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September 11, 2010 #3,955 Publisher-Barry Block, DPM, JD

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Congratulations to STEPHEN BENNETT, DPM of New York, NY, winner of a copy of Reconstructive Foot and Ankle Surgery: Management of Complications: Expert Consult - Online, Print, and DVD by Mark S. Myerson, MD (Value $229).

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 2011 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.

This week's prize is 15 contact hours of PM's CPME-Approved CME program (Value $139).  

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

We've just mailed the September 2010 issue of Podiatry Management. This special orthotics and biomechanics issue includes over a dozen articles on this timely topic. In addition, you'll  find our usual assortment of features, including our columns, and a CPME-approved CME.

September 2010 Podiatry Management

Vit E and Magnesium Helpful for Charley Horse: CA Podiatrist

Steven Subotnick, DPM, a sports podiatrist in Hayward, CA and author of Sports and Exercise Injuries says that a Charley horse and a leg cramp are different. The leg cramp comes on gradually and is mostly the result of not enough blood supplied to the muscle. He says that this usually occurs in the elderly. A Charley horse "comes more suddenly and isn't necessarily related to physical activity or using the muscle,"

Dr. Steven Subotnick

Dr. Subotnick, suggests that taking either Vitamin E (but not for more than two weeks) or magnesium would help relieve the pain. He says a good source of magnesium comes from fish, especially halibut and mackerel, tofu, spinach, pumpkin seeds, and rice bran.

Source: Carol Roach, Health & Fitness [9/9/10]

Editor’s note: On this, the 9th anniversary of 9/11, we continue our proud tradition of publishing the following note from the editor, which was published in PM News on 9/12/01 and circulated via the Internet throughout the world.

It is just after 3 AM here in New York City and I simply can't sleep. Looking out the window of my bedroom on the 17th floor, there is an unobstructed view of the Manhattan skyline. I search again for the once familiar sight of the two tall white buildings that marked the lower end of the skyscraper-filled island. All I see are some eerie search lights of the rescue crews.

Like everyone else, I have been in shock all day, particularly since I witnessed in real-time the morbid views of the second plane hitting the World Trade Center and the sequential collapse of both towers.

World Trade Center 9/11/01

The gamut of emotions runs from shock, fear, sadness, to anger. Barely one half-century after the Holocaust, despite all our technological advances, man remains uncivilized. The realization sets in that the terrorists who committed this crime could have and still could set off a nuclear bomb, killing millions. The safety and security we have taken for granted in America is and will never be the same.

My phone has been ringing all day. Family and friends call to determine that everyone is safe. My mom calls to tell me my brother was scheduled to be at the WTC at 9 AM and was at the subway station when the first plane hit. Had the plane hit five minutes later, he would have been on an elevator headed for certain death.

Unfortunately, many thousands were not so lucky, including many employees of Blue Cross/Blue Shield, which only a few years ago moved from midtown to this location. There will be many tears shed as the names of those murdered in this horrific disaster become known, many unnecessary funerals to attend. So many innocent lives lost for no reason. So many families destroyed.

Later this morning, my wife and I will donate blood and attempt to do what we can in this time of crisis. We know the entire podiatric community will collectively pray for those affected by this catastrophe and provide whatever support is needed.

MD Podiatrist Excited About Raven's Super Bowl Prospects

As Jews worldwide ushered in the New Year this week, the Baltimore Ravens were preparing to kick off their 15th NFL season in a nationally televised game Monday night, Sept. 13, against the New York Jets. Emotions promise to be high as the Jets are making their regular season debut in a new stadium and the Ravens face Jets head coach and former Ravens defensive coordinator Rex Ryan. Many excited Ravens fans are already talking about Super Bowl prospects.

Dr. Edward Orman

Podiatrist, Dr. Edward Orman said, “I think the Ravens should have a good season and go deep in the playoffs, if they can avoid key injuries. Flacco should have a breakout year. He finally has good receivers and this being his third year, this is when most top QBs begin to gel. I am looking forward to two home playoff games, including the AFC championship game, then on to Dallas.”

