August 10, 2006 #2,650 Editor-Barry Block, DPM, JD

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Podiatrists Continue Battle Against Flip Flops

As flip-flops smack heels through every town, mall and beach this summer, podiatrists are shaking their heads. "Flip-flops are the No. 1 culprit when it comes to people and foot ailments," says podiatrist Wendy Winckelbach. "They're great when you're in a public gym or shower and want something on your foot for protection, but they're not designed for you to run all over town in."

Winckelbach has seen the ills these flimsy kicks bring about. One patient in her 20s was feeding a city parking meter when her flip-flop slid off the curb. She twisted her ankle and snapped the bone. "Flip-flops just don't offer a lot of protection," Winckelbach says.

A recent influx of such ailments and injuries prompted the American Podiatric Medical Association to issue a news release urging people to ditch their flip-flops for more supportive sandals. Included were the results of a survey conducted to discover how many women value comfort over fashion. Just 33 percent of those asked chose comfort. "We'd like that number to be higher," says Dr. Harold Glickman, immediate past president of the APMA. "I realize what time of year it is, but we'd like to see more women think of comfort and shoes instead of flip-flops."

Source: Poughkeepsie Journal [8/8/06]

CMS Proposes 5.1% Cut in Physician Payments

The Bush administration on Tuesday proposed a federal rule that would cut Medicare reimbursements for physician services by 5.1% for 2007, the New York Times reports. Administration officials said the cut is necessary to offset faster-than-expected increases in Medicare spending for physician services, the Times reports (Pear, New York Times, 8/9). Medicare reimbursements to physicians increased 10% in 2005, and reimbursements for physician services and hospital outpatient services combined are expected to increase 10.6% in 2007, according to the Wall Street Journal (Zhang, Wall Street Journal, 8/9). The government estimates Medicare will pay a total of $61.5 billion to 875,000 physicians and other providers in 2007.

CMS Administrator Mark McClellan said the rise in Medicare spending on physician services is the result of "increases in the number and complexity of services furnished to Medicare beneficiaries, including more frequent and intensive office visits, and rapid growth in the use of imaging techniques, laboratory services and physician-administered drugs." According to the Times, the increased spending "directly affects beneficiaries because their premiums are set each year to cover about 25% of projected spending" for Medicare Part B, which covers physician services and other outpatient care. McClellan said Part B premiums likely will increase 11% to $98.40 for 2007. He said it would cost the federal government $13 billion over five years if Congress acts to block the proposed cuts, as it has done in past years (New York Times, 8/9).

Source: American HealthLine [8/9/06}

Scientific Meeting is Most Successful Ever

Many records were broken at the APMA Scientific Meeting, including the number of attendees and exhibitors. This was a high energy meeting in which podiatrists were able to celebrate both the scientific and practice gains of the past few years. Most attendees expressed great enthusiasm as to the direction and future of the profession.

Podiatry Management’s Podiatry Hall of Fame Luncheon was a rousing success, raising over $12,000 for the APMA Educational Foundation’s Student Endowment Fund. The roasting of inductee Warren Joseph, DPM was “well done” by APMA Executive Director Glenn Gastwirth, Harry Goldsmith, and Eric Hubbard.

Next year’s Scientific Meeting will be in Philadelphia.

Query: Loan for Buying Into a Practice

Does anyone have any experiences, good or bad, with a particular lender for loans to cover the costs of a buy-in to a practice? Any recommendations?

Josh Prero, DPM, N. Woodmere, NY, drjoshp@yahoo.com

Query: Services at Assisted Living Facilities

A question has come up regarding billing for podiatry services at an assisted living facility. The question is whether the care is covered and subject to the general rules for foot care. I have always been of the opinion that an initial visit could be billed as such, with the appropriate POS (33), and code CPT 993XX for a medically necessary visit. After that, any care rendered is subject to coverage limitations and medical necessity. So, class findings are needed if nail care is performed, or a visit may be used if it is a medical service being provided.

I have also been of the opinion that you shouldn't bill an E&M every time the patient is seen in addition to any nail/lesion care rendered, if there is not a separate reason for the E&M. Am I correct?

Brian Kashan, DPM, Baltimore, MD

Response: It would be my expectation that the medical necessity and/or requirements to support this service would be no different from those applicable in the office setting.

I recognize that, by virtue of being in an assisted living facility, these patients are somewhat compromised. However, there is some degree (albeit limited in skill and scope) of oversight in the ALF, and some would argue whether these patients would be at greater risk in their own homes. Your overall perspective on the care, as framed in your question, seems quite appropriate to me.

