The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

August 27, 2008 #3,334 Editor-Barry Block, DPM, JD

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Congratulations to Tara Blitz, DPM of Easton, MA, our second weekly survey contest winner, who has won a TempTouch® donated by Diabetica Solutions, Inc. (Value $99.95).

This week's prize is a Codingline Gold subscription, which includes "Direct to Expert" Hotline, CodinglinePRINT, discounts on Codingline products and services, plus much more (Value $529) . To enter the contest, complete the survey at www.podiatrym.com and send us question #43, along with your name and address. Be sure to vote in the survey for the 2009 inductees in the PM Podiatry Hall of Fame. All entries are eligible for future weekly prizes, so enter early.

Foot Problems Rarely Get Better on Their Own: NY Podiatrist

There's a reason we talk about "getting back on your feet" after an illness or staying "on your toes": healthy feet are necessary for an active life. Yet many doctors don't even look at a patient's feet during checkups, says Valley Stream, NY, podiatrist Andrew Shapiro, a spokesman for the American Podiatric Medical Association. That's a mistake, Shapiro argues, because foot problems rarely get better on their own. Feet tend to deteriorate with age, as the pad of fat on the sole slowly wears down and the effects of any structural problems--legs of unequal length, for example--accumulate.

Dr. Andrew Shapiro

Untreated problems can alter a person's gait, bring on other ailments and make it painful to walk or exercise. And when things get bad enough that people limit their movements, inactivity becomes another threat to their health. The feet also frequently provide the first warnings of diabetes and arteriosclerosis. So don't ignore your feet—they may be telling you something important.

Source: Temma Ehrenfeld, Newsweek, [8/26/08]

Appeals Court Upholds Death Penalty for IL Podiatrist

A federal appeals court panel has upheld the death penalty for a Chicago foot doctor convicted in 2005 of killing a disabled patient to keep her from testifying against him in a Medicare fraud case. In Monday's ruling, the three-member panel of the U.S. Seventh Circuit Court of Appeals agreed that the evidence was strong that Ronald Mikos (MEE'-kos) murdered Joyce Brannon and engaged in witness-tampering.

Dr. Ronald Mikos

The court dismissed some of Mikos' arguments, including his contention that federal agents didn't have the legal right to take weapons and ammo from his storage unit. One of the three judges did dissent on the question of sentencing, arguing that Mikos was entitled to a new death penalty hearing.

Source: Associated Press [8/25/08]

Census Bureau Finds Decline in Ranks of Uninsured

The number of uninsured people declined 3.2% to 45.7 million, or 15.3% of the population, in 2007 from 47 million, or 15.8% of the population, in 2006, according to a report released by the U.S. Census Bureau. The percentage of those covered by government health programs increased to 27.8%, or 83 million, in 2007 from 27%, or 80.3 million, in 2006, the Census Bureau found in its report Income, Poverty and Health Insurance Coverage in the United States: 2007. In other findings, the number of uninsured children declined 6.9% to 8.1 million from 8.7 million. The numbers of those covered by private or employer-based coverage did not change much from 2006 to 2007.

While some healthcare experts were encouraged by the report, Karen Ignagni, president and chief executive officer of America’s Health Insurance Plans, cautioned that a modest decline in the uninsured rate does not reduce the urgency of the healthcare crisis. “Today’s report showing that 45 million Americans are uninsured highlights a critical social and economic challenge that the nation must address,” she said in a written statement.

Families USA Executive Director Ron Pollack called the data “troublesome,” saying that public safety net programs such as Medicaid and, to some extent, Medicare, have swelled by 2.7 million as employer-based coverage has declined. “It is ironic at the very time the Bush administration has tried to cut back on Medicaid and twice vetoed the extension of children’s health coverage, the public safety net cushioned the loss of employer-based health insurance,” Pollack told reporters at a news conference in Denver.

Source: Jennifer Lubell and Matthew DoBias, Modern Healthcare [8/26/08]

Protect Your Reputation

Maintain control of your professional reputation by adhering to this guideline: Pretend that your "personal microphone" is always on. In other words, don't say anything at work that you would not want others to hear or repeat.

Source: Adapted from: Know Your Boundaries at Work by Darin Painter

Query: Finalizing of Chart Notes

In a discussion with another podiatrist, a question surfaced. He takes brief notes in his own shorthand while with the patient with the assumption that he will rewrite or transcribe them into a proper, full and legible note afterward (i.e., before the next patient or later in the day). Sometimes he gets busy and he doesn't get to transcribe his own notes until the next day, the next week, or 3 or 6 months later. Is there a requirement that notes be placed in final format in any particular time period following the visit? When you sign it, do you sign and date on the day you signed or when the original brief notes were taken?