Source: Stacy Karten, Baltimore Jewish Press [9/10/10]

Query: Bromhydrosis/Hyderhydrosis

I have a 30 yr old patient with excessive sweating and odor of both feet. The odor is her main personal concern. I have used: Certain Dry, B-Drier, antibacterial soaps, epsom salt soaks, wicking socks, absorbent powders, formalin, and Ditropan. There is no hyperthyroidism or hypoglycemia. Any recommendations?
 
Darryl Burns,  DPM, Monterey, CA

Query: How to Bill a Pan Met Head Resection?

How would I bill a pan metatarsal head resection with arthrodesis of the 1st metatarsal-phalangeal joint and arthroplasties of 2nd, 3rd, 5th proximal interphalangeal joint - all on the left foot? I was thinking CPT 28292-TA, but would I also bill CPT 28755-TA-59? And, for arthroplasties, would I then bill CPT 28285 for each?

Anna Sanders, Clarksville, TN

Response: The the fusion of the 1st metatarsal-phalangeal joint is coded as CPT 28750.
Removal of the lesser metatarsal heads is coded:
CPT 28112 for each lesser metatarsal head
CPT 28113 for the 5th metatarsal head resection.

If by arthroplasty, the doctor did both bone resection and soft work to reduce hammertoe-type deformities, then you would bill CPT 28285 for each digit - CPT 28285-T1, CPT 28285-T2 CPT,  28285-T4  (you may need a "-59" modifier also appended, depending on payer requirements).

You would not append a "T" modifier to the fusion of the metatarsal-phalangeal code. An "LT" modifier would be appropriate. You also would not bill for a bunionectomy - none was described.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here
APMA Members: Click here for your free Codingline Silver subscription

RE: Recalcitrant Ingrown Nails (Arti Chopra Amin, DPM)
From: Robert Scott Steinberg, DPM, Jordan S. Sheff, DPM

I had a patient return with a recurrence of a border. Before I repeated the procedure, I thought about what I might have done wrong, or what else could have happened. I settled on the idea that the borders at the phalanx were deeper down the sides of the phalanx.  On the redo, I more carefully felt all the way back into the corner, as I separated the border. Then, just to make sure, after the second phenol swab, I gently roughed-up the nail root with the narrow curved bone rasp, followed by one last phenol swab. This became my new procedure. Since then, I do not know of any recurrences. 
 
Robert Scott Steinberg, DPM, Schaumburg, IL, doc@footsportsdoc.com

I had a patient with the same problem years ago. He had a single hallux nail that was ingrown after 4 P&As. I performed a terminal Symes amputation on that toe, and he did fine and was very happy with his results.

Jordan S. Sheff, DPM, Newport, RI, jsheff@newportfootcare.com

RE: Pearls For Periungual Fibromas? (Jeffrey Kass, DPM)
From: Multiple Respondents

It has been my experience that just removing the lesions is not enough. One must resect the nail area and the matrix region to have a reasonable result. Otherwise, these lesions will re-occur. 

Steve Berlin, DPM, Baltimore, NY, drstevenberlin@yahoo.com

When I hear the words periungual fibromas, especially those that are recalcitrant, I remember a patient who presented with tuberous sclerosis. It's associated with mental retardation. Also, these patients present with periungual fibromas called Koenen's (pronounced "Kernan's") tumors. As a long shot, I'm wondering whether Dr. Kass's patient might fit this picture.

Carl Solomon, DPM, Dallas, TX, cdsol@swbell.net

Dr. Kass reports a case of recurrent periungual fibroma, even after he retracted the proximal nail fold. These lesions arise from the dermis, but they can "originate" in different locations. They can arise dorsally from the 1) underside of the proximal nail fold itself; 2) they can arise from the proximal most aspect of the sulcus of the fold, and 3) even from the dermis of the matrix.

In the first two locations (more common than the third), it is common for the nail plate to develop a longitudinal ridge owing to pressure on the proximal nail matrix. When arising from the dermis of the matrix tissue, the fibroma will actually dissect the hard nail plate and appear to grow within the plate. These differentiations, and the clinical appearance of the nail plate, and knowledge of how nails grow are critical to the pre-operative and intra-operative evaluation, to make sure one adequately resects the lesion at its origin.