As an expert witness for the OIG, I would just remind you that this site of service has been the subject of some abuse/overutilization in the past, so make sure that you leave a very clean and visible paper trail.

Rick Horsman, DPM, Olympia, WA

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

RE: D.F. Night Splint For 4 Y/O (David Gutierrez, DPM)
From: Multiple Respondemts

I have been able to get splints made from a company called Dynasplint. Although I have not had to obtain one this small, my representatives have told me they can custom make pretty much anything so I suggest you might give them a call. www.dynasplint.com

Have you considered referral to a pediatric neurologist for evaluation? Many times this is a mild case of cerebral palsy, and they seem to respond well to Botox injections. I have seen this presentation many times in the last few years, and referred for neurological eval and Botox. This coupled with night splinting has helped quite a bit.

Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

We used to say that young children habitually toe-walking suffer from "prancer's syndrome." They often have a family member with a limp or cast walking an injury that they are imitating.
First, make sure they do not have a fixed equinus,i.e., you can dorsi-flex the foot 10 degrees with the knee straight. Then fabricate a wedged heel lift to give the child ground contact sense (at first, it may be very high), B/L. Then as the child begins to weight the heels, wean away the lift. If this is a true prancer's syndrome, I am not sure what a night brace would do?

Dennis Shavelson, DPM, NYC, NY, drsha@lifestylepodiatry.com

With my many years of experience, I am not aware of any off-the-shelf pediatric night splint (dorsi-assist) AFO. I would recommend two suggestions. 1) I would suggest casting the child in the closest position to neutral for a custom made (dorsi assist) dual pull strap ankle foot orthoses. This device will allow the parent or any healthcare provider to stretch the Achilles tendon tightness to a more neutral position. This device is either hinged or made from a more flexable plastic. This would be worn only at night time. I have had many years of success with this.

2) Once your patient is close to a more neutral position I would than suggest having the lab that is manufacturing your AFO to wedge the original cast to neutral (90-ninety degrees) so you do not have to re-cast your patient. They should than manufacture a solid ankle AFO that the child will wear during the day. This should be worn all day with a sneaker.

Steven Goldstein, Certified Orthotist, Clinical Promotional Marketing, steveng555@aol.com

Try Wheaton Brace Company.

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

EQUIPMENT FOR SALE

Ritter X-Ray machine, Mayo stand, Oxygen mask and tank, Polaroid 8X10 X-Ray processor and cassette, Ritter Clave autoclave, Whitehall JO-140 portable whirlpool, Glass bead sterilizer, Foredom cord drill with hand piece, JanL model 100 nail dust extractor, 3 podiatry cabinets, Polaroid 545 3X5 X-Ray developer, 3 8X10 X-Ray cassettes. The equipment is located in NY. Please call 845-359-1070.

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

PRACTICE FOR SALE - BERKELEY CALIFORNIA

Well-established office in professional medical building; Biomechanics, Geriatrics and General Podiatry; Excellent growth potential for surgery; Payor base MC, PPO, and self-pay (NO HMOs); Reliable referrals from local physicians; Electronic billing in-house; Transition terms negotiable. Send letter of intent to: foot4sale@sbcglobal.net

ASSOCIATE POSITION - GULFCOAST OF FLORIDA

Great opportunity in rapidly growing practice for a PSR- 24/36 BE/BC podiatrist with strong surgical skills. Hospital privileges available at 548-bed hospital system, new hospital is being built and multiple surgical centers. Candidate should perform rearfoot & ankle surgery, including Charcot reconstruction. Candidate needs to be ethical and motivated and must have a current Florida license. Established practitioner or new practitioner OK. Salary + percentage + benefits including insurance and 401K. Fax CV to (239) 566-8778.

POSITION AVAILABLE-RETIRED OR DISABLED PODIATRIST-DELRAY BEACH FLORIDA

Full or part time position in start up pharmaceutical company. Duties would range from answering phones to publishing scientific papers. Please contact: rhm123@gmail.com

Southeast Florida Podiatrist Needs Top Notch Candidate

South Florida podiatrist looking for an astute, personable, extremely well trained podiatrist with excellent clinical skills and acumen. My practice is busy, rapidly growing, and referral based. Looking for a full time associate to start immediately. Partnership opportunity available. I require someone who can work independently and wants to help elevate this practice to a new level. Email your resume to podiatry49@hotmail.com

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

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

ASSOCIATE POSITION- SOUTH CAROLINA

Associate position available in South Carolina south of Charlotte. Two office practice, with two podiatrists, in a growing area. Well-rounded practice with all aspects of podiatry. Opportunity for future partnership. Please send CV to cathykop@hotmail.com or fax it to 803-396-8657.

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