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September 26, 2007 #3,050 Editor-Barry Block, DPM, JD

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PICA to Sponsor Barry University’s Podiatric Rite of Passage Ceremony

The Podiatry Insurance Company of America (PICA) has committed to being the exclusive sponsor of Barry University’s School of Podiatric Medicine White Coat Ceremony for the next five years.

Barry University School of Podiatric Medicine and Surgery, Class of 2009

The clinical lab coats presented to the students during the annual ceremony mark the passing from classroom to clinic training and have been recognized since ancient times as the attire of the medical profession. When the Barry University School of Podiatric Medicine was founded in 1985, there were only 18 students, no clinics, and only one hospital affiliation. Now, the school has nearly 200 podiatric medical students with over 250 hospital-based externships, an affiliated three-year surgical residency training program, four Foot and Ankle Institutes, and more than 900 podiatric medical graduates.

The next white coat ceremony will take place on Friday, May 30, 2008 at 5 p.m. PICA’s committed support of $5,000 per year for the next five years, amounts to a gift of $25,000, noted Dr. Chet Evans, vice president for Medical Affairs and dean of the School of Podiatric Medicine.

Health Insurance Premiums Up 6.1%, Fast Outpacing Inflation and Wages

The rising cost of health insurance continues to drive a slow but steady decline in employer-sponsored coverage and an increase in the number of uninsured people, according to the authors of an annual employer survey.

Premiums increased 6.1% on average in 2007 -- the slowest rate since 1999, according to the "Survey of Employer Benefits 2007" by the Kaiser Family Foundation and the Health Research & Educational Trust. But that figure is more than twice the 2.6% rise in inflation and outstrips the 3.7% boost in workers' earnings.

Source: Doug Trapp, AMNews [10/1/07]

Query: Treatment For Verrucae

This 64 year old female presents with cracking plantar aspect of the foot B/L. She says problem started after a pedicure after being "rubbed and scraped" with a pumice stone. The punch biopsy report from two sites says verrucae.

Verrucae

Aldara has been effective, but expensive for the whole plantar surface B/L. Her medical history is negative. Any suggestions would be very helpful.

Kevin Lam, DPM, Naples, FL

Query: Lapidus vs. Midfoot Fusion

The physicians (in our practice) and I had an interesting discussion regarding the Lapidus procedure (CPT 28297). The physicians wanted to verify whether it is appropriate to bill CPT 28292 (Keller/McBride-type bunionectomy) with CPT 28297 (Lapidus-type bunionectomy) when rendering both services.

They also wanted to know the difference between billing the midfoot fusion vs. the Lapidus procedure. They are similiar codes with very different reimbursement. I can give them basic coding differences and CCI rules, but I wanted to get some feedback from other physicians.

Terri Phillips, CPC, Tulsa, OK

Response: Codes CPT 28290 - CPT 28299 are "bunionectomy" codes. Only one bunionectomy can be performed and billed per foot (anything else would be duplicate billing) by surgical procedure definition.

The different bunionectomy/hallux valgus correction codes represent variations on how (or to what extent) hallux valgus/bunion corrections are accomplished based on the presenting deformities. The Lapidus-type bunionectomy involves a metatarsal-cuneiform fusion plus a bunion correction. It is performed when there is 1) instability in the metatarsal-cuneiform joint, and/or 2) metatarsus primus adductus, and/or 3) arthritis in the metatarsal-cuneiform joint - and a bunion/hallux valgus deformity is present.

"Midfoot" is not a good term to use. Most - although not all - sources consider the "midfoot" to be the mid-tarsus area of the foot, not including the metatarsal-cuneiform joint (while the forefoot is considered the metatarsals and structures distally). It would be better to specify the involved joint.

If the 1st metatarsal-cuneiform joint is NOT being fused, then both procedures, Lapidus-type bunionectomy [CPT 28297] and "midfoot" fusion (CPT 28740 [arthrodesis, midtarsal or tarsometatarsal, single joint] or CPT 28730 [arthrodesis, midtarsal or tarsometatarsal, multiple or transverse], depending on what was done) could be separately billed.

If, however, the 1st metatarsal-cuneiform joint is being fused along with the performance of a bunionectomy procedure (non-osteotomy-type), then CPT 28297 would be the only code billed.

