The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 27, 2008 #3,359 Editor-Barry Block, DPM, JD

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2008 OCPM Residency Fair is Largest Ever

On September 19th, the 4th annual OCPM Residency Fair welcomed 50 residency programs from 14 states. Approximately 200 OCPM students, including 88 third year students attended the fair. It was the largest residency fair ever to be held at the Ohio College of Podiatric Medicine.

OCPM students attend residency fair.

The fair served as an excellent opportunity for students to explore options for clinical training and postgraduate studies, specifically clerkships and residency programs. Representatives of residency programs gained exposure by promoting their programs and interacting with a new population. Many of the representatives were impressed by the level of interest and knowledge possessed by OCPM students.

By building valuable relationships, Jennifer Kenney, the Graduate Placement & Clerkship Coordinator, expects to grow attendance next year and continue to provide valuable networking opportunities for OCPM students.

Man Charged with Identity Theft of IL Podiatrist

Bail was set Wednesday at $50,000 for a former office manager accused of using the identity of Dr. Dennis Haggerty, a retired Elgin podiatrist to run up about $7,000 in credit card bills, police said.

Angel L. Castro, 46, was charged Tuesday with one count of aggravated identity theft, police said. Bail was set at a hearing in Kane County Circuit Court.

Castro was an office manager for an Elgin podiatrist who retired in January 2006, police said. Castro is accused of using the podiatrist's name and other personal information to obtain a credit card and make $7,189 in purchases over the last year, including a computer, said Ann Dinges, spokeswoman for Elgin police.

Source: Carolyn Rusin, Chicago Tribune, [9/25/08]

Physician Blogs Pose New Patient Privacy Risks

Many people are blogging these days, including physicians. Some say the rapidly expanding medium provides a great opportunity for doctors to better educate patients and the public about the practice of medicine. But others warn that medical blogging also presents new risks of breaching patient privacy. As blogs proliferate, some hospital privacy officers are considering policies that would provide professional standards for employees engaged in the activity, and protect their institutions from potential violations of HIPAA.

Julie Chicoine, compliance director at The Ohio State University Medical Center, offers the following pointers for physicians:

• Be careful. "You should…write as if your patients, co-workers, colleagues, etc. are going to read your posting every day, and know that it came from you.
• Focus on education and general medical principles. Avoid information that is too specific and situations that are likely to be identified by others in your local community.
• Ask your malpractice carrier if they have issues with this topic.
• Never post in the heat of passion. No matter what the circumstances, allow yourself a cooling-off period before logging on and sharing your concerns.
• Blogs are not the appropriate forum for medical mistakes or hospital errors.
• "Aggressively pursue those concerns through the appropriate administrative channels within the hospital.
• Post a disclaimer that posts are not medical advice.

Source: Report on Patient Privacy [9/22/08]

Focus on Service Recommendations

To improve patient service, lead your staff through the following exercise, which will focus employees on what they do well and motivate them to continue doing those things. Ask participants to write themselves a letter of praise from a fictional patient. Each letter should highlight three aspects of the employee's behavior or attitude that impressed the customer, and it should mention the effect each action had on the patient. Start the process by sharing this fill-in-the-blank form:

Dear ______________

I wanted to write to thank you personally for the service you provided (when) _________________

You helped me out in a number of ways. First, you (action) _____________________. That (effect) __________________________. I also appreciated the the way you (action) ______________________. Your (patient service strength or skill) ___________ made me feel like a valued patient.

Source: Adapted from: "Write Yourself a Letter" , Impact Learning Systems International

Query: Nerve Conduction Testing In Office

Is anyone familiar with doing nerve conduction testing in the office. Does anyone know of a company that will perform the services or any equipment to recommend to purchase? Is anyone familiar with Brevio by Neumed or Neurometrix.

