The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

August 11, 2007 #3,011 Editor-Barry Block, DPM, JD

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NY Podiatrist Says “Golden Ruler” Helps Determine Correct Shoe Size

If it’s hard for an adult to think straight when their feet hurt, imagine how difficult it is for children in ill-fitting shoes to pay attention in class. So what’s a parent to do? “Take a ruler to them”, is the advice of New York State Podiatric Medical Association, (NYSPMA) President, Dr. Robert Rampino. “Parents need to make sure their children are measured for shoe size and proper fit each and every time they buy shoes.”

Dr. Robert Rampino

The New York State Podiatric Medical Association, the largest statewide component of the American Podiatric Medical Association, acknowledges how difficult it is to live by the “golden ruler.” “Kids always want what looks good, not necessarily what fits the best,” says Dr. Rampino. “What’s more, few shoe stores have sales professional properly trained to measure and fit shoes,” he adds. Still, taking kids to the store and having them take part in the selection process builds better foot health. Here are some tips to make it easier.

New OCPM Campus Officially Opens

The Ohio College of Podiatric Medicine (OCPM) officially opened its doors this week to OCPM students and the podiatric community. After a two year process of obtaining the former Realty One building and transforming the 115,000 square foot facility into a podiatric medical education institution, OCPM has completed its historic transition of moving from University Circle to Independence, Ohio. Construction began with a groundbreaking ceremony in September of 2006 for the 7,000 square foot, 300-seat lecture hall addition. Today, students have the luxury of learning podiatric medicine in a state-of-the-art medical facility situated on 27-acres of wooded land that can rival any medical college in the country. With its high-tech caliber laboratories and equipment, newly created computer learning and media center, enhanced library and study rooms, upgraded school cafeteria, and renovated administrative office spaces, the Ohio College of Podiatric Medicine is positioned to become the leader in podiatric medical education for the 21st century.

New OCPM Building in Independence, OH

“When you see were we came from and where we are today, it is a complete “180” and a milestone for OCPM,” says Thomas V. Melillo, DPM, President of OCPM. “Our students, alumni, and the podiatric community will learn, conduct research, and apply podiatric medicine in a first-class, highly sophisticated manner never before seen in the 91-year history of the college. We are very excited to be in our new home in Independence and are looking forward to a great future for OCPM.”

IL Podiatrist Balances Career and Family

Dr. Abigail Mahoney of Peoria, IL always knew she wanted children. But professional aspirations - including four years of podiatry school in Chicago and a three-year residency in Washington, D.C. - meant she delayed childbirth until age 36. There was a time in Abigail Mahoney's life when she didn't know if her dream of having a family would ever materialize. She was in her early 30s, preparing for a career as a doctor. Her days were consumed with work and study. And the right man hadn't come along.

Dr. Abigail Mahoney

She met John Mahoney, a hand surgeon, at age 35. They married a year later and started trying to have children immediately. As doctors, they both knew the potential risks involved with having children past a certain age. "Those eggs weren't getting any younger," she said. "We felt like our best chance for (having a family) was right away." Beyond age 35, pregnant women are considered of "advanced maternal age" and special precautions are taken, Mahoney said. The older the mother, the greater the chance for chromosomal abnormalities such as Down syndrome.

The Mahoneys also knew getting pregnant could be more difficult. But it happened quickly - with no miscarriages. Today Jack is 2 and Graham is 1. Abigail, 39, works as a podiatrist in Peoria three days a week. She said the family's scenario is not unlike those of many of their friends and colleagues who also took time to establish careers before having children.

Source: Sonya Embry, Peoria Journal Star [8/6/07]

Query: Graston Technique

Has anyone heard or used the Graston technique for chronic tendon pathologies or plantar fasciitis pathology?

Philip E. Larkins, DPM, San Marcos, CA

Query: Loupes

I need a recommendation for a pair of loupes to be used in-office to remove foreign bodies. None of the podiatry catalogs seem to carry them.

James M. Petko, DPM, Falls Church, VA

Query: Coding Cryosurgery for Neuroma Treatment

I have been told 3 different codes to use when performing cryosurgery for treatment of a neuroma. We are billing the procedure as CPT 28899 (unlisted foot/toe code), and sending the op report.

I previously read somewhere that a doctor was using CPT 64704 (neuroplasty, nerve of hand or foot) or CPT 64708 (neuroplasty, major peripheral nerve, arm or leg; other than specified). I thought these codes were for decompression or freeing of intact nerve, not freezing of a nerve.

I also had an insurance company demand that I bill CPT 64640 (destruction by neurolytic agent; other peripheral nerve or branch), if I wanted to get paid. This seems closer to the procedure than the CPT 64704 or CPT 64708. Does anyone else perform cryosurgery for neuromas? If so, what is your take on the CPT coding of it?

