The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

August 15, 2007 #3,014 Editor-Barry Block, DPM, JD

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MRSA is a National Problem: VA Podiatrist

Several professional and college football players across the country have died or been hospitalized in recent years from MRSA. The Centers for Disease Control and Prevention (CDC) says MRSA is on the rise, particularly in people who utilize health clubs and locker rooms or school gyms.

Dr. Catherine Page

Local doctors say they aren’t seeing MRSA in their practices, but that it does exist and people should be aware of it. “It (MRSA) can be found anywhere people are in close quarters,” said Dr. Catherine Page, a Danville podiatrist. “I haven’t seen any (MRSA) in my office, but nationwide it is a problem.”

Page treats a variety of foot problems, including athlete’s foot. “The athlete’s foot can come from any contaminated surface,” she said. “Keeping things spotless helps a lot.”

Source: Rebecca Blanton, Danville Register & Bee

Barry University Welcomes New CME Director

The Barry University Division of Medicine has announced that Urmala Roopnarinesingh has been appointed director for continuing medical education.

Urmala Roopnarinesingh, MSHSA, Director, CME Program

Roopnarinesingh holds a BA in sociology and English literature from the University of the West Indies in Trinidad and an MS in health services administration from Barry University. She comes to the Division of Medicine from the Barry University School of Nursing where she was director of marketing and development.

20/20 Imaging Introduces Dedicated Direct Radiography System

Crystal Lake, IL - based 20/20 Imaging LLC. (formerly Reina Digital Imaging) has announced the arrival of podiatry’s first dedicated Direct Radiography (DR) system. Newly appointed Sales Manager Susan Ott states “It’s a catalyst for workflow efficiency; the new 20/20 DR transforms an ordinary practice to a workplace on the cutting edge of digital imaging technology. No more film (analog) processing, cassette and imaging plate (computed radiography – CR) handling, 20/20 DR is a true “click” and “view” process!” This system can be field upgraded to work with existing x-ray equipment.

20/20 Imaging LLC., provides imaging expertise for every type of diagnostic modality by creating packages of products with installation and service. In addition, 20/20 Imaging plans to offer its EXTREME 1012 Computed Radiography (CR) scanner specifically designed for podiatrists, and the entire EXTREME line of solutions to orthopedic, chiropractic, veterinary and other types of practices.

Query: Discharging a Patient

I have been treating two ladies for several months who always accompany each other to all office visits. They are not related. Patient A has complicated issues including a posterior tibial tendon rupture, advanced PVD, and several failed forefoot surgeries. Patient B has only been treated for palliative care. Patient A recently received a HAFO for treatment of her tendon rupture. On their most recent visit, patient B got very combative with both myself and patient A in reference to the HAFO, which did need obvious adjustments due to rubbing. All attempts at defusing the situation were fruitless, and I found myself aggravated at patient B.

I would like to discharge patient B from my practice. My question is, can I also legally ban her from coming to the office if patient A continues as a patient? If not, can I insist that she not accompany patient A into the treatment room during the visit, and stay in the waiting area.

Jason Cohen, DPM, Bronx, NY

Editor’s comment: PM News does not provide legal advice. The fact that Patient B accompanies Patient A implies that some kind of relationship exists, .e.g., friends, neighbors, etc. While you certainly can discharge any patient for being disruptive or non-compliant, banning someone who accompanies a patient to your office is problematic. It’s seems logical to call Patient A to discuss the matter and see if Patient A can find someone else to accompany her to your office.

Query: Two E/M Services - One Day

Are there any circumstances at all in which 2 E/M services can be billed on a single day?

Jon Goldsmith, DPM, Omaha, NE

Response: While the use of "wellness codes" could allow the use of multiple E/M services on the same visit, in more practical situations the answer is "no, you cannot bill two E/M visits for the same date of service, even for different diagnoses."

So, for example, if the patient was seen in your office, and admitted to the hospital, and evaluated by you again on the same day, you would bill for only one E/M service. Or, for example, if a patient was seen in your office in the morning for follow-up of an infection, and then she's seen in your office or the ER for a traumatic injury the same day, you can only bill for one E/M service (which would be valued on E/M information from both encounters). It may not seem fair, but that's the rule.

