The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 17, 2008 #3,350 Editor-Barry Block, DPM, JD

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NM Podiatrist Discusses Surgical Options for Arthritis of the Feet

The most common site for arthritis in the toes is the large joint at the base of the big toe, although arthritis can certainly cause problems at the other toe joints, too, says Dr. Richmond Kilpatrick, a podiatrist with Presbyterian Medical Group. Total and partial joint replacements are available for the toes. In a partial, or hemi, replacement, the end of one of the bones in the joint is removed and a small canal is created in the bone to hold the stem of an implant with a metal base. That base articulates against the adjacent bone, restoring motion.

Dr. Richmond Kilpatrick

In a total toe joint replacement, the ends of both bones in the joint are flattened and canals created on both ends. A silicone-like implant is inserted in the joint and stems on both sides of the implant are fitted into the canals.

Another alternative is arthrosurfacing, Kilpatrick says, in which damaged cartilage is removed from an arthritic toe joint and a metal cap is attached to one of the bones. The capped surface simply articulates against the end of the other bone. One of the best methods of pain relief remains fusion, in which the surgeon removes part of the toe joint, letting the toe bones grow together, or fuse.

Source: Albuquerque Journal, [9/15/08]

NYCPM Student Goes on Mission to El Salvador

Last month, New York College of Podiatric Medicine(NYCPM) third-year student Nicholas Giovinco worked for eight days in rural El Salvador as one of several volunteers from the International Institute for Foot and Ankle Surgery (IIFAS), a group dedicated to providing podiatric medical care as well as to training indigenous doctors to provide that care.

(left to right) Chris Menke, DPM, NYCPM 3rd-year student Nicholas Giovinco, and Dr. Joseph Giovinco

This year’s IIFAS mission to El Salvador was the Institute’s fourth annual mission to that country. The participants in the mission were Joseph Giovinco, DPM, an alumnus of NYCPM (1980); Chris Menke, DPM; and Nicholas Giovinco. The group brought with them over $25,000 worth of medical supplies donated by private individuals and companies.

The members of the group stayed with a family of local physicians in the town of San Miguel, and immersed themselves in the local culture, food and way of life. The medical campaign began with the evaluation of over 100 patients at the hospital of Nueva Guadalupe and nearby villages. Treatment for these patients included clinical and surgical care. A typical day thereafter consisted of surgical rounds in the morning, followed by serial castings, clubfoot surgeries, and reconstructive surgery for foot and leg.

IL Podiatrist Shaves His Head to Support Cancer Awareness

Dr. Joseph Borreggine, a podiatrist who practices in Charleston, IL recently shaved his head on behalf of the St. Baldrick's Society at the Razorz Edge Salon for cancer awareness in children. Borreggine lost a cousin in 1975 due to a brain tumor, and did this in honor of her memory. Borreggine volunteered as a shavee this past month and raised over $500 during his pledge campaign.

Dr. Joseph Borreggine goes bald for charity.

In conjunction with the event, Borreggine conducted a free foot screening at his office, where patients were able donate money and receive a free foot exam. There is a dedicated webpage available for anyone to make a donation to St. Baldrick's which can be accessed via Dr. Borreggine's practice website (myfeethurt.net). Dr. Borreggine will continue to accept donations for St. Baldrick's through the end of the year.

Steer Clear of Political Flare-ups

Many Americans look forward to Election Day for no other reason than that Nov. 5 promises a temporary halt to political rancor and debate.

Remember: Even if you are right in what you say about a political issue, you risk antagonizing between one-third and two-thirds of your patients.

Not sure whether your comments are likely to offend? Imagine that you are sitting as a patient in a doctor’s office and the practitioner starts to push a viewpoint that you personally disagree with. Then ask yourself how you would feel about that doctor. That should convince you to purge your remarks of political asides.

Source: Adapted from Communications Briefings [November 2008]

Query: Practicing Without Malpractice

I heard of some OBGYN's in a state out West who have their patients sign a waiver or contract or something of that sort stating that they give up any right to sue the doctor by signing this document. My guess is because malpractice insurance has become so outrageous, that some doctors are dropping their malpractice insurance to cut costs. My impression is that more and more doctors are going "bare" with regard to malpractice insurance. Is anyone doing that in our profession? Any comments on concealing assets in a legal manner and dropping malpractice insurance because it is becoming unaffordable? Is anyone doing it successfully? Has anyone tried it and then been sued and lost their shirt over it.

Stephen Pirotta, DPM, Bentonville, AR.

Editor’s note: PM News does not provide legal advice. The expression “concealing assets in a legal manner” is an oxymoron. In law, there is a concept known as “fraudulent conveyance” which states that you if transfer money to avoid a judgment, a court can negate that transfer. There are several podiatrists who practice bare, and recently PM News reported on one who is currently sitting in jail. Saving money by going bare is a gamble most podiatrists rightfully do not want to take.

Query: Coding Multiple Arthrodesis

If a surgeon performs the following joint fusions, how would this be coded?

1. Arthrodesis of navicular-medial cuneiform joint
2. Arthrodesis of first tarsometatarsal joint
3. Arthrodesis of second tarsometatarsal joint
4. Arthrodesis of first metatarsal base to second metatarsal base
5. Arthrodesis of medial cuneiform to middle cuneiform

Heidi Stout, CPC, New Brunswick, NJ

Response: I would suggest CPT 28730 (arthrodesis midtarsal or tarsometatarsal joints, multiple). I know a lot of procedures were done, and it may not seem like the reimbursement is enough, but the code selection is what it is.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here

RE: Risks of Prescribing Opiates For Chronic Pain
From: Michael M. Rosenblatt, DPM

I have not read the actual study in the Journal PAIN MEDICINE, which suggested that the actual risk from prosecution by DEA is "manageable and less" than is supposed by physicians.. But the article describing this study is suspect. It suggests that this study reviewed ALL physicians, and concluded that the actual number of prosecutions was small compared to the aggregate.