Jim Malone, DPM, Bakersfield, CA

Response: The proper coding of cryosurgical destruction of a neuroma would be CPT 64640 presuming

1) The nerve meets the "peripheral nerve or branch" definition; 2) The cryosurgical techique employed destroys the nerve/neuroma.

Typical examples of CPT 64640 (or other codes in the section) performance are via various injection or percutaneous methods using imaging guidance or a nerve stimulation (as opposed to first exposing the nerve/neuroma through incision). CPT, however, does not specify how you isolate/expose the nerve for destruction (it would have been nice to have a parenthetical instruction) in the CPT 64600 - CPT 64681 coding section. The section header merely states "Destruction by Neurolytic Agent (e.g., Chemical, Thermal, Electrical or Radiofrequency)."

You didn't mention the technique you used or would be using - percutaneous vs. open - for cryosurgery. Since it would be unusual, given the availability of imaging or nerve stimulation guidance techniques, to first "open" the foot when employing a "destruction by neurolytic agent," one might argue the necessity for doing so. In all probability, CPT 64640 was never intended to include an "open" approach. In case you did an open approach, or if you are just unsure of or uncomfortable with the coding, I would recommend you bill CPT 64999 (unlisted procedure, nervous system) - not CPT 28899 (unlisted procedure, foot or toe) - to give the payer an opportunity to determine whether the open cryosurgery procedure/technique is within plan language in terms of benefit exclusion/limitations, standard of care, and medical necessity. Be sure to include an op report, and a letter of explanation. You should choose and include a work-comparable existing CPT code like CPT 28080 or CPT 64776 to validate the fee you are claiming for the unlisted procedure. Payment will be subject to the payer's plan language

Harry Goldsmith, DPM , Cerritos, CA

RE: IL Hospital Found Negligent in Credentialing
From: Howard L. Lazar, DPM, JD

PM News' presentation headline for this news item mischaracterizes the event, and may have negative repercussions for significant numbers of our colleagues. The hospital was found negligent, not because a Non-ABPS podiatrist was on staff, but because it failed to adhere to its own bylaws. Those bylaws require staff podiatrists to have surgical residency training and ABPS eligibility or certification. The defendant podiatrist had neither status with the ABPS.

The case does not hold that plaintiff's damages resulted from the surgeon's lack of certification. Neither does the case suggest that hospitals should require staff podiatrists to be certified by the ABPS. It merely indicates that hospitals must adhere to their own bylaws in credentialing matters.

The PM News headline for this story inaccurately makes it appear that hospitals would be considered negligent in granting privileges to holders of other certification credentials. Readers of this column may presume their hospitals will force them to seek ABPS certification. The mischaracterization of this story will produce an unfair competitive edge of significant proportions favoring the ABPS.

Hospitals may escape this form of liability by eliminating the requirement for specific certification credentials. Better yet, hospitals could go back to what they did years ago: satisfy themselves that applicants for privileges are competent to hold them.

Howard L. Lazar, DPM, JD, Bloomfield Hills, MI howardlazar@comcast.net

Editor’s response: We are in agreement that hospitals should grant privileges based on training and competency. ABPS certification should not be the sole measure by which podiatrists are granted privileges. Restrictive bylaws such as in this case only serve to exclude otherwise qualified podiatrists from operating in hospitals. This does not serve the greater interests of the public because it forces those podiatrists to operate in a non-hospital environment or restricts their right to make a living.

We believe that hospitals should accept any officially board certification for general privileges, and then limit the surgical scope of a podiatrist based on competency to perform specific procedures.

RE: Test to Confirm That Osteo Has Resolved (Edward Orman, DPM)
From: Multiple Respondents

A Tech-labeled white blood cell scan should be a good predictor of osteomylitis. A small bone biopsy with a Jamshidi or other biopsy needle is the gold standard. Just make sure your biopsy site is away from the original ulcer site.

Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

Check the Sed rate or CRP. If they fall within normal range, the osteomyelitis treatment is complete.

Simon Young, DPM, New York, NY, Simonyoung@juno.com

The only way to know for sure if osteomyelitis is still present is via bone biopsy. Is the wound closed? If not, biopsy and culture the bone....Otherwise, you can do an MRI, but bone will most likely "light up" regardless of infection because of stress reaction from long standing ulcer....another option is WBC tagged bone scan....you can also follow the patient with periodic x-rays.

More importantly, let clinical appearance of the digit be your ultimate guide. If the wound is closed and there are no signs of infection (ie; erythema, edema, calor, or drainage) present, I would take patient off all antibiotics and see how he does. If it becomes "angry" then you have your answer, and address accordingly ... However, often these patients do fine. I have several patients with chronic osteomyelitis of their digits who are not on any antibiotics and show no clinical signs of infection. These patients, like yours', wished to keep their toes and are doing well. Periodic x-rays show no changes. Therefore, I leave it alone.

