACTICE OPPORTUNITY- CHICAGO / NORTHWEST INDIANA

Chicago-Home Physicians specializes in house calls to the elderly homebound. Full and part-time positions available in Chicago/Northwest IN. Competitive Compensation, including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax-773-486-3548. E-mail sschneider@homephysicians.com www.homephysicians.com

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

HOUSE CALL PRACTICE FOR SALE – SOUTHERN CALIFORNIA

House Call practice for sale which includes approx. 400 patients and continued referrals. Perfect 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-PARTNER WANTED MICHIGAN-DETROIT AREA WESTERN SUBURBS

Great opportunity-must be hard working, reliable, responsible and good with patients & staff surgical training a plus-partnership after 1 yr. Michigan license required. Fax resume to 248-478-1370 Starting salary $200,000. plus benefits plus percentage. Serious inquiries only

FOR SALE MICHIGAN-DETROIT AREA

Michigan practice Detroit western suburbs for sale. 3 offices, great locations approx 1.5m gross, Buy outright or overtime. Call 561-213-9400 after 7:00 p.m. Serious inquiries only

PRACTICE FOR SALE -ST PETERSBURG, FLORIDA

Well established (27+ years) general Podiatry practice. Great location -surrounded by 4 retirement communities. Must sell quickly due to health reasons. Contact Irwin Ayes DPM at ayesent@earthlink.net or 727-544-5425.

LONG TERM CARE PRACTICE OPPORTUNITY- DOWNSTATE ILLINOIS, & CHICAGO AREA

We specialize in providing conservative ethical care to residents in long term care settings. Immediate part-time positions available in downstate IL, and the Chicago metropolitan region. Competitive compensation and expenses. Contact Dr. Brian Aronson. Phone-773-775-0300 Fax-773-775-0883.

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

WEEKLY SPECIAL - One week of ads (6x) for only $75

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