Not every physician treats chronic pain. In fact, only a small number actually do on a regular basis. When DEA makes the assumption that your prescriptions must "compare" to others in the area, this is a spurious requirement. Medical doctors have a wide range of practice specialties and preferences. There is no reason to require or anticipate homogeneity.

Any doctor who routinely prescribes opioids for chronic pain, and this may also include a small number of podiatrists, still have reason to continue to fear DEA prosecutions. Worse, when it comes to your time to require narcotic analgesics, perhaps in treatment of a painful tumor, your doctor might not be inclined to give you the required doses. I hope that is untrue, but the study, at least as reported in this article, does not suggest otherwise.

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

Restrictive Covenant (Name Withheld)
From: Ivar E. Roth DPM, MPH

For what it is worth, the buyout seems very reasonable and this Dr. signed the document when he started work for this practice. From my perspective, there is NO question that this Dr. is obligated to pay what he contractually signed for. I would like to hear why he thinks that he should not pay?

Ivar E. Roth DPM, MPH, Newport Beach, CA, ifabs@earthlink.net

RE: Chiropractors and Orthotics (Bob Kornfeld, DPM)
From: Robert K. Hall, DPM, CPed, Dennis Shavelson, DPM

In the past, I have been referred patients by area chiropractors for foot pain issues. In many cases, the problems were biomechanical (pronation). Often, when I dispensed fully -posted functional orthotics, the foot pain stopped. So did their associated back pain. A detailed report was then sent, citing the faulty biomechanics, lauding the DC for recognizing this issue and thanking them for their confidence in coordinating their patient’s care with me.

Result - no more referrals, since these patients didn't need more chiropractic adjustments.

Morale- Do what's right for the patient. Referrals are good- whether from other specialists or from their patients.

Robert K. Hall, DPM, CPed., Ft Lauderdale, FL, robertkhalldpm@bellsouth.net

Years ago, to pulse the orthotic industry, I became (and quickly dropped being) a C.Ped. and I became the "Biomechanics Editor" for an online chiropractic site called ChiroView. After four years of functional lower extremity biomechanics in podiatry college and clinical and practical experience, the best diagnosis, treatment and follow-up of patients biomechanically stereotypically lives in the podiatry community.

Our devices should stand as the final biomechanical answer for foot and postural suffering, pain syndromes and performance issues. Pedorthitc, shoe store, ski shop, chiropractic and physical therapy devices cannot offer levels of relief and correction that compare with podiatric treatment in our offices. If you think rubber butter, cork and OTC scaphoid pad orthotics coded L3000 compete with even the most basic foam cast, 3 degree varus rearfoot, post-to-cast podiatry semi-rigid device, you might be better off looking at home for reasons why your orthotics are not being dispensed as often or for a high enough fee.

When was the last time you took a course/conference dedicated to biomechanics? When was the last time you read articles on state of the art biomechanics by Payne, Dannanberg, Ritchie, Scherer, or Glaser?. When was the last time you upgraded y our biomechanical presentation? When was the last time you upgraded your diagnostic, casting, prescribing or dispensing techniques for orthotics?

Chiropractors will always be able to find a lab that will fabricate orthotics for them. It is too easy to ask labs never to dispense to them with the threat of removing your business. John Baptiste Moliére stated: It is not only for what we do that we are held responsible, but also for what we do not do. .

Dennis Shavelson, DPM, Medical Director, The FootHelpers Lab, drsha@foothelpers.com

RE: False Testimony by Expert Witness (Walter Perez, DPM)
From: Barry Mullen, DPM, Adam Cirlincione, DPM

Editor's note: These extended-length letters appear at: http://www.podiatrym.com/letters2.cfm?id=21972&start=1

PRACTICE FOR SALE -OREGON, WILLAMETTE VALLEY

Established practice in beautiful Willamette Valley of Oregon. Provider practices fulltime and has a well-established patient base with a strong patient flow. Practice is well-positioned for new growth and development. Doctor will transition after sale providing introductions to local referrals and healthcare facilities. Surgery privileges at local hospital and surgery center. Oregonpractice@comcast.net

PRACTICE FOR SALE - MAINE, SOUTHERN

Well-established practice located in Southern Maine seeking an associate. This is the only podiatric provider in the community. All services are office and hospital-based. No nursing homes. Senior doctor desires to bring an associate in to become partner. Strong patient base with very small amount of palliative care. southernmainepractice@comcast.net

PARTNER WANTED - COLORADO

State-of-the-art practice with EMR and digital x-rays, in our physician-owned Medical Office Building and Surgical Hospital. Focus on Sports Medicine, pediatric and adult flatfoot, bunion surgery, and homeopathic care. Great opportunity for self starter. Please send CV and letter of introduction to: greg@stilwellfeet.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 full-time podiatrist in a multi practice location in the Chicagoland and Northwest Indiana area. Must have two years of surgical residency. Please e-mail resume to d-kitchens@footexperts.com

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent practice associate leading to partnership opportunity for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes.Top hospitals. Fax CV with references to 703-491-9994

PRACTICE FOR SALE – CALIFORNIA

Practice is available immediately for sale in sunny Capitola, CA. The office space is available for lease or month-to-month. The practice has a loyal patient base which is mostly home visits and skilled nursing facilities in Santa Cruz county. The practice can be moved to another location or merged with an existing practice. Asking price $35,000.00. dtarsky@gmail.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

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