The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

August 26, 2009 #3,632 Publisher-Barry Block, DPM, JD

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Podiatrists Say Diabetes Prevention Isn't Attention-Getting 

It costs $1,400 to cover the oozing sore on the diabetic’s foot with a piece of artificial skin, helping it heal if patients keep pressure off that spot. So, when Medicare paid for the treatment but not the extra $100 for a simple walking cast to protect it, an artificial skin maker last year started giving free casts to some needy patients. Without the right cushioning, "the person will walk to the bus stop and destroy it," fumes Dr. David G. Armstrong of the Southern Arizona Limb Salvage Alliance.

Dr. David G. Armstrong

"There’s no magic medicine right now for the diabetic foot," says specialist Dr. Lawrence Lavery of Texas A&M University, who bemoans that simple-but-effective preventive care just isn’t attention-getting. "People come in (saying), ’Hey, my wife noticed a bloody trail today as I was walking across the linoleum in the kitchen. What should I do?’"

Dr. Lawrence Lavery

"There’s great variability in how insurers pay for foot screenings before someone’s deemed at high risk," says Dr. Harry Goldsmith, a consultant on podiatric reimbursement. A thorough foot examination can identify those patients who have circulation problems or a lack of feeling in their feet or difficulties in healing.  Medicare patients who have certain risk factors qualify for the next step, periodic reimbursed hygienic foot care by a doctor. While the covered foot care is important to reduce the chances these "at risk" patients accidentally injure themselves by trying to cut their nails or their calluses, even more importantly, the visits with a podiatric physician allow for periodic foot examinations directed at identifying early on any problems, such as infections or wounds, as well as note any changes in circulation or feeling, affecting the patient.  Identifying and preventing a foot problem from progressing is the key to keeping at risk patients on their feet and healthy, says Goldsmith..

Dr. Harry Goldsmith

Source: Lauran Neergaard, Associated Press [8/24/09]

GOP Outlines ‘Seniors Healthcare Bill of Rights'

Congressional Republicans have issued a so-called “Seniors' Healthcare Bill of Rights” to ensure that any forthcoming reforms don't shortchange or bankrupt the nation's elderly.

“Republicans believe that reforms to America's healthcare system are necessary, but that reform should first do no harm, especially to our seniors,” the Republican National Committee said in a written statement. Protecting Medicare is at the top of the Republicans’ bill of rights. “President Obama and congressional Democrats are promoting a government-run healthcare experiment that will cut over $500 billion from Medicare to be used to pay for their plan. Medicare should not be raided to pay for another entitlement,” the document stated.

The GOP accused the Democrats of developing a plan that would give patients less power to control their own medical decisions or end-of-life treatment, and create government boards that would decide what treatments would or wouldn't be funded.

Source: Jennifer Lubell, Modern Healthcare [8/24/09]

EHRs Have Open-Source Software Alternatives

For physicians trying to figure out how to adopt health information technology without going broke or dealing with salespeople, open-source software may sound like a godsend. Proponents of open-source software -- developed with an open code that is made available, at no cost, in the public domain to download and change as needed -- say it provides a health IT system that costs much less than commercial, proprietary systems. And, physicians who adopt open-source programs can participate in a collaborative community that can help them get the most out of their health IT systems.

But as with any system, there are trade-offs. For example, while open-source software is free, you will need to have a plan for installing and supporting the system. And while an active community could mean getting the upgrades and tweaks you need in real time, if the user community eventually fades away, you might be stuck with an extinct program. Then there's the question of whether your open-source program will qualify under the Dept. of Health and Human Services' "meaningful use" definition. This is critical if doctors want to share in the $19 billion in health technology money available through the federal stimulus package, as well as in future funds from government programs.

Source: Pamela Lewis Dolan, AMNews [8/24/09]

Don't Respond Defensively to Personal Attacks

Train employees to respond to personal attacks with a direct question instead of a defensive answer. Example: “You sound angry. Are you?”

Source: Adapted from “Employee Relationships: Dealing With Difficult People at Work,” via Communication Briefings

Query: Alcohol Sclerosing Injection Denial

I just received a rejection from Blue Cross/Blue Shield for procedure, CPT 64632 (destruction by neurolytic agent; plantar common digital nerve). The reason given was that Blue Shield does not pay this type of provider for this service. Can that be correct? Can Blue Shield not pay a provider licensed to perform this service? It seems prejudicial. What is my recourse?

Bob Kornfeld, DPM, Manhasset, NY

Response: Many times when explanations like "does not pay this type of provider for this service" are given for a new code (as of January 1, 2009), the payer has not updated their claim processing software. Typically, with the help of your state association, the payer will modify the editing program allowing reimbursement. Be aware, however, that there is no guarantee that the payer will include the service under its benefit program (not a plan benefit). Also, the payer could label this type of injection investigational/experimental, or the payer could require you to provide that the concentration of alcohol you are injecting meets the "destruction by neurolytic agent" definition, or the payer could impose special review requirements, such as pre-authorization or prepayment review.

