The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

August 14, 2007 #3013 Editor-Barry Block, DPM, JD

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When: July 29-31, 2008 (following the APMA Annual Meeting)
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Speakers: Harry Goldsmith (Codingline) and Barry Block (PM News)
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Ill-Fitting Shoes a Major Factor in Foot Problems AL Podiatrist

Statistics show that by age 50, 29 percent of the population has missed work or another activity due to foot problems. Dr. John Odle, a Jasper podiatrist, cited a recent Veterans Administration study which revealed that 76 percent of patients are wearing shoes that don’t fit properly. “I find this particularly true among seniors,” Odle said, “although the same is probably true throughout the population. Ladies are the worst offenders, although they are most adamant that they are wearing the right size.”

Dr. John Odle

Odle said inappropriately sized shoes are most likely to cause corns, calluses, ingrown toenails and foot pain. Odle said foot pain can cause knee, back or other joint pain. The pain can be an early indicator of serious conditions like arthritis, diabetes, phlebitis, neuropathy or even a strain or break.

In diabetic patients, poorly fitting shoes have been identified as a major factor on the path to foot ulceration and infections. To compound matters, many of Odle’s diabetic patients have neuropathy (loss of feeling) and are even more likely to have poorly fitting shoes, since they have little or no pain sensation where shoes are rubbing.

Source: Source: Lon Williams, The Daily Mountain Eagle, [8/10/07]

Fate of Medicare Pay Raise Hinges on Contentious SCHIP Negotiations

Just before leaving Washington for their August break, House lawmakers passed a measure that would prevent Medicare physician pay cuts for the next two years. But final approval is far from certain.

The move is part of legislation to reauthorize and expand the State Children's Health Insurance Program. The Children's Health and Medicare Protection Act of 2007, passed by the House on Aug. 1, would turn the 9.9% and 5% Medicare payment reductions expected in 2008 and 2009 into 0.5% increases for each year. The next day the Senate passed the Children's Health Insurance Program Reauthorization Act of 2007, which would renew and boost SCHIP but not change Medicare physician pay.

When Congress reconvenes in September, a conference committee will try to craft a compromise between the two substantially different bills. Because SCHIP will expire Sept. 30 without congressional intervention, lawmakers are under a tight timetable

Source: David Glendinning, AMNews [8/20/07]

Thompson Drops Out of Presidential Race

Former Wisconsin Gov. Tommy Thompson is dropping out of the race for the Republican presidential nomination, a campaign official said Sunday. His campaign released a statement saying the Republican is leaving the campaign trail several hours after WITI-TV in Milwaukee reported that Thompson told one of its reporters he was withdrawing.

The campaign statement said Thompson intends to take some time off before returning to the private sector and his non-profit work. "I have no regrets about running," Thompson said in a statement issued by his campaign Sunday night.

"I felt my record as governor of Wisconsin and secretary of Health and Human Services gave me the experience I needed to serve as president, but I respect the decision of the voters," he said. "I am leaving the campaign trail today, but I will not leave the challenges of improving health care and welfare in America."

Source: Associated Press [8/13/07]

Query: Rest Pain in Distal Hallux

I have a few elderly patients, who present with an unusual pain in their distal hallux, around IPJ or nail unit, which is present only when resting; predominantly at night. This pain is severe enough to keep them from resting, and is not alleviated by pain medicines or even narcotics. Their only relief is from standing up and/or walking.

As far as differential diagnoses; I’ve considered ischemic (but patient will have digital hair), neuritic (but no response to neuropathic medicine (Lyrica)), and arthritic (but no pains in other joints with worse arthritic changes). Any thoughts from the forum would be appreciated

Atalay Sahin, DPM, Fall River, MA

RE: Red Blotches on Plantar Surface of Feet (Burton J. Katzen, DPM)
From: Multiple Respondents

The following article may be useful in making a diagnosis.

http://archderm.ama-assn.org/cgi/reprint/134/1/76.pdf

Editor’s note Dr. Markinson’s complete note can be read at
http://www.podiatrym.com/letters2.cfm?id=15203&start=1

Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org

They look very much like the pedal version of erythma nodosum. Deep incisional or excisional biopsy specimen should be obtained for best visualization because a punch biopsy is likely to produce an inadequate sample. It is best to send the specimen sample to a board certified dermatopathologist (rather than a general pathologist) for a definitive diagnosis.

