The Voice of Podiatrists

Serving Over 9,800 Podiatrists Daily

September 01, 2007 #3,029 Editor-Barry Block, DPM, JD

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Congratulations to Deborah L. Cook, DPM of Mentor, OH, our weekly survey contest winner, who has won an ACME MADE Designer Slim Computer Bag (Value $149).

Bones and Cartilage

This week's prize is a copy of Bones and Cartliage by Brian K Hall (Value$104) . To enter the contest, complete the survey at www.podiatrym.com and send us question #45, along with your name and address. Be sure to vote in the survey for the 2008 inductees in the PM Podiatry Hall of Fame. All entries are eligible for the grand prize of a one-week Windjammer Caribbean Cruise.

Simple Stretch Can Relieve Plantar Fasciitis Pain: FL Podiatrist

Plantar fasciitis is a common problem for people who spend a lot of time on their feet. "It's an inflammation of the supporting soft tissue structure on the bottom of your foot," Podiatrist Michelle Detweiler said. Detweiler said unsupportive shoes make matters worse. "You need to be in a sneaker-type shoe with firm support around the back of your heel through the arch, more of a well-cushioned platform," Detweiler said.

Dr. Michelle Detweiler

Arch supports in shoes can help the disorder, and night splint while sleeping is often recommended. In severe cases, cortisone injections might be needed. Detweiler said the best thing to do for the pain is stretch. "Before you step out of bed, reach down, grab the front of your foot and pull up," she said. "You'll feel a stretch in the arch area. You should hold this for a period of 10 to 15 seconds before you put your first step to the ground in the morning."

A recent study followed 82 patients for more than two years and found 90 percent of those who followed a simple stretching routine required no further treatment.

Source: WTVJ-TV NBC 6 Miami (FL) [8/29/07]

Alleged RSD Following Complex Osteotomy (Kentucky)

Facts: Karl Adkins suffered for years from pain in his foot. In 1992, he had a surgery to remove a bone spur. The symptoms returned and in 2000, he treated with the defendant podiatrist,. That January Miller performed a radical osteotomy inserting a log screw.

The procedure didn't go well and despite two additional repair surgeries, Adkins, then age 44, continued to complain of pain in his right big toe. He has since been identified as suffering from RSD.

Adkins, a railroad yardmaster for CSX, now limps and has had difficulty working. His medical bills were $ 16,735 and he sought $ 50,000 for future care. The jury could award $ 100,000 for past suffering, plus $ 367,500 more for in the future. Impairment was capped at $ 715,711. His economic expert was Dr. William Baldwin, Lexington, KY.

Plaintiff's liability theory alleged negligence by defendant both in his surgical selection and then his technical performance of the procedure. The expert for Adkins was Dr. Richard Wiener, Columbus, OH, who was also a subsequent treater.

The defendant defended the case that the procedure was properly selected and performed. The complications were just that and not negligence. His expert was Dr. Gerard Yu, Cleveland, OH.

This jury in Greenup found that Miller had not violated the reasonably competent podiatrist standard and awarded Adkins nothing. A defense judgment closed the case.

Result: Verdict: Defense verdict on liability (September 29, 2006).

Plaintiff’s Expert: Richard Wiener, Columbus, OH

Defendant’s Expert: Gerald Yu, DPM (Now deceased)

Source: Kentucky Trial Court Review

AFL-CIO Campaigns for Universal Health Insurance

The AFL-CIO launched a campaign to achieve universal health insurance by 2009. “America isn’t running the way it should. Healthcare costs are pushing people to the edge and now 47 million have no coverage,” said AFL-CIO President John Sweeney at a news conference to announce the initiative. Sweeney said the labor federation was making the 2008 elections a “mandate on fixing the broken system.”

While it’s not endorsing any specific plan or presidential candidate, the AFL-CIO said it would fight for reforms that would control rising costs and give families the “opportunity and responsibility” for preventive care and the right to choose one’s own doctor. The labor group is also asking the government and employers to do their fair share to restore balance to the system.

“The first big push” of the campaign will be in early September, when union members will hold President Bush responsible for his failure to support reauthorization of the State Children’s Health Insurance Program, Sweeney said.

Source: Jennifer Lubell, Modern Healthcare [8/29/07]

Query: Requirements for a Podiatrist to Serve as a Coroner

I’ve seen a couple of articles recently about DPM’s serving as coroners. Are there any minimum requirements to be a coroner? I would’ve thought this was out of our scope of practice.

Scott Hughes, DPM, Monroe, MI

Query: Inpatient E/M Codes

What are the new and subsequent visit hospital E/M codes currently acceptable?

John DiMaggio, DPM, Bandon, OR

Response: If you are listed as the admitting physician of record, your initial assessment of the patient would be billed with the appropriate CPT 99221-99223 code.

If you are not the admitting physician of record, your initial assessment of the patient would be billed as CPT 99231-99233 (subsequent hospital encounter). In the narrative instructions just before the CPT 99221 codes in CPT, it tells you that the initial encounter by a physician who is not the admitting physician should be billed with CPT 99231-99233 ("subsequent hospital care") codes even though it is their initial encounter. Subsequent visits, regardless of whether you are the admitting or another non-attending physician of record - or even if you had initial provided a consultation service, would be billed with CPT 99231-99233.

If you are the admitting/attending physician, the work you do on the last day of the patient's hospital stay is billed with CPT 99238-99239 depending on the amount of time spent and documented. If you aren't the admitting/attending, the work you do on the last day of the patient's hospital stay is reported with CPT 99231-99233.