While you work on the big picture of reversing the denial language, you should appeal your specific denial. Include in the appeal the medical records associated with and leading up to the decision to perform CPT 64632. You may want to copy your state scope of practice, and include it to show that, indeed, you are licensed to perform the procedure.

Harry Goldsmith, DPM, Cerritos, CA

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

RE: Income Per Patient (Michael Cohen, DPM)
From: Multiple Respondents

Keep in mind that average numbers represent a wide range of possibilities. In the example of the $90 average income per patient cited by Dr. Guiliana, the range can be from a low of $50 per patient to well over $170. For this reason, do not set the “average” as your final target.  Also, keep in mind that increasing total revenue is determined by multiplying the average revenue per patient by total volume, and total profit is found by subtracting total expenses.  Increasing volume and/or average revenue per patient simultaneously impacts such things as quality, costs, office capacity, and available time, so any major improvement in profit will ultimately require focusing on “everything.”

Jon Hultman, DPM, MBA, Los Angeles, CA,  jhultmaned@calpma.org

The best way to increase income per patient is to drop out of managed care contracts. Then, you create a realistic fee schedule based on your practice's unique expenses and monetary requirements.  
 
Bob Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com

That’s a great question, and luckily, there is a great answer. The answer is to become active in the pursuit of how you treat your patients. As doctors and surgeons, we must attend the requisite academic meetings to hone our knowledge and skills. Unfortunately, just being an excellent doctor is not enough in today’s environment. You must lean the “business” of medicine. This includes marketing, coding, employee and money management, patient satisfaction, and procedural efficiencies within the office - just to name a few. Even if you are an associate, there is a good chance you may not always be. The last thing you want is to be scrambling for this knowledge in the eleventh hour. 

Although “per patient value” was discussed, this is in no way the total picture of practice success, how well you are treating your patients, nor should it be viewed as the mark of success.  Having said that, I know that this number increases as you find ways to code for what you are already doing, make sure the money gets to your office, and learn how to keep more of it once it gets there.  I also know that it increases as you learn better ways of treating the conditions we treat. 

One of the best ways of finding out all of this information is to become a member of the AAPPM (American Academy of Podiatric Practice Management (aappm.org). I don’t say that because I am a member of its board. I say that because early in my career, I was so impressed, I kept attending the meetings and I can attest that it has changed my career exponentially. The Academy has some of the best meetings I’ve ever attended, it provides assistance throughout the year with a resourceful web site, monthly mentoring conference calls, such as the one you were on, and is always available to its members. If you put your patients first, live by the golden rule, and use the resources that are available to you, success will follow. 

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: We're Medical Doctors (Alan Sherman, DPM)
From: Multiple Respondents

It may be somewhat “flattering” that doctors outside our profession may want to call themselves podiatrists. In the United States, however, I am pretty sure that designating oneself as a podiatrist is an infraction of the law unless that person holds a Doctor of Podiatric Medicine degree. Those people who call themselves podiatrists and do not hold the proper degree should be reported to the proper state board of podiatric medical examiners.

Pete Harvey, DPM, Wichita Falls, TX, pmh@wffeet.com

Healthcare reform, should it occur, will expand the need for primary care specialists exponentially. The one thing that seems absolutely true is that the U.S. is not remotely prepared for the predicted explosive demand. Even if you include nurse practitioners, physician assistants and others in the mix, it seems obvious that there will not be enough providers.
 
The next obvious step is to find a system whereby podiatrists can contribute in a more allopathic module. Obviously MD’s would be dead set against it, but our training is already very close to that of MDs in many categories. Certain systems like GYN and Urology could be excluded, but some aspects of general practice, like pulmonary, infectious disease, circulatory, and cardiac care would be permitted and expanded.
 
We would continue to provide (surgical) foot and ankle lower extremity care, as DPMs, but patients could come to see us for a multitude of other issues. If and when a condition arises that is not covered in our extended license, patients would be referred. All medical providers refer, and do for many reasons. Why not start the discussion now?
 
Two and three year surgically trained DPM’s should be allowed to take a 6 month fellowship on “allopathy” to be granted the new license. I’m not sure what the title of the new provider would be, but this would be open to suggestions….”(DPM—Allopathic)” 
 
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

Editor’s note: Dr. Allen Jacob’s extended-length note can be read at: http://www.podiatrym.com/letters2.cfm?id=28361&start=1 

RE: Timing of Charging for Orthotics (Lowell Scott Weil, Sr., DPM)
From: Paul Kesselman DPM, Ian Klein, DPM

Medicare establishes the date of dispensing as the date one must bill for a DME device, and all professional services related to a device are also inclusive of the devices HCPCS code. Many insurance carriers have policies which somewhat deviate from Medicare’s. Some companies include all the professional services (casting, biomechanical), whereas others such as Cigna (see recent APMA postings) do allow for separate casting coding.