Chris Seuferling, DPM, Portland, OR, cseuferling@comcast.net

The gold standard to confirm an osteo is bone culture (textbook answer). In theory, you can take a take a bone sample through a different site. (Are you likely to do this in a distal phalanx - I say no) With a distal phalanx, I would say once you see bone erosion/lysis of the phalanx, the entire bone must be considered infected just because the size of the bone is so small.

In this type of case, once the toe became infected, I order an ESR. It usually is high in cases of osteo and upwards of 100 (normal 0-10). As your infection is responding to antibiotics, you should over time see this value go down, and the majority of cases comes down to normal, or mildly elevated. ESR's as we know are non specific, however this pattern I find to be very consistent. If your ulcer has closed, I would continue the patient on antibiotics for an additional two weeks. (I am giving you my own clinical practice guidelines.) I find when there is an underlying osteo, ulcers will not close. Based on this if your ulcer closed - I feel your osteo has gone dormant. It may "awaken" through trauma or other means, but I feel it would be safe to say it has gone dormant. I would continue serial x-rays. At this point, I do not see the point in any other diagnostic modalities such as MRI, bone scans, etc.

Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com

ASSOCIATE POSITION - NORTH TEXAS

Looking for motivated, hardworking, personable individual with minimum PSR/24 training. The practice has been well established in the community for over 20 years. Our practice offers a large self-owned office, State-of-the-Art Surgery Center, and competitive salary with profit sharing. Send CV with references to info@ntfootcare.com, or fax to 903 868-2975.

PRACTICE FOR SALE--LOS ANGELES, CA AND VENTURA, CA

Selling fully equipped practice in Los Angeles. Located in medical office building with ample free parking. Satellite office in Ventura, CA can be sold separately or together. Potential for further future growth. Sale price comparable to the cost of starting a new practice. Inquire at tkhk@sbcglobal.net

ASSOCIATE POSITION -CONNECTICUT-NORTH HAVEN

Seeking a part-time associate for a busy, well-established, respected, growing practice. Desiring an ethical, motivated, personable, well-trained PSR12/24/ or 36 podiatrist. Our practice is well-rounded and diverse with a good mix of sports medicine, diabetic care, surgery, podopediatrics, and general podiatry. Email information and CV to Pedy7@aol.com with subject heading “Podiatry Associate.”

ASSOCIATE POSITION SANTA FE, NEW MEXICO

Immediate opening for PSR 24/36 individual in three office practice. We are looking for an ethical, hard working, well trained Podiatrist. Partnership available. Please Fax CV to sfpodiatry@aol.com

PODIATRIC FELLOWSHIP POSITION AVAILABLE – CALIFORNIA

This one year fellowship will emphasize reconstructive foot/ankle surgery and research. Located in beautiful Sonoma Valley California. Must have a current California license and have completed a PSR-24,PM&S 24,or PM&S 36 residency program. Please send all letters of interest and a recent CV to Thomas Chang, DPM, Director, at podiatricri@yahoo.com or call (949) 412-8445.

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax 773-342-4201 -E-Mail sschneider@homephysicians.com -- www.homephysicians.com

ASSOCIATE POSITION – GREATER BOSTON AREA

Full-time comprehensive practice with hospital teaching affiliation west of the greater Boston area looking for motivated, ethical, surgically trained podiatrist. Competitive salary and benefits. Call 508-872-9288

ASSOCIATE POSITION - SOUTHERN NEW JERSEY

Busy multi-dimensional practice. 20 minutes from Philadelphia. Board qualified/certified ABPS. Ethical, motivated, personable. Starting 65K plus health, malpractice, CME, bonus incentive. E-mail resume TotalFootCare@aol.com

A well established, ethical solo podiatry practice wishes to expand its current surgical services in the near future by hiring a full-time associate with PSR 24-36 training which includes very strong surgical rear-foot and ankle reconstruction, diabetic limb salvage and ER trauma. Successful association may lead to partnership. ABPS Board qualified/certification is required. Applicants must be personable and caring to patients. Practice in an office base within a new state-of-the-art orthopedic surgical hospital environment and plenty of future expansion capabilities for a bright, eager, reliable associate. Email complete CV with current references & photo to footdoc352@cox.net

PRACTICE FOR SALE OR SHARING- CENTRAL FLORIDA

Practice all phases. Wound care, hyperbaric privileges nearby. Excellent building, location, and exposure on busy highway. Outstanding place to live and work; low penetration by managed care. Ample parking and accessibility with 2,000 sq. ft building designed and equipped for podiatry (lease or buy) 7 minutes from hospital. Great price, terms and opportunity to grow. 352-357-7499 - windnwave@earthlink.net

ASSOCIATE POSITION - NORTHWEST PENNSYLVANIA

Multi-specialty group is looking to add another Podiatric Surgeon or General Podiatrist to our well-established group. Office locations in northwestern Pennsylvania. Unlimited opportunities exist for the right Associate, wound care experience is a plus. Please forward your CV to adminsec@ips-mso.com

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