The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 05, 2009 #3,641 Publisher-Barry Block, DPM, JD

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Due to technical reasons, we are resending this issue. Some readers received an edition which did not include the section "RESPONSES/COMMENTS (NON-CLINICAL). We apologize for any inconvenience.  

Congratulations to Arthur Gudeon, DPM of Rego Park, NY, winner of an Insight scale (Value $79.95).

We encourage you to participate in this important survey at www.podiatrym.com/survey Completing this anonymous survey provides us with valuable data, which we will publish in the February 2010 issue of PM. It also makes you eligible to win thousands of dollars of valuable prizes. Enter by sending Question #43 (no answer necessary) to bblock@podiatrym.com along with your name and address.

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This is also your opportunity to vote for the next DPM and Non-DPM inductees into the PM Podiatry Hall of Fame. 

TX Podiatrist Advocates 3-Hour Rule for High Heels 

Whether it's stilettos, block heels, or wedges - Center for Orthopaedics podiatrist Tyson Green says when you consistently put your foot in unnatural positions, pain will ensue. "With high heels, you put more pressure on the forefoot area and the ball of the foot," says Dr. Green, "so a lot of people will get what we call metatarsalgia or pain underneath the ball of the foot." The trend of pointy heels has given way to more women complaining of toe pain. "The inside of the big toe will have some nail problems or will cause a type of ingrown toe nail," says Dr. Green.

Dr. Tyson Green

The unseen problems can also be more severe - like stress fractures and osteoarthritis. Dr. Green says since it doesn't look like high heels are going out of style anytime soon, there are some changes women can make to ease the pain. "There are different types of inserts, padding, different shoes. Varying the height of the heel is usually a good option," he says.

Dr. Green advises women to abide by the "3-Hour Rule." That means if you'll be on your feet for more than three hours, opt for lower heels with plenty of room in the toe-box area.

Source: Britney Glaser, KSLA-TV News [8/31/09]
 

FL Podiatrist Advocates Simple, Inexpensive Treatment For Morton's Toe

Dr. Burton Schuler says he has the secret to getting rid of many of those aches and pains in your body. The first place to look is your foot. “You have been putting abnormal stress and strain on that one joint.” Dr. Schuler says you may have a medical condition known as Morton’s Toe. He says millions have but don't know it.

Dr. Burton Schuler

Morton's Toe is when one bone in your foot, the first metatarsal, isn't working right and literally millions of people have this condition and it causes them to have pain. Dr. Schuler says it can cause bunions, corns and calluses, and most foot pain. But it can travel beyond that. "Their back, their knee, their hips, it can even cause TMJ, fibromyalgia, restless leg syndrome or leg cramps.

Dr. Schuler says the treatment is so simple some people just can't believe it will actually work."The treatment is very simple, inexpensive pad that costs between two and three dollars." Dr. Schuler has put all this information in a book entitled "Why You Really Hurt", a book that's doing quite well on Amazon.com.
 
Source: Neysa Wilkins, WJHG - News Channel 7 (FL) [9/1/09] 

Pfizer to Pay Record $2.3B Penalty for Drug Promos

Federal prosecutors hit Pfizer Inc. with a record-breaking $2.3 billion in fines Wednesday and called the world's largest drugmaker a repeating corporate cheat for illegal drug promotions that plied doctors with free golf, massages, and resort junkets. As part of its illegal marketing, Pfizer invited doctors to consultant meetings at resort locations, paying their expenses and providing perks, prosecutors said.

The government said the company promoted four prescription drugs, including the pain killer Bextra, as treatments for medical conditions different from those the drugs had been approved for by federal regulators. Authorities said Pfizer's salesmen and women created phony doctor requests for medical information in order to send unsolicited information to doctors about unapproved uses and dosages.

Use of drugs for so-called "off-label" medical conditions is not uncommon, but drug manufacturers are prohibited from marketing drugs for uses that have not been approved by the Food and Drug Administration. They said the junkets and other company-paid perks were designed to promote Bextra and other drugs to doctors for unapproved uses and dosages, backed by false and misleading claims about safety and effectiveness. Bextra, for instance, was approved for arthritis, but Pfizer promoted it for acute pain and surgical pain, and in dosages above the approved maximum.

Source: Devlin Barrett, Associated Press [9/2/09]

Query: Coding/Modifier Issue

I have been receiving denials for billing CPT 99213, CPT 11042, and CPT 11721. The denied code for CPT 11721 says, "included in payment for procedure that has already been adjudicated."  Any opinions?

Kimberlee Colaluce, St. Petersburg, FL

Response: Assuming you are properly documenting the 2nd procedure, simply add -"59" to indicate a separate and distinct procedure.

Richard Papperman, MBA, CHBME, Cape May Court House, NJ

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

RE: Subchondral Microcysts (Greg Caringi, DPM)
From: Allen Mark Jacobs, DPM, Robert Bijak, DPM

If the specter of osteomyelitis has been raised by MRI, you had best consider and reasonably rule out that possibility. Absent open biopsy and culture, obtain a CBC, CRP, or consider percutaneous/arthrocentesis and a C&S. Document well the reasons that you do not believe it is osteo (clinical signs and symptoms, laboratory studies, etc ).
 
Realistically, the diagnostic possibilities are AVN, reaction to Orthosorb, and far less likely, an undiagnosed inflammatory arthritis of DJD.  