Rory Cohen, DPM, Brooklyn, NY

Query: I & D of Gouty Tophi

We have a patient with multiple gouty tophi on both feet. I believe the ICD-9 code is 274.82 (gouty tophi of other sites).

What is the procedure code for an incision and drainage of the tophi? The left 3rd toe, right hallux, and right 5th metatarsal head were drained.

Bruce Block, DPM, Kew Gardens, NY

Response: I would recommend using CPT 28003, incision and drainage, below fascia, with or without tendon sheath involvement, multple area.

Howard Zlotoff, DPM, Camp Hill, PA

Codingline subscription information can be found here

RE: Onychomycosis in a 12 Year Old (Ira Weiner, DPM)
From: Barry Mullen, DPM

If KOH or PAS is + and corroborates onychomycosis, then treat the underlying infection. Dose the Lamisil per body weight, though it is very likely that most 12 year olds can be dosed as adults. Monitor the liver function tests per your standard adult oral fungicide practice protocol. As an aside, unless a toenail is very dystrophic and painful, I find it extremely rare that total nail avulsion is required; and have seen some pretty nasty post-traumatic iatrogenic toenail dystrophy from the nail root trauma caused by prior avulsion attempts.

Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

RE: Onychodystrophy (Dale Smith, DPM)
From: Multiple Respondents

Based on the photo of Dr. Smith’s patient, and given the otherwise negative history, this does appear to be a mycotic infection despite the negative cultures. Does the patient have a history of getting pedicures, walking barefoot, playing sports, or any other risk factors for acquiring a fungal infection? Keep in mind that "nail clippings" will often not be enough to yield a positive culture or at least produce the causitive organism, based on my experience. Also, did you run a PAS stain along with the micro?

I would treat this patient with an oral antifungal agent after LFTs are taken and I would expect improvement as long as she does not re-infect herself.

Greg Cohen, DPM, Brooklyn, NY, gcohen428@yahoo.com

Dr. Smith, fungus does not always grow -- it could be a subtle fungus. Other than aerobic, anaerobic, fungus -- what about yeast? Do the nails have an odor? Does she present w/pitted keratolysis on the soles of her feet? Are her nails well hydrated? Are they fragile and break? Try Biotin supplements – it does wonders for brittle nails! Is she a runner or have constant trauma to her nails?

Roody Samimi, DPM, San Diego, CA; roody.samimi@gmail.com

In the August 2006 Podiatry Management Magazine, Dr. Brad Bakotic and I published an article entitled "The Pathogenesis of Toenail Dystrophy.” A new classification system is suggested that defines repetitive microtrauma as a major precursor to fungal invasion of toenails in most cases. Dystrophic toenails classify as microtraumatic, pure fungal or mixed (a fourth category of yeast, psoriasis, blunt trauma, etc. also exists). Dr. Smith's case is classical for non-fungal repetitive microtrauma dystrophic toenails.

Using Neoteric Biomechanics terminology, the flexible forefoot functional foot types have primary functional hallux limitus and secondary hallux interphalangeus extensus, causing a callus subhallux IP joint, and repetitively smashing and scuffing the distal hallux nailplate against the shoe toebox (distal hallux onychodystrophy). This cascade then produces onycholysis and microfragmentation of the nail plate, which allows fungal invasion that rarely succeeds in a normal nail plate (lesser toes, fingernails). Also, note in Dr. Smith's picture, the scuffing of the 2nd and 3rd toes with no 4-5 involvement.

The treatment is a foot orthotic that functionally corrects hallux limitus sufficiently to leverage peroneus longus and flexor hallucis longus, reducing the interphalangeus elevatus enough to allow a normal nail to grow with time. Neutral-cast and rearfoot-posted Root devices (the current custom gold standard) and advances such as Cluffy wedges and MASS theory devices do not produce enough correction to the forefoot pillar.

Foot Centring that is negative cast-corrected, fully forefoot-posted, and incorporates 1st ray cutouts, combined with forefoot chamber modification in shoe selection, has been shown anecdotally to "cure" the microtraumatic portion of dystrophic toenails.

