The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 20, 2008 #3,353 Editor-Barry Block, DPM, JD

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Orthotics Can Prevent Pain During Pregnancy: CA Podiatrist

As pregnancy advances, as many as 80% of women experience significant pain in their feet, legs, neck, and back. Most people believe wearing good shoes and massage is all you can do about this very common affliction. According to Dr. Ron Worley, a San Diego podiatrist, a hormone is released in pregnancy that allows stretching of ligaments in the pelvis to facilitate the birthing process.

Dr. Ron Worley

“Unfortunately, Relaxin allows the foot ligaments to stretch, thus allowing the feet to spread and flatten out. This causes pain and strain in the arch, heels, on the knees, hips, and back and adds to the strain produced by the growing baby.” Dr. Worley says custom-made foot orthotics offer great relief.

“Orthotics are custom-made supports that cradle the feet inside the shoes and hold them in a corrected position. They are a safe, effective, non-invasive treatment for the foot and postural problems of pregnancy. They are effective in treating the same problems in others, as well.”

Source: I-Newswire.com [9/18/08]

FL Podiatrist is a “Weekend Engineer” at Railroad Museum

The Railroad Museum is a museum where you ride the rails. “This glorifies the railroading experience of the 1950s, which was the heyday of passenger railroading in America” says Peter Mason, a Largo, FL podiatrist who serves as volunteer engineer.”

Dr. Peter Mason

Mason is quick to invite guests onto the half-century old iron horse #1633 for a 90 minute tour. “We’re just here to make people happy and teach them about railroads, he exclaimed.

Source: Florida on a Tankful

Hospitals Slow to Subsidize Physician EMRs: Study

Because of the burden of other ongoing hospital information technology projects, budget limitations and lack of physician interest, hospitals are not significantly taking advantage of the relaxation of federal physician self-referral and anti-kickback regulations. These regualtions allow subsidization of physician purchases of electronic medical-record systems. This was the conclusion of a Robert Wood Johnson Foundation-funded study released today by the Washington-based Center for Studying Health System Change.

In the study of 24 hospitals in 12 representative metropolitan areas, only seven reported pursuing a strategy to provide financial or other support for physicians to purchase EMR systems, with four saying they had begun implementing or had implementation scheduled in the near future. The other 17 hospitals were said to be in various stages of planning and evaluation with no action expected to be taken this year.

According to the report, the main factors identified for motivating hospitals to support physician EMR adoption were quality and efficiency improvement and "aligning physicians more closely with the hospital."

Source: Andis Robeznieks, Modern Healthcare [9/18/08]

Draw Out Patient Concerns

Patients who are trying to hide something from you may voice concerns or make requests repeatedly. Don't glide over them. Instead, point out that the person has raised the issue before, paraphrase the concern in your own words, and ask if that is the underlying concern.

Example: "You have mentioned a couple of time how deep-seated that problem is. Perhaps you are wondering if this surgical procedure really can correct your bunion and relieve your pain. Is that the source of your hesitation?"

Source: Adapted from Passing the Test: Masterng the Hidden Agenda in Client Conversations by Morley Segal and Patricia Day Williams

Query: Foot Pain From Use of Growth Hormone?

I have a 12 y/o male patient who presented to my office with B/L severe leg, foot and heel pain for several months duration. Recently the LE pain has increased in intensity, making it difficult for the child to walk. No swelling, eccymosis or dermatologic changes. There was pain on palpation: medial tibia, plantar navicular, medial and lateral body of calcaneous. No muscle strength or joint mobility testing could be done.

Medical history is significant for: Nodular Lymphocyte Predominant Hodgkin’s lymphoma which the patient was treated for in 2006. Osteoporosis was diagnosed 4 days ago. Medication: Growth hormone somatropin injections for the last 10 months. The patient’s parents just discontinued this treatment 2 weeks ago. An MRI, ordered by an oncologist, revealed joint inflammation. On the patient’s initial visit, I treated him as if he had calcaneal apophysitis. OTC orthotics, stable shoes, heel lifts and stretching as tolerated.

Has anyone had any experience or heard of any adverse reactions (as described) from growth hormones? One of the precautions for somatropin is a slipped capital femoral epiphysis.

Ayne Furman, DPM, Alexandria, VA

Query: Loss of Income Insurance

We are victims of Hurricaine Ike and had to close our office due to lack of electricity and are still not sure of when we can regain power to see patients. We carry a Loss of Income policy with our insurance company but I was told it was a "grey area" when it comes to doctors as they can always reschedule patients. We have a very busy practice with only so many hours in a day and it will be next to impossible to reschedule the patients (not to mention surgeries) that we had to cancel, plus the existing ones. Does anyone have experience with this matter relative to Loss of Income Insurance and how to file the claim so it would be more insurance-specific?

Name Withheld (Texas)

Query: Denial CPT 11720 - Billed With CPT 11719

I was denied on CPT 11720 for a patient with NGS Medicare (NY). She was seen in her home. The patient had two painful, mycotic toenails while the remaining nails were both painful and dystrophic. The patient has peripheral vascular disease with qualifying class findings. I billed as follows:

CPT 11720 linked to ICD-9 110.1 (onychomycosis) and ICD-9 729.5 (pain) on the next line
CPT 11719-Q8-59 linked to ICD-9 703.8 (dystrophic nail) and ICD-9 440.20 (peripheral vascular disease).