Ronald Werter, DPM, NY, NY, hawkeyedpm@aol.com

Editor’s comment: PM News does not provide legal advice. Sound documentation policy is that raw notes should be transcribed and signed as soon after they are taken as possible. This is because the patient visit is still fresh in your mind. The longer the delay in completing the note, the higher the probability that relevant material will be forgotten or omitted. The final note should be dated for the actual day it is signed. Similarly, any changes in a note should be initialed and dated for the day those changes were added.

Waiting “3 or 6 months” to transcribe and sign a note demonstrates a disorganized poor practice pattern, and is extremely problematic should the chart be audited or subpoenaed for a malpractice case.

Query: Navicular Excision and Fusion

I have a case where the majority of the navicular was removed due to avascular necrosis which resulted from severe comminution from a prior fracture. An allograft was used, and the talus fused to the first and second cuneiforms. A combination of internal and external fixation was used.

Can I use CPT 28730 (transverse midtarsal fusion) alone, or could I use it also with a non-union repair code, CPT 28320? Or does anyone have another suggestions for me on this very difficult case.

Gregory Still, DPM, Denver, CO

Response: This does not seem to be an actual repair of a non-union, but rather it was excised/fusion. From a coding standpoint, the overall procedure would be a fusion in the midfoot area, CPT 28730. The use/type of fixation is not an issue from a billing perspective, unless, you used both internal and external fixation. If that is the case, I would recommend you additionally bill the application of uniplane ex-fix.

If you feel that the procedure(s) you performed are well above the norm for the code, then you could append it with a "-22" modifier.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here

RE: Course on Manipulation Prior to Casting (James M. Petko, DPM)
From: Howard J. Dananberg, DPM,

I have seen countless positive effects from lower extremity manipulation, and I am very pleased to hear of interest in this method of care. Manipulation involves far more than simple changes to joint ranges of motion, and can have a profound effect on the neurological system via alteration in the pain sensation threshold and muscular facilitation for guarding of the joints about which they function. It is a part of my practice I could not imagine working without.

As far as courses go, I will be giving a series of day seminars sponsored by Vasyli Medical: September 25, 2008, St Louis, October 4, 2008 New York (Long Island), October 17, Region One, Boston, November 1, 2008, Dallas and November 17, 2008 Tampa. Info about these meetings (except Region One) is available at vasylimedical.com in the seminar section. The subject matter involves sagittal plane theory, functional hallux limitus, custom and pre-fab orthotic treatment options, manipulation, and practical with treatment of participants, using the principles provided during the meeting. This will be a multi-disciplinary meeting and there is often a good deal of give and take among participants. Attendees are also given a DVD of the PFOLA sagittal plane and manipulation workshop along with a complete set of course notes. For the Region One meeting, visit massdpms.org for further information about the workshops offered there.

I have also published a series of articles on this and other sagittal plane concepts specifically for the Vasyli Medical website. These are available on-line to all, and just navigate through the Knowledge section. Other references include:

Dananberg, HJ, Shearstone, J, Guiliano, M “Manipulation Method for the Treatment of Ankle Equinus”, Journal of the American Podiatric Medical Association, 90:8 September, 2000 pp 385-389.

Dananberg, HJ “Ankle Manipulation as a Method of Care for Foot/Leg Pathology: Case Reports”� Journal of the American Podiatric Medical Association, 94:4 August 2004, pp 395-399.

Howard J. Dananberg, DPM, Bedford, NH, howiedbpg@aol.com

RE: Standard of Care Soft Tissue Masses (Bryan C. Markinson, DPM)
From: Erik L. Kenyon, DPM, Allen Mark Jacobs, DPM

The number of malignant masses that are removed from the foot is extremely small. I have removed hundreds of masses and found only one malignancy. To have an MRI on every mass, much less a frozen section on every mass, when you look at the probability of a malignancy, is not really a cost-effective or even required. A lot can be made from the history, location and physical exam. Large, quickly enlarging masses or masses in unusual locations benefit from a pre-operative MRI for assistance in planning and diagnosis. I don't think that you can find fault in not obtaining a frozen section during the routine excision of a mass, but if there is a malignancy, it absolutely needs to be referred to someone who specializes in the treatment of malignancy.

Erik L. Kenyon, DPM, Modesto, CA, ekgoal@yahoo.com

Malignant soft tissue lesions of the foot are uncommon. That is a statistical fact. The suggestion that MRI with contrast is REQUIRED prior to surgical intervention for extirpation of ANY soft tissue mass is NOT representative of the standard of care, and such comments only serve to provide inaccurate representation of daily practice. This situation is analagous to the "everybody should recieve DVT prophylaxis assertion."

Clearly, atypical lesions deserve greater pre-biopsy/excision diagnostic evaluation or possibly referral to more experienced healthcare providers. The suggestion that typically presenting ganglionic cysts require pre-excision MRI with contrast is a total waste of healthcare resources.