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

RE: Network vs. Non-Network (Mark Levine, DPM)
From: Multiple Respondents

The most obvious answer is to drop the plans. My question to those who have chosen this option is: are they billing the patients their high out-of-network deductibles and copayments, or are they just writing them off? Are they being honest with their patients when asked if they take a plan, even though what the patient is really asking is if they participate in-network?

I have come the conclusion that fees will elevate if patients no longer have access to the care because they cannot find an in-network doctor to do it. This is because the fee is so low that they cannot find an out-of-network doctor to write off the deductible. In other words, patients really do not have in-network coverage for a procedure because they cannot find a doctor willing to do it in-network. If patients want services, they have to PAY out-of-network.

Patients can still get procedures done without paying, because in-network doctors are still doing them at losses, and they can still find out-of-network doctors to do it without paying. I believe this will eventually change as doctors cannot afford to continue practicing this way, thus we will see fee elevation.

Paul Liswood, DPM, Brooklyn, NY, dr.liswood@verizon.net

Editor's note: Extended-length letters by Drs. Goldstein and Larkins appear at: http://www.podiatrym.com/letters2.cfm?id=22191&start=1

RE: Aetna Changes Policy on 1st MPJ Implants (Howard Stone, DPM)
From: Michael Tritto, DPM

The change to Aetna’s policy regarding bunionectomy with implant was the result of dialogue between Aetna’s medical and policy directors and members of APMA’s Health Systems and Coding Committees. Last spring, when reimbursement denials were reported to APMA, discussions were held with not only Aetna, but UnitedHealthcare on this issue. Aetna reported that it had scheduled a review of the policy in September. We would like to thank members, as well as implant manufacturers whose input helped convince Aetna of a need to modify its policy. APMA will continue to review and to challenge medical policies that are inappropriate, unreasonable, or not consistent with promoting the highest level of care for our patients.

September 19, 2008 revision to Aetna’s Clinical Policy (Bulletin 0708): Metatarsal-Phalangeal Joint Replacement.

This is a significant change from their previous policy, which considered all 1st MTP joint replacements experimental and investigation. While this policy falls short of including total joint metallic implants, it is an important step in the right direction and APMA applauds Aetna’s willingness to dialogue on policies that affect APMA memberships and will continue to work with Aetna, relaying our concerns and requesting clarification of certain aspects of the policy. APMA strongly recommends that members be familiar with payers’ medical policies and clinical guidelines. Additionally, members should always check patient benefits and eligibility prior to performing surgical procedures, and obtain a pre-authorization when appropriate.

APMA will continue to advance and advocate for the profession of podiatric medicine and surgery for the benefit of its members and the public.

Michael Tritto, DPM, Chair, Health Systems Committee, APMA, mtdpm@verizon.net

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ASSOCIATE POSITION - TAMPA BAY, FL

Live, play and practice in West Central Florida. Associate position available, leading to partnership, in a well-established, expanding, solo practice in the Tampa Bay area. Great pay and benefits in a dynamic medical/surgical practice. Join our caring, compassionate, educated team. E-mail cover letter, CV and references to rvalins18@aol.com

ASSOCIATE POSITION – CONNECTICUT

Full or part-time position available for a podiatrist licensed in CT. This practice encompasses wide variety of patients including Diabetic wound care and general podiatric care. Must be willing to cover all aspects of the practice including nursing homes and house calls. Please e-mail CV to RPMDPM@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

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

ASSOCIATE POSITION – ORANGE COUNTY, NY

Immediate need for podiatrist to work a few Saturday mornings a month and possible weekday schedule. No call, No after-hour responsibilities, just a good experienced doctor. Work to full-time status, if desired. A great opportunity for the right person Orange County area. Easy commute from surrounding counties. Contact with resume to Phinster18@hotmail.com

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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.

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