G Dock Dockery, DPM, Seattle, WA Gdockdockery@aol.com

What Dr. Katzen has described and the appearance of the lesions seen in the photograph may represent Erythema Nodosum. There are a number of possible causes, such as certain drugs sulfonamides, birth control pills, estrogens, strep infections, sarcoidosis, Behcet's disease, and inflammatory bowel diseases. In about 30-50% of cases the etiology is unknown. A deep punch biopsy may be utilized to confirm the diagnosis.

David M. Feingold, DPM, South Plainfield, NJ, footfixer1@aol.com
I would suggest an elliptical biopsy of both the skin and subcutaneous tissue, taken from the margin of the lesion, using the 3:1 length to width ratio. Make sure that you get both affected tissue and normal tissue. Pathological examination may make the diagnosis for you

Robert A. Boudreau, DPM, Tyler, TX, RBFTDOC@aol.com

Looking at your pictures and abnormal lab tests, my first inclination is that these lesions appear to be local subcutaneous hemorrhages with inflammation. Of course, the definitive diagnosis would be to get a tissue biopsy, but that is not easy on a 12 year old. At this point you have to ask yourself -What can cause these lesions. First of all, a Protime of 15.7 is considered highly elevated in a 12 year old. There usually is no reason for a Protime to be over the control (usually 12 seconds) in a healthy twelve year old. Also, a Mean Corpuscular Volume (MCV) less than 80 shows small microcytic red cells, but obviously the red cell morphology was not done, because the results would have included the presence of microcytic cells.

My first thought would be to check the red cells, platelets, clotting factors, and a Sickle-dex to rule out sickle cell anemia or trait. Sickle cells can also effect the liver, decreasing clotting factors and increasing Protimes. Sickle cell can cause DIC (disseminated intravascular coagulation syndrome) which also has to be ruled out. You should check the liver enzymes and other liver tests. Anything that affects the liver can cause increased protimes and microcytic anemia, such as hepatitis, or viral infections, as well as neoplasms, vasculitis, and even snake bites, spider bites, and environmental toxins-(lead, radon, ect.).

Also, autoimmune problems such as lupus and scleroderma might cause the lesions, so obtaining an ANA, anti-DNA, LE prep, and immunoglobulin assays might help. Of course, at that point, you might as well do the tissue biopsy, and if all else fails, give a Medrol Dose Pack to see if anything changes. if it gets better- it is some type of inflammatory process, and if it doesn't, then it is from an infection of some sort, or metabolic.

Randy Bernstein, DPM, Dearborn Heights, MI, foottdude@aol.com

Could Dr. Katzen's patient be the victim of abuse? Get a good and reliable history from the child with no parent present.

Sam Ruggiero, DPM, Buffalo, NY, sfrdpm@adelphia.net

RE: Coding Cryosurgery For Neuromas
From: Steven H. Goldstein, DPM, Marc Katz, DPM

As one who has performed cryosurgery for 4 years, we use the CPT 64640 code, which describes destruction of a peripheral nerve by thermal or chemical means. Freezing the nerve certainly fits into the definition of the CPT-4 code. We have had almost 100% acceptance of this code by every major insurance carrier in NJ. An operative report is provided only at the request of the carrier. I do agree that since cryosurgery does not have its own unique code the 64999 unlisted procedure to nerve is far better than the 28999. You can always send an operative report so the insurance company has a better idea of what was performed. I have seen reimbursements run from 165 to 1000 dollars depending upon carrier with the average being about 450 dollars.

Steven H. Goldstein, DPM, Livingston, NJ, stevefootdr1@cs.com

The correct code is CPT 64640. This includes destruction of the nerve by freezing which is a neurolytic agent. Also in the description this includes a peripheral nerve. I use this code on a regular basis with no problems. This has been confirmed by the person that writes the policy for FL Medicare.

If you happen to be releasing the intermetatarsal ligament you could code a 64726 in addition to the Cryo.

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

PRACTICE FOR SALE - NORTHERN NJ

Doctor retiring and staff willing to stay. Great location with drive by traffic and foot traffic. Doctor willing to stay for smooth transition. Hospital access and on major insurance plans. Call 614-264-3798

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 - 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

Staff Privileges at Certified Surgical Facility Available- NY & LI

Certified operating rooms which qualify under the new NY Patient Protection Law (which will require accreditation for in-office procedures) are available in Manhattan East 60th Street and Plainview, Long Island. Staff privileges still available. Call 516 433-4447 for information or e-mail podo2345@aol.com

ASSOCIATE WANTED - PHOENIX, AZ AREA

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

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

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