Since the first two presentations are more common, some part of the proximal nail fold may have to be resected, instead of just flapping it back down. In the case of origin from the proximal most aspect of the sulcus, I find that a "cold steel" type elliptical wedge encompassing clinically normal tissue on both sides with primary closure is the best way (not perfect) to remove the lesion and minimize nail plate deformity. Unless these lesions are painful, or the diagnosis is suspect, there is no compelling reason to remove them.

Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org

RE: Scanning X-Rays (Barry Rosen, DPM)
From: Ken Meisler, DPM

I researched scanning x-rays and was told that it is very time-consuming, even with a $1,500 scanner. I believe there are scanners designed for x-rays that might be faster, however, they are much more expensive. I spoke with a few other podiatrists and found that the easiest way is to take digital photographs of the x-rays.
 
As old patients come in, I take all new x-rays on my 20/20 digital system and then I take digital photos of their old "film" x-rays and store them under the patient's chart # in Picasa. I then either put the x-rays in long-term storage "off-site" or destroy them. It is very quick and the quality is excellent. I do have a good quality Nikon SLR with 60mm macro-lens, however, I think you will be surprised at the quality you can get from a less expensive camera. You can then access your EMR program and see if you can download them into the patient's chart. If not, it is very easy to pull them up in Picasa.

Ken Meisler, DPM, NY, NY, kenmeisler@aol.com

RE: Mini C-arm Purchase (Craig Breslauer, DPM)
From: Jeffrey Conforti, DPM

I had two Hologic mini c-arms that were terrific.  I sold them, but not because they were bad units.
 
Jeffrey Conforti, DPM, Clifton, NJ,  jconfortiusa@yahoo.com

RE: Changing a Medical Record Under Threat (Aimee Judy, PMAC)
From: Michael M. Rosenblatt, DPM

Aimee Judy reported where a patient demanded that the podiatrist change a medical record to remove the risk of a pre-existing condition in order to assure insurance coverage. While it is true that the doctor cannot "erase" any medical records, it is also probable that this will not satisfy the patient. The editor responded also that the medical record cannot be changed, but lined-out, re-signed and left visible.
 
This situation can lead to violence against the doctor. Reporting it is essential, as well as carefully documenting it. Predicting violent behavior is very difficult. But there are some indications here that suggest this risk. It may help to try to "mollify" the patient, without doing anything illegal.
 
You can suggest to the patient that healthcare reform has now passed and difficulties with pre-existing conditions will stop. You can tell them that you could be prosecuted for a crime if you do what they demand, and that (in a worst case scenario) you could lose your practice license. Above all, you need to project  "sympathy" with the patient and the problem. If the patient feels you are unresponsive or "against them" there could be a violent reaction. Believe me when I say that violent incidents against doctors have occurred for lesser reasons!

In the meantime, vary your office hours and parking locations. Never drive the same way home twice for several weeks. Take reasonable precautions. As for notifying the police, that is hard to recommend at this time, unless a direct threat has been issued against you. Your best "defense" is to try to maintain contact with the patient in a "sympathetic" light, even though you cannot actually do what they demand.

Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

RE: PICA Case Closed Volume 16 Issue 3 Summer 2010 (Ira Baum, DPM)
Tip Sullivan, DPM

There is an interesting article found in Medscape Medical News regarding malpractice. Aug. 5, 2010- AMA practice survey (the equivalent of PM's survey) which polled 5,825 physicians (2007-2008). 95 claims were filed for every 100 physicians. 66% of claims were dropped or dismissed and 90% of the cases that go to trial were won by the physician.

Why do we go to trial? We go to trial to have a group of our peers make a judgment regarding...

Editor's note: Dr. Sullivan's extended-length letter can be read here.