I was paid on CPT 11719, and denied CPT 11720 with a CO-B15 denial, "payment adjusted because this procedure/service is not paid separately." This is the first time I can remember being denied this. I've never had this problem before. Any help would be appreciated.

David Sands, DPM, Great Neck, NY

Response: You have committed the mortal sin of combining at-risk foot care (CPT 11719 linked to peripheral vascular disease) with symptomic mycotic toenail debridement (linked to pain). If the patient has PVD where they have non-mycotic nails, doesn't that same foot with the mycotic toenails qualify for at-risk care as well?

I would consider resubmitting the claim as follows using your PVD ICD-9 diagnosis: CPT 11719-Q8, CPT 11720-Q8-59 .

If the patient also had hyperkeratosis requiring treatment, it would be added as: CPT 1105x-Q8 with no other modifier.

Paul Kesselman, DPM, Woodside, NY

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RE: Hyperbaric Oxygen Chambers (Joe Gonzalez, DPM)
From: Ira Weiner, DPM

With regard to DPM's being able to legally supervise hyperbaric treatments, here in Nevada, several of us were able to lobby the state to allow DPM's to legally supervise hyperbaric treatments. The law was passed as a temporary measure, making Nevada only the second state to allow this. We were assisted by the CEO of a local hospital in getting this important measure passed.

There are, however, some caveats and most importantly, it is up to the individual hospital as to whether or not they will permit it according to their bylaws regardless of whether or not the DPM is certified to do this. Second, the hyperbaric center has to be associated with the hospital's main campus with a full-service emergency room on site.

Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

I am not in agreement with Dr. Suzuki's take on hyperbaric treatment and scope of practice for podiatrists. The Board of Podiatric Medical examiners in Tennessee have been asked to address this issue on many occasions. Our scope of practice act, does not preclude podiatrists from supervising hyperbaric treatment. I would doubt any other states law specifies you cannot supervise such treatment. The issue is: Will you get paid or not for supervising? Those are two separate issues. And as for not being able to examine a patient’s ears, I respectfully disagree. I regularly examine patients' ears for chronic tophi deposits, and I am sure others do the same. We should always examine the patient, and not just the foot.

David Long, DPM, Paris, TN, ParisDPM@aol.com

RE: Dealing With Employees Who Forget to Punch In and Out (Cheryl Martinetti, PMAC)
From: Joel Lang, DPM

The employees are not 'forgetting' to punch in or out - they are showing you that they resent the process. Paying by the hour is the fairest way to compensate employees in my opinion, but you need to respect their honesty until proven otherwise.

I suggest you have a time-sheet that you photocopy for each pay period and have employees notate their time in and out by hand. If someone forgets, establish a default number, either for the time in or out, or the number of hours credited for that day. They will appreciate the trust you show in them. The blanks of the sheet will encourage employees to remind each other to sign in or out. With the clock, they do not know who has or who has not.

You may find that an occasional employee will try to take advantage of the system by a few minutes each day, but the confidence you show your staff as a whole will more than make up for it. Eventually, that individual will be found out.

Joel Lang, DPM, Cheverly MD, langfinancial@verizon.net

RE: Restrictive Covenant
From: Pat Caputo, DPM

For basic discussion, a restrictive covenant must be reasonable to be enforceable. Since most physician contracts include a restrictive covenant, many state courts employ a balancing test to determine if a covenant is reasonable. While complicated and variable state to state, many factors are weighed, including duration of restricted period, geographic distance of restricted area, as well as the nature of the practice specialty and community needs. Three concepts needed to consider a covenant not to compete reasonably are; 1) the provisions are not broader than necessary to protect the business interest of the employer, 2) are not unduly burdensome as to restrain trade of the physician under restriction, and 3) are not harmful to the public interest. An AMA website offers some more insight. ( ama-assn.org/ama/pub/category/12716.html)

Pat Caputo, DPM, Holmdel, NJ, pat_caputo@alumni.rutgers.edu

RE: False Testimony by Expert Witness (Walter Perez, DPM)
From: David Mullens, DPM , Esq

As an attorney specializing in healthcare law, I completely respect the rights of an injured plaintiff to seek relief through the legal system and there certainly are cases where the treating podiatric surgeon has fallen below the standard of care with resulting (avoidable) injury to a patient. I can also tell you there are many podiatric “experts” willing to say whatever the plaintiff’s attorney wants them to say – as long as the hourly “expert” fees are paid.

PM News performs a wonderful service by publishing complaints from doctors like Dr. Doolan, who maintains he has been the victim of intentional false testimony on the part of a plaintiff’s expert. Let the plaintiff’s expert explain himself/herself to the podiatric community through a response posted in PM News. If the plaintiff’s expert chooses not to respond, well, that allows an obvious inference to be drawn.

David Mullens, DPM, Esq, Palo Alto, CA, dmullens@mullenslawoffice.com

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

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

PRACTICE FOR SALE - CORAL GABLES FLORIDA

Well-known practice for over 20 years. Excellent location on Coral Way with heavy traffic, great visibility and plenty of parking. Busy, fully-equipped, full- time office with established patients. Grossing over 300K with tremendous growth potential. Office is currently open and ready to take over immediately. For additional info contact QVAN@aol.com or 305-975-5516.

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership 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 - 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

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

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

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