Harry Goldsmith, DPM, Cerritos, CA

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RE: Brace Recommendation for Polio Patient (Frank J. DiPalma, DPM)
From: Josh White, DPM, CPed, Itamar Rosenbaum, C.Ped

SafeStep features two different ready-made AFOs that integrate the energy storing properties of carbon fiber. The Peromax by Euro International (suggested L- code 1951) fits larger calves and limits plantar-flexion while it provides high energy return.

The Ossur AFO Dynamic (suggested L- code 1932) features an anterior tibial shell that creates medial-lateral stability at midstance and increases spring-loading during the later part of stance. Both of these devices fit easily into ready-made shoes. They are contra-indicated for rigid, triplanar, ankle-foot deformities, severe spasticity or fluctuant edema.

Josh White, DPM, CPed, President, SafeStep, joshwhite@safestep.net

Typically, in most cases of polio, there is an equinus present as well as a cavus foot type that is shorter in shoe size than the contralateral foot. Depending on the tri-planar position that the ankle and subtler joints are now in after the fusions, and if there is any range of motion left in primarily the frontal and capital planes, would help determine what type of brace or support would be appropriate. Since the posterior muscle group has primarily been affected in this individual, there is a lack of propulsion in his gait, but dorsi-flexion is still available to a degree even though he has had an ankle fusion.

If this is the case, then depending on the patients weight and activity level, you could use either a polypropylene AFO with an anterior stop, or a custom carbon composite AFO. The carbon composite AFO will give him more of a springy feeling since this device can be designed to have several different rigidities in one device, giving you control over how much motion he will have at the ankle, subtalar joint and in the distal end of the foot plate. The carbon composite device can also be made with either a medial, lateral, anterior or posterior strut, and what seems most appropriate at this time would be any one of the strut positions but the posterior.

To try something that is over-the-counter, you could call Allard USA and ask them for their Toe Off brace. In conjunction with any brace, a rocker sole would also be appropriate in this case, making the propulsion phase of the gait, no matter how much or how little he has, a smoother easier part of his gait cycle. Additionally, the graphite device will take up very little room in his footwear.

Itamar Rosenbaum, C.Ped, New York, NY, nycped@verizon.net

RE: Sclerosing ETOH injection for Tarsal Tunnel (Alan K. Mauser, DPM)
From: Multiple Respondents

ETOH for tarsal tunnel syndrome? Where is the EBM (at any reasonable level) for the use of cryoablation in the treatment of tarsal tunnel syndrome? I believe that I missed that class.

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

Injecting the PTN is a gutsy thing to do, but it can work miracles on people suffering from CRPS or people who have failed TTR surgery with scarring. I would never inject for a "virgin" tarsal tunnel; as I believe it is "against the standard of care." I always inform patients that injecting the nerve will cause a)intrinsic muscle atrophy b) hyperhidrosis c) sensory loss, etc. In my experience of seeing chronic pain patients, the alcohol injections to the PTN works quite well, and never have I seen a corticospinal, spinothalamic problem. Patients notice a significant decrease in allodynia.

Bottom Line: Inject at your own risk & practice Informed Consent.

David Weiss DPM, Richmond, VA, podmed2@verizon.net

Due to unpredictable results with complete tarsal tunnel releases, I have been using etoh injections for tarsal tunnel symptoms as well as medial calcaneal neuritis for about 18 months. The results with medial calcaneal neuritis (approximately 15 patients), have been extremely good. The results with the posterior tibial nerve directly under the laciniate ligament (9 patients), have been pretty good. Patients should be chosen carefully. If a varicosity or soft tissue mass is causing symptoms, etoh injections will not help.

I typically perform an MRI with patients who fail orthotic therapy and steroid injections to rule out a soft tissue mass or varicosity. I inject ½ c.c of .4% alcohol directly into the nerve sheath. The patient must feel a Tinel’s sensation prior to injecting the alcohol. I inform patients it may take 2-5 injections prior to seeing noticeable relief. I typically give 5-10 injections. Most patients improve enough to avoid surgery. Some get complete relief though some numbness may persist due to a tight laciniate ligament.

Just like sclerosing injections for neuroma’s, I inform my patients that some symptoms over time may recur requiring some “touch up” injections. Anytime you have a conservative and apparently safe option that can possibly avoid surgery, I believe you should try it first. To date, the only side-effects that I have seen has been with neuroma injections which have caused a low percentage (5%) of patients to develop mild fat pad atrophy in the area of the injections. There are no known side-effects to date with the tarsal tunnel injections.

Howard A. Stone, DPM, Glenview, IL, justus313@comcast.net

Editor’s Note: This topic is now closed

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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

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