The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

October 01, 2008 #3,362 Editor-Barry Block, DPM, JD

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IN Podiatrist Gives Meaning to Life of Daughter Lost to Heroin

He was anybody's dad. He had just spoken to his 20-year-old daughter before she disappeared into the bathroom. Minutes later, he found his little girