The Voice of Podiatrists

Serving Over 9,800 Podiatrists Daily

September 22, 2007 #3,047 Editor-Barry Block, DPM, JD

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“Every ounce at the foot, is like a pound at the hip” : CT Podiatrist

Tennis players who want to increase their speed or agility on the court choose lighter sneakers. Speed shoes, as they are sometimes called, weigh about a quarter-pound less than most high-performance footwear and can minimize fatigue during a long match. “Every ounce at the foot, is like a pound at the hip,” said David Sharnoff, a podiatrist in Shelton, CT, who has advised players on the Women’s Tennis Association Tour.

Dr. David Sharnoff

Lightweight shoes, he said, lessen stress on “lower extremity joints.” Built with weight-saving mesh, these shoes are cooler than your average clunker.

Source: New York Times [9/20/007]

Lack of Exercise and Poor Nutrition Lead to Hypertension: CA Podiatrist

A recent study by Morehouse School of Medicine reports that the rate of high blood pressure is on the rise among American children. In addition to putting children at risk of chronic health problems later on, high blood pressure can have more immediate effects and require constant monitoring, according to researchers, who added it was their belief that childhood obesity is the main reason for the increase of this disease.

Dr. Ernest Hook

"Our nation's children have entered a perfect storm of consuming diets that are high in fat, sugar and salt, while engaging in an increasingly sedentary lifestyle where television, video games and computers have replaced biking, swimming, slides, swings and monkey bars," said Ernest Hook, DPM, president of the California Podiatric Medical Association.

Source: The Acorn [9/20/07]

Maintenance of Board Certification Growing in Importance

Increasingly, efforts to boost quality and gain better value from the world’s most costly healthcare system are including attention to Maintenance of Certification, a little-understood but rigorous process by which physicians maintain board certification. For example, Democratic presidential candidate Hillary Rodham Clinton, in laying out the quality portion of her three-part healthcare reform plan in August, specifically touted these programs as a key step in enhancing quality. From the presidential campaign trail to hospital and health plan board rooms, Maintenance of Certification is a growing force in the industry.

Several of the nation’s biggest health plans—including Aetna, Cigna, Humana, UnitedHealth Group and national and regional Blue Cross and Blue Shield organizations—are embracing Maintenance of Certification as part of their recognition and reward programs. Physicians who do not participate are not highlighted in plan directories and miss out on higher plan reimbursements. Savvy hospital leaders, meanwhile, are examining ways to use elements of maintenance of certification to respond to the Joint Commission’s new requirements for physician credentialing and privileging. Furthermore, the National Quality Forum and the AQA quality alliance will be considering Maintenance of Certification for quality measurement endorsement.

Source: Cary Sennett and Christine Cassel, Modern Healthcare [9/20/07]

Query: Abnormal Osteoproliferative Changes in Toes

This 50 year-old Caucasian male has a chief complaint of discolored nails and a gradual enlargement of the tips of the hallux and fourth toes of both feet. There is no pain, injury, or previous surgery. Unremarkable medical history. Culture of nails revealed T. rubrum. X-rays were read by a radiologist as, "deformity of both the distal phalanx of the first and fourth digits."

Abnormal Osteoproliferative Changes in Toes

The x-ray film of left foot clearly shows some form of abnormal osteoproliferative reaction involving the distal phalanges of the hallux and fourth toes in a sunburst pattern. Of special note is the erosion of the corresponding middle phalanx of the fourth toe. Is this a manifestation of an underlying systemic illness or arthride, or perhaps a bone tumor such as osteosarcoma (primary) or a malignant metastasis from an occult site? Although I intend to promptly refer this patient to a musculoskeletal tumor specialist, I am looking for some basic answers or diagnostic clues that I can use in reviewing these films with the patient.

Greg Caringi, DPM, Lansdale, PA

Query: Coding for the Bivalving of a Cast

Is there a CPT code I can use when a physician bivalves an existing cast that he/she previously applied? I considered using CPT 29700 (removal or bivalving; gauntlet, boot or body cast), but this code should only be used if the cast was applied by another physician.

Tina Houser, Houston, TX

Response: You are correct that CPT 29700 can only be used if the physician who is bivalving the cast did not apply the cast.

If the cast was applied following a procedure that has a global period (such as bone surgery or fracture care), and you are still within the global period, then you also cannot bill for an evaluation and management service. If, however, the doctor did not bill a treatment CPT with a global period (e.g., the patient had a fracture, but rather than billing the CPT for closed reduction of a fracture, he/she billed an E/M service + cast application), then an E/M service may possibly be billed, assuming there was a distinct evaluation and management performed and documented.

Mark Schilansky, DPM, Catskill, NY

Codingline subscription information can be found at:
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RE: Discoloration of Nail (Zeeshan Husain, DPM)
From: Marc Mizrachy, DPM, Kent Biehler, DPM

This looks like a Pseudomonas infection of the nail. I like to remove as much abnormal nail as possible and then use Cipro otic solution The nail plate is always loose in these cases and the liquid can be easily placed underneath the remaining nail. If I do a total nail avulsion, then I may just use Silvadene or gentamycin cream instead.

Marc Mizrachy, DPM, Bridgewater, NJ, marcmiz@optonline.net

From the pictures and description you gave, the nail appears as if the cause of the discoloration and partial detachment from the nail bed is repetitive trauma. This is found when a patient has functional hallux limitus. As the first MPJ locks up during gait, the toe becomes ridged except for an increased dorsi-flexion of the tip of the hallux. Combine this with a shoe that has a flexible sole and you have a scenario of the nail being traumatized, causing it to partially detach from the nail bed and thicken. As the nail breaks down and becomes gryphotic, it can also pick up a fungal infection it that area.

Kent Biehler, DPM, Adel, GA, Kent.Biehler@va.gov

RE: Cosmetic Foot Surgery Prevents Future Structural Problems
From: Lawrence Oloff, DPM

When I read this reprint concerning "Dr. Footnomenal", I can only say that I am speechless. Over the last couple of years I have watched with trepidation the slow emergence of a trend towards cosmetic foot surgery. What possible arguments can exist for an invasive approach to what are essentially pain free normal functioning feet? Isn’t our primary goals as physicians are to cure disease and eliminate pain? When patients are pain free, clearly they have reached a point that we strive for as an end point of our treatment. When patients start out pain-free, surgical intervention has only risks and no benefits. No one can argue that there are legitimate situations where cosmetic surgery is indicated in the foot (i.e.. post trauma, burn wounds, gross congenital deformities, etc.).

I personally do not believe that “toe tucks" falls into this category. I imagine that doctors who practice the art of toe sculpturing for non medical reasons rationalize the basis for such approaches on the adverse psychological effects of possessing serious medical conditions such as wide feet and long toes. My answer is that is why we have psychiatrists. Advocates of this approach may also argue that this approach is “no different from breast implants.” My answer to those would be to consider the ramifications of a poor functional outcome after cosmetic foot surgery. The issue then becomes not just fitting into your Manolo’s but being able to get out of bed in the morning.

I would leave one thought to those who practice this art. Would you perform such a procedure on your asymptomatic mother or child? If you can still say yes, I would suggest looking in the mirror and asking the question one more time.

Lawrence Oloff, DPM, San Jose, CA, lmop11@comcast.net

RE: Humana Settlement Check (R. Alex Dellinger, DPM)
From: Robert Scott Steinberg, DPM

“We recommend that you add another $63.46 and mail your check to APMA Educational Foundation, 9312 Old Georgetown Road, Bethesda. MD 20814. If every podiatrist donated $100 to the Foundation, life would be much easier for our debt-burdened students.

The Humana class action settlement underscores how little Humana actually cares about providers. This tiny, no.....minuscule settlement clearly sends a message. The message for us is the insurance company executives see class action suits like this as a simple cost of doing business. In fact, this settlement is so ridiculous that it will embolden insurance companies to continue mistreat providers.

As for our debt-burdened students, what kind of spineless, roll-over-and-play-dead legacy are we leaving them?

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

I felt equally as incensed that for five years nine months of claims mismanagement we receive the magnanimous amount of $37.54. But far more important was that I thought they were supposed to in addition to a cash settlement agreed to revise their claims processing and payment processes to make them more transparent and more in line with other insurers. Within the last several days I've received several claims wherein if any additional service is provided on the same day as an initial visit, the initial visit is denied as part of the service. No other insurer to my knowledge at this time that I deal with does this, including the public aid department. Who is responsible for overseeing their compliance with what they agreed to besides the pittance cash settlement?

Dale M. Smith, DPM, Chicago, IL, DMSmithDPM@aol.com

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 -- www.homephysicians.com

PRACTICE FOR SALE - HARRISBURG, PA

Well established, very profitable, full time surgical and general podiatry practice available. Looking for a highly motivated individual for a turn key operation. Owner willing to stay on and to teach and train the right individual to run a successful practice. Multiple financial and employment options are available. E-mail blkdmddoc@aol.com

P/T ASSOCIATE POSITION - QUEENS, NY

10 yr old practice seeks motivated, surgically-trained individual . Fax CV with hours available to (718) 458-0053.

ASSOCIATE POSITION – CINCINNATI, OH

This is your once in a lifetime opportunity to join one of the largest, most successful practices in the United States. Start immediately with a six-figure income. If you are motivated, and knowledgeable in practice management, your income is unlimited. Please fax resume to: 513-577-7261

IN-NETWORK PODIATRIST WANTED – MANHATTAN

Busy Manhattan Office (2 locations) needs IN-NETWORK PODIATRIST, Can start immediately-Do not reply unless you are in with all plans Please respond to gelus07@yahoo.com

ASSOCIATE POSITION – LOUISVILLE, KY

Immediate opening for multi-office podiatric practice specializing in general podiatry, high volume orthotics, surgery, and advanced wound care. Looking for a motivated, surgically trained podiatrist. Partnership opportunity. Competitive starting salary, benefits, and pension. Please submit: CV, letter of intent and references to: jbroyles23@yahoo.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City. Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

PAIN-RELIEVING DEVICE FOR SALE

Matrix pain device, upgraded with latest Sanexas software. Great working order, operating manual, and programs to treat nerve and muscle pain, edema, circulation, inflammation, and other health problems. $28,000 new, will sell for $12,000. Covered by Medicare, most all insurances, coding and billing information provided. Photo can be seen at http://www.outcomemedical.com/matrix E-mail don@outcomemedical.com

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