Mark Schilansky, DPM, Catskill, NY

RE: Rest Pain in Distal Hallux (Atalay Sahin, DPM)
From: Multiple Respondents

The presence of digital hair is not a guarantee of vascular health. The symptoms described are classical features of arteriosclerosis obliterans. The involved arteries are not totally occluded, and blood flow is adequate during activity. When the patient is at rest, particularly abed, cellular respiration slows, and the demand for gas exchange and nutrients declines. Consequently, the heart rate slows, stroke volume decreases, and blood pressure drops. The blood pressure may then be too low to force blood through the partially occluded vessels, resulting in impaired vascular supply to downstream tissues. These tissues now receive insufficient blood, and become ischemic. If limb dependency and activity abate the symptoms, ischemia must be your primary, and most severely threatening, diagnosis. Total occlusion should be presumed imminent until proved otherwise. This patient should be seen by a vascular specialist immediately. Time is of the essence.

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

I suggest consideration of an arterial Doppler to better assess possible SFA occlusion that can often manifest as distal first ray pain. SFA stenosis can co-exist with the presence of digital hair.

Godfrey Viegas, DPM, Crystal Lake, IL, gviegas1234@sbcglobal.net

Rest pain in foot/ankle/leg that resolves by standing up," strongly suggests that it is an ischemic process. If the pain is that severe, you should do a complete vascular work-up immediately, or refer them to a vascular specialist (Vascular surgeon, interventional cardiologist, or interventional radiologist) whom you can trust to communicate back to you after their vascular work-up.

According to this systemic review..."Khan, et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006; 295(5)536-546" ... they found that physical examinations (lack or presence of pulses, digital hair loss, shiny skin, nail change etc) are not sufficient enough to "rule in or rule out" peripheral arterial disease (formerly called peripheral vascular disease). In other words, this particular patient of yours may have severe blockage in her leg arteries, and she can still have digital hair.

Unfortunately, podiatrists have been sued successfully for missing the diagnosis of PAD (Peripheral Arterial Disease) and the patient having major leg amputations afterwards. As a foot and ankle specialist, you should be aware of the danger signs of ischemic legs, as we estimate that we have 12 million PAD patients in the US, and one-third of diabetic patients also have PAD.

Kazu Suzuki, DPM. Los Angeles, CA. kazu88@gmail.com

I had a patient who had a forefoot varus condition where the hallux was recruited to hold the arch up and this caused the pain at night when patient was off of the foot. An orthotic resolved the pain after 2 weeks. Check the patient for a hallux hammertoe as well as loss of fat padding at the tip of the toe. Also - if the nail is too long it can irritate the posterior nail fold and cause pain..

Joel Morse, DPM, Wash, DC, Foxhallfoot@aol.com

RE: Coding Cryosurgery For Neuromas ( Marc Katz, DPM)
From: Harry Goldsmith, DPM

I disagree with Dr. Katz's statement that "If you happen to be releasing the intermetatarsal ligament you could code a 64726 in addition to the cryo." CPT 64726 is not the code that should be billed for releasing the intermetatarsal ligament.

CPT 64726 is defined as "decompression; plantar digital nerve" and is included in the "Neuroplasty (Exploration, Neurolysis or Nerve Decompression) section of CPT. CPT qualifies neuroplasty as "the decompression or freeing of intact nerve from scar tissue, including external neurolysis and/or transposition." AMA's CPT Assistant notes that CPT 64726 (as well as CPT 64722) is "described as an 'open' incision repair of injured nerve(s) that includes 'external neurolysis' by division of perineural adhesions and/or excision of perineural scar tissue."

Incising the intermetatarsal ligament in order to eliminate or reduce neuroma (digital nerve) symptoms is...an incision of the intermetatarsal ligament that does not include exploration of the nerve, freeing it from any adhesions, releasing it from any scar tissue, etc. Several recent (and successful) techniques use a minimal incision/percutaneous approach. There is no currently existing code for an incision of an intermetatarsal ligament. I would recommend billing the procedure as CPT 28899, unlisted foot procedure.

Harry Goldsmith, DPM, Cerritos, CA, hgoldsmith@codingline.com

Editor’s note: This topic is now closed.

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

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

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