Some insurance companies also have a different fee schedule for all orthotic codes for orthotists than they do for physicians. This is because they consider the HCPCS code as an all-inclusive service for the orthotists, whereas for the DPM, they are assuming they will be paying separately for evaluation and follow-up visits. Therefore, it is up to the individual provider to inquire with each carrier and ask:

What their policies are with respect to what the appropriate dates of service and when they may be billed? Do they consider the casting and biomechanical separately from the devices? May an E/M coding be billed on any follow-up exams related to orthotic modifications and repairs?

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

I remember a few years ago, a DPM getting indicted in Florida. One of the charges against him was billing for orthotics before actually dispensing them, and it was definitely not a Medicare patient, because Medicare doesn't cover traditional orthotics, yet 85%  of the podiatrists in the PM News quick survey  answered that they bill at the time of casting.
 
Ian Klein, DPM, St. Petersburg, FL, iklein1@tampabay.rr.com

ASSOCIATE POSITION – CENTRAL FLORIDA

Growing practice east coast of central Florida looking for full or part-time associate willing to buy into practice. PSR 24/36 Please contact: pfk4@yahoo.com.

ASSOCIATE POSITION - CAMBRIDGE, MA

This well-established practice in podiatric medicine and surgery presently has two office locations and a rehabilitation hospital with a focus on wound care. This is a fast-moving environment that continues to grow and necessitates a podiatrist who is eager and willing to support this growth. Candidate must have completed a surgical residency. This is a full-time position but will entertain part time yet requires an individual who is flexible with coverage as needed. Send CV and Letter of Interest to: dmost5@aol.com

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

ASSOCIATE POSITION - NEW JERSEY

Established successful practice in Central New Jersey seeking PT/FT Associate. PSR 24/36. Please forward CV to rpg145@gmail.com or fax 908 753-0199.

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

ASSOCIATE POSITION - FREDERICK, MD

Well-established and growing 2 office state-of-the-art practice located in medical/professional buildings. EMR, Digital X-ray, Ultrasound, DME provider, etc. Competitive Base Salary plus bonus, malpractice, health insurance, etc. PSR 24 minimum/Board Qualified or Certified with ability and desire to take ER call. If interested, forward CV to DOCSBNB@aol.com

ASSOCIATE POSITION - BOSTON, MA

Associate wanted, Full-time or part-time, for busy long time, well established, and well-rounded practice. Good mix of general podiatry and surgery. Office will generate approximately 100+ surgical cases per year. Must have surgical background, ABPS Qualified minimum needed to obtain hospital privileges. Associate position is open for partnership or purchase. Contact robert.nunberg@comcast.net

PRACTICE FOR SALE-VIRGINIA (SOUTHEAST)

Very busy office near Williamsburg. Currently, a satellite office 2 days a week. Great opportunity to make office full-time. Grosses approx. 130,000/year. The office has everything needed to start practicing. All included. Must sell. If interested, e-mail totalfootcareva@hotmail.com

LOOKING FOR ASSOCIATE POSITION  – CHICAGO, IL

I am a hard working and Ethical Podiatric Surgeon looking for Associate/Partnership position in the Chicagoland area. Please contact A773K@aol.com  or cell phone (713) 992-6113. 

ASSOCIATE POSITION - DALLAS/FORT WORTH AREA

Seeking well-trained ABPS board certified/qualified foot surgeon for surgical practice with national foot/hand/orthopedic surgery group. Excellent salary/benefits. E-mail CV and cover letter to: slb99@pdq.net

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to fmassuda@footexperts.com

ASSOCIATE POSITION – NORTH CAROLINA

Very busy practice in Western North Carolina, seeking Full-time Associate with hospital and surgical training. If interested please fax resume to 828-252-2272 or e-mail to mfas828@aol.com

EQIPMENT FOR SALE - ORTHOTIC FABRICATION SYSTEM

Amfit Orthotic Insole Fabrication System with Footfax SL Contact digitizer- For Sale Machine, Laptop, rolling bag, small inventory of shoes, insoles, all cords, parts and hardware Asking $10k.OBO! Please contact Jeff at Jhunt@psbank.net for further information, pictures.

WANTED: PRACTICE TO PURCHASE IN BERGEN COUNTY NJ

DPM interested in purchasing a practice in NNJ. If you are considering selling/retiring/slowing down etc let's talk and come to a mutually beneficial arrangement. Open to all situations/options. Contact: AdvancedFtCare@aol.com for quick deal.

ASSOCIATE POSITION - MARYLAND

Full time, hard-working, happy and personable Foot Surgeon needed for busy and growing practice in Frederick and Hagerstown Maryland. PM&S-36 or more required. We have a well-rounded, high tech practice with all types of pathology encountered in our two offices and in two local hospitals as well as our on-site accredited and certified ASC. Very competitive compensation. Please send your CV to drmichaels@rfainstitute.com

  ASSOCIATE POSITION - FLORIDA

Busy practice in East Central Florida in search of full-time podiatrist to perform routine foot care in office and nursing home. Competitive salary and full benefits available. Reply to jrdpm@bellsouth.net

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