The only location wherein the philosophy of "a complete work-up for everything" is supported is in the office of plaintiff lawyers, not the offices of the average healthcare provider. With all due respect, perhaps Dr. Markinson needs to step away from the world of academic medicine and not tell those of us in daily practice what the "standard of care" requires.

Allen Mark Jacobs, DPM, St. Louis, MI, allenthepod@sbcglobal.net

RE: NAOMI DR (Pete Harvey, DPM)
From: Susan Ott

The NAOMI DR product was originally designed for the veterinary market, which was not successful. Then, a couple of years ago, they introduced this product to the podiatric market. From my experience as a sales manager for digital imaging equipment, I’ve had podiatrists mention to me their displeasure of image quality the NAOMI DR produced. I’ve been told by a couple of doctors, that they purchased the system with the intent to save money, only to find they aren’t using it at all, due to the image quality, lack of support and training. On the other hand, a doctor mentioned he was pleased with the product. The best a person can do is to research the product, check references, and request a demonstration of the product to see the image quality first-hand.

Please do not confuse the NAOMI DR with any other DR product(s) in the podiatry market. There are very good CR and DR digital imaging products available to the podiatric market that are designed for podiatry.

Susan Ott, Regional Sales Manager, iCRco – Chicago, IL

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

ASSOCIATE POSITION - WV/KY

Huntington WV Ashland KY area associate wanted with reasonable buy-in; great chance for growth; established patient base with all aspects of podiatry great for the established practitioner or new residency graduate. Any interest please respond to greatteayspodiatry@gmail.com

ASSOCIATE POSITION - NORTH TX

North Texas practice 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, excellent hospital involvement, and competitive salary with profit sharing. Send CV with references to info@ntfootcare.com, or fax to 903 868-2975.

MINNESOTA - IMMEDIATE OPENING

Well-established practice with 8 offices in the Minneapolis metro area seeking a highly motivated PSR 24/36 trained podiatrist for a full time or part time associate position. ABPS certified, qualified or eligible preferred. Excellent income potential with benefits including health insurance, malpractice insurance, relocation expense, association dues, license fees, hospital dues, continuing education expense. Possible buy-in or buy-out in future. Heavy emphasis on surgery and sports medicine with minimal RFC. Please e-mail CV to footandankledoc22@hotmail.com

PRACTICE FOR SALE - MINNESOTA

Minnesota-2 well established prime office locations for sale in the Minneapolis suburbs. Great income potential with large MD referral base .Can purchase one or both offices together. 175k gross/ each office. Owner will help with transition. Please e-mail minnesotadpm@live.com

EQUIPMENT FOR SALE - DOPPLERS

Selling 2 brand new Dopplers by Hadeco. 1 Hadeco Smartdop-30EX and 1 Hadeco Smartdop-45 Dopplers. Both come with their default accessories included, have never been used and are fully functional. Please email alinka345@gmail.com all inquiries.

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-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

ASSOCIATE POSITION AVAILABLE- NEW YORK

Full-time associate position in our well-established Midtown Manhattan and Forest Hills practices. Well-rounded practice with hospital based surgery and all phases of podiatric care. We are seeking PSR 24/36 trained podiatrist with good surgical background. Compensation to also include malpractice expenses. Forward CV to slurie@papapc.net or Fax to # 212-753-3521

ASSOCIATE POSITION – ILLINOIS

Quality Podiatry Group provides quality services to residents at long term care facilities. We are currently offering full-time or part-time positions for motivated ethical podiatrists. Immediate openings available. If interested fax curriculum vitae to 312 225-9366 or e-mail feetwork@aol.com

IMMEDIATE POSITION AVAILABLE TN/GA

We're in search of a motivated, well-trained DPM who is great with patients. Our well-established multi-doctor, multi-office practice is located in Southeast Tennessee/North Georgia. Must have Tennessee or Georgia license. Please reply via email to ikraus@sprynet.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 for this practice, ABPS Qualified minimum needed to obtain hospital privileges. Associate position is open for partnership or purchase. Contact robert.nunberg@comcast.net

Christie Clinic is a large Multi-Specialty Group practice located in Champaign, Illinois. We are seeking a PSR-36 ABPS Board Certified or Board Eligible podiatrist to join a well-established Podiatry department. Must be competent in all phases of podiatric care, Surgical and Conservative. This position will involve rotating through multiple office locations with surgical privileges available at two medical centers and two outpatient surgery centers. Very competitive salary, bonus plan, vacation, and health/mp insurances. Forward CV to wpierce@chrisiteclinic.com

PRACTICE FOR SALE MN: PRIME LAKES AREA

WEEKLY SPECIAL - One week of ads (5x) for $89 One month of ads (20x) for $340 .

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