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

I would suggest a rheumatoid panel. RA has small cysts early on, and also a thyroid profile for the osteopenia (hyperparathyroid). Do the usual metabolic chem panel with CA, alkaline phosphatase, and kidney function. Also, low estrogen can increase osteoclastic activity.

Robert Bijak, DPM, Clarance Center, NY, rbijak@aol.com

RE: Non-Fixated Osteotomies (Arden Smith, DPM)
From: Bob Hatcher, DPM, Pete Harvey, DPM

I would refer readers to the ACFAS Preferred Practice Guidelines regarding fixation of metatarsal osteotomies. The document on "Central Metatarsalgia" addresses surgical intervention, but rather carefully avoids the topic, indicating that fixation of central met osteotomies may or may not need to be performed. The document entitled "Tailor’s bunion and Associated Fifth Metatarsal Conditions" specifically addresses fixation in this manner: "In general, it is preferable to provide stable fixation of any osteotomy of the fifth metatarsal. However, in certain instances, where inherent stability and integrity can be maintained by other means of immobilization, internal fixation of distal osteotomies maybe deferred."

Hopefully, this will be of help not only in clinical situations, but in unforeseen legal ones as well.
 
Bob Hatcher, DPM, Raleigh, NC, Bob.RFC@intrex.net

Dr. Kass is correct that medical opinions might sometimes be purchased. If this were not true, it would, indeed, be interesting to see how many podiatrists would testify against other podiatrists in med-mal cases. There would probably be far fewer plaintiff experts in the courts.

However, printed standard of care (SOC) guidelines are an ivory tower nicety and a potential legal nightmare. If the SOC was used to defend you, and you won, then the SOC was great. However, if you lost because of that same SOC, then that is another story altogether. The only real answer is national tort reform such as we have in Texas.

As usual, Dr. Weil has made an astute observation, and left this particular discussion open-ended. Never say never. Never say always. The truth can be somewhere in-between.

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

RE: Posterior Tibial Neuropathy (Frank DiPalma, DPM)
From: Chris Browning, DPM

"Posterior tibial neuropathy" is a synonym for tarsal tunnel syndrome. The symptoms your patient describes are some of the classic signs and symptoms of tarsal tunnel. Injecting the "forefeet" probably won't help. Try injecting the tarsal tunnel. A thorough tarsal tunnel release of all branches of the posterior tibial nerve may be on the horizon for your patient. 
 
Be cautious with using EMG/NCV for tarsal tunnel diagnosis. You can send the patient to 5 different neurologists and get 5 different reads. MRI can be helpful to look for other causes like space occupying lesions/tumors/tendinosis/itis, but is not necessary. You can try Anodyne therapy if your patient refuses surgery.
 
Chris Browning, DPM, Nederland, TX, chrisbrowning@att.net

RE: Removable Walking Casts (Arden Smith, DPM)
From: Charles Morelli, DPM

Dr. Smith asks, "How are my colleagues dealing with patients who are in need of, but not covered for [DME] and who refuse to pay [or can't] for anything not covered by their insurance?"
 
I have never had a patient refuse to pay for any device that they "are in need of" if their insurance does not cover it.  Most people, even those who have a "financial issue", can scrape together the $100.00 they might need to cover the cost of a removable cast or CAM walker, a device that might have cost you all of $30.00 to purchase. When given the choice of a possible BKA due to infection or spending a few dollars to prevent it, most will choose the latter.
 
If they refuse, then read them the riot act, discharge the patient, and make sure you note documents.Document and document again what had transpired. Or, if they are truly destitute, be a mensch and give it to them .

Charles Morelli, DPM, Mamaroneck, GA, podiodoc@gmail.com

I think the answer is that you are running a medical practice, not a free clinic. Although, you obviously care for the well-being of your patient, ultimately, the patient is responsible for the cost of their care. If they have insurance - great. If not, they have to pay for your service. If you believe the best treatment is to have a modified CAM walker, then you tell this to the patient and you document it. If they can't afford it, then maybe you offer them a cheaper alternative, possibly a "u" shaped pad around an ulcer, or a cut out Plastazote. With Obamacare, things will only get worse. Insurance companies will pay for less and less. Do patients pull the same thing when they go to fill their car with gas or buy food at a store? If they don't pay at the pump, they don't get their gas; if they don't pay the clerk, they don't get their food.
 
In the past, I have had an occasional patient bring back a CAM walker, telling me their sprain or fracture has healed and they were going to throw it out. If it is in decent condition, you may consider disposing the soft liner, keeping the shell, and purchasing a new liner. Some companies do that, and then you can ask the patient to pay only the cost of the new liner. 
 
Jeffrey Kass, DPM,  Forest Hills, NY, jeffckass@aol.com
 

ALASKA- ANCHORAGE- IMMEDIATE OPENING – DON’T HESITATE

One of state’s largest podiatric providers is looking for an associate to join the practice with becoming a partner as part of plan. Practice has modern office on the campus of Alaska Regional Hospital and opportunities for surgery, in-office care and ancillary services. Great place to live for the outdoorsman. Three-year surgical residency preferred. contact: mcrosby@providerresources.com  AK03.

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 – 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 - 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

LOCUM TENENS POSITION – PHOENIX, AZ

Locum Tenens position available in West Valley Phoenix office beginning September 15th. Salary negotiable. One to two days a week in a friendly and casual office. Please direct all inquiries to drlaurel@cox.net.

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 – 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.

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.

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 - 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.

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