IMMEDIATELY AVAILABLE- ASSOCIATE POSITION -CT (FAIRFIELD AND NORTH HAVEN)

Great opportunity. Join one of the largest podiatric groups in Connecticut. Well-established and progressive offices. Electronic medical records, digital x-ray, diagnostic ultrasound, Padnet vascular studies, nerve conduction studies, pinpoint and CO2 lasers, electrical stimulation and ultrasound therapies. Seeking a well-trained, personable, and highly motivated individual. Please send resume and current photo to dr.kassaris@yahoo.com

ASSOCIATE POSITION - SAN ANTONIO, TX

Immediate opening for motivated podiatrist with good people skills.  Associateship leading to partnership for the right applicant to help develop fast growing Northside San Antonio Texas practice. Attractive office and beginning income. CV and letter of interest to sadpmoffice@gmail.com

ASSOCIATE POSITION - FREDERICK, MARYLAND

Well-established group practice is located only 45 minutes from both DC and Baltimore. Immediate opening for a minimum PSR 36 Podiatrist for full time position. We have it all: EMR, digital x-ray, ultrasound, ASC, etc. Excellent salary with bonus structure and benefits. Please email resume to docsbnb@aol.com

MANHATTAN - FULL-TIME POSITION

Available for a Board certified/qualified podiatrist (PSR-24, PM&S-36 ). Located in Downtown Manhattan in a multi-specialty Orthopaedic office. We have a high-volume practice that treats routine care, trauma, sports-related injuries, hospital consults, and ER Consults. Contact fscudese@seaportortho.com

ASSOCIATE POSITION – NEW MEXICO

Enjoy the outdoors? Enjoy sunshine? Enjoy beautiful vistas? Come to the Land of Enchantment. Albuquerque position: Move into a ready-made practice, full ownership in five years when I retire. Board certification is necessary for hospital staff privileges. Recently renovated office with digital imaging, diagnostic ultrasound, EHR in process. Contact fitz@abqpodiatry.com

ASSOCIATE POSITION - BLOOMFIELD, NEW JERSEY

Part-time office, part of larger practice looking for associate with well-rounded podiatric skills. Board qualified a must. Ground position leading to partnership. Please email CV to doccapo@yahoo.com

ASSOCIATE POSITION - SW FLORIDA GOLF, BOATING & BEACHES

Great opportunity to join a well established podiatry practice. Excellent mix office/surgery, motivated experienced staff. Seeking full-time Associate PSR 12-36. Salary $100 Thousand + bonus package with benefits, early buy-in available to right candidate. Email resume to capecoralpodiatry@live.com or fax to 239-573-9201

FULL-TIME ASSOCIATE NEEDED FREDERICK/HAGERSTOWN, MARYLAND

Reconstructive Foot & Ankle Institute, LLC needs full-time DPM at least PMS 36 to join premier group in Frederick/Hagerstown, MD. ASC, EMR, DR-digital radiography and ultrasound, Vascular/nerve testing, DME, retail store, strong hospital affiliations, salary, bonus and benefits. Respond to drmichaels@rfainstitute.com

POSITION AVAILABLE - NEW YORK

Well-established, multi-doctor podiatry practice with offices in Putnam and Westchester counties. Compensation based on productivity. Excellent opportunity for recent residency graduate to build skills and learn practice management. Full-time preferred but right part-time candidate will be considered. Email cover letter and CV to: podiatry2011@gmail.com

PRACTICE FOR SALE – MASSACHUSETTS

Solo Practice Grossing over $700K yearly 4 days a week. Mostly surgical with heavy emphasis on peripheral nerve patients and pediatrics. General bread and butter podiatry as well. No Medicaid very little Medicare. Very modern office. 30 minutes north of Boston. Modern new equipment (digital x-ray, ultrasound, computer network, etc.). Great referral network. Website included. Option to buy the condo 3500sq ft. Have PICA practice evaluation to show you. Call 978-944-7789 for details.

PRACTICE & STATE LICENSED ASC FOR SALE (MARYLAND, DC SUBURB)

Full-time 38 yr old podiatry practice with state licensed surgical center. Fully equipped with digital x-ray, diagnostic ultrasound, 2 orthotic scanners, computer network, and well-equipped surgical suite. Retiring owner will stay on as needed for transition. Email dpmpracticeforsale@yahoo.com

MEDICAL SPACE AVAILABLE- MANHATTAN

Multispecialty Medical Building with 24/7 doorman. Prime Luxury Building and Location, Gramercy, Stuyvesant, Peter Cooper Area. 305 Second Avenue (17th-18th). Prior tenants past 23 years; podiatrist, dentist (plumbing/electric intact), internist. Ideal for podiatry, co-share with dentist, MD, etc. (flexible lease terms). E-Mail; jbdrun@aol.com Phone; 480-951-2480.

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

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