The only exception to the above is if the patient is admitted and discharged on the same calendar day. If you are the admitting/attending physician, you bill the combination codes CPT 99234-99236 for all of the work (admit, discharge and everything in between) you did that day. If you AREN'T the admitting/attending for one of these same calendar day admit/discharge (and the consultation criteria aren't met), then you bill CPT 99231-99233.

It goes without saying that this is presuming you won't be performing surgery. If they do have surgery, you can only bill an E/M code if assessment that day resulted in the decision to do surgery that day or the next. In that case, you'd add modifier "-57". But if it was a planned surgery, then no E/M codes are billed for the initial or subsequent evaluations of the patient, as compensation for those assessments in included in the global payment for the surgery.

Joan Gilhooly, CPC, CHCC, Deer Park, IL

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RE: High Cost of Malpractice (Richard Benjamin, DPM)
From: John Levin, DPM, Joe Boylan, DPM

I have to echo Dr. Benjamin's comments regarding Dr. Gorman. I too was involved in a case in which he testified, under oath that an amputation of a lesser digit, with osetomyelitis/septic joint, confirmed by biopsy was below the standard of care. His affidavit was filled with inaccuracies and totally lacked any reasonable scientific rationale for his conclusions. Even after being furnished with MRI reports, plain film x-rays and definitive bone biopsy results, and in spite of failure of six weeks of antibiotic therapy, Dr. Gorman chose to give false testimony regarding the true standard of care. I was dragged into this case which took over two years to resolve.

While I was finally dropped from the suit, at what cost to PICA? The case settled against one of our colleagues who did nothing wrong medically but just happened to have a post-operative complication from a hammertoe surgery that lead to osteomyelitis of the digit and adjacent metatarsal head. Once conservative therapy failed the definitive procedure was performed, (a digital amputation and distal ray resection) the patient healed uneventfully and actually had a quite functional result.

PICA paid over 70K for the claim against the operating surgeon in addition to the costs of my defense in this case. People like Dr. Gorman need to be "outed" They add to the cost of medical care and malpractice insurance. He is nothing more than a leech on system who seeks to profit at his colleagues expense. What a hypocrite to sand up and claim the costs are out of control and that were "in a deep hole." Jack, without people like you, the system might not be as bad off. Shame on you!

John Levin, DPM, Atlantis FL, John.Levin@OCPBC.com

It’s good news regarding the lowering of insurance premiums in PA. I would submit to Dr. Gorman that additional relief would be forthcoming if he were to sign and adhere to the ACFAS- Expert witness testimony standard and affirmation statement.

Joe Boylan, DPM, Ridgefield, NJ, Drb0327@aol.com

RE: Predislocation Syndrome (Michele Parker, DPM)
From: Multiple Respondents

In regards to injecting any local steroid in the area of a pre-dislocated MPJ, I would strongly recommend not using this course of treatment. There have been numerous times where I have seen joints become dislocated from the steroid's breakdown of connective tissue regardless of the strength of the steroid. This could lead to potential litigation. he issue also becomes you are letting the patient dictate the treatment plan. When this happens, you lose control of the patient. Sometimes it is better to let this patients walk away and find another physician. I have had this happen early on in my practice, and I remember this saying, "The success of your treatment depends upon which one of us is the doctor."

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

The treatment with infiltrated steroids would not be indicated, since the evidence reports worsening of the problem by weakening soft tissues. My advice is to use biomechanical control of subtalar joint and first ray with plantar support with a semi-soft silicone (custom-made) separator of the first space.

Marta Losa Iglesias. Phd, HLD, Spain, marta_losa_iglesias@hotmail.com

Although it is done, I would be concerned with injecting steroids for this particular condition. If the plantar plate/ capsule is weak or torn, the steroid injection can cause more harm than good. Taping, shoe modification and rice have not helped the posting stated. How the foot was taped or the shoe modified was not mentioned.

I realize all cases are different. I have had good success in these cases with placing a moleskin "u" pad under the second met head and then taping the toe in a plantar-flexed position with Elastoplast and sometimes even 1 inch Coban. I change the dressing weekly and then give electrogalvanic stimulation and ultrasound. (I rarely give physical therapy in my office but this is one time where I do find it helps). Sometimes I even place the patient in a cam walker after doing the taping.

I have on occasion given a plain local anesthetic to the MPJ without any steroid. I guess if all else fails surgery is an option. I did cringe when reading the last 4 words of the posting though - never "force" a surgery.

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

If the patient doesn’t want surgery or steroid injections please consider treating the patient for functional hallux limitus with lesser metatarsal overload. Consider orthotics with first ray cutouts, 2-5 reverse Morton extension, kinetic wedge, etc. You may also consider placing a Cluffy wedge in the shoe to pre-dorsiflex the hallux (article by James Clough in JAPMA last year). A Cluffy wedge often works well as a stand-alone device for 2nd MTPJ pain.

Michael B. DeBrule, DPM, Marshall, MN, drdebrule@starpoint.net

I want to comment on the last line of this posting that really bothered me, "last resort prior to forcing surgery?." I really believe this is where some doctors get into trouble. I feel that it is the doctor’s job to explain the situation to the patient in terms they can understand and then let the patient make their own informed decision about how to proceed. "Forcing" surgery on a patient should never be anything that is even considered.

Theresa M. Hughes, DPM, Galesburg IL, tmhughes@galesburgclinic.com

RE: Weeping Lesion on Leg (Barry Mullen, DPM, Philip Organ, DPM)
From: Bryan Markinson, DPM

This extended length note appears at http://www.podiatrym.com/letters2.cfm?id=15469&start=1

Editor’s Note: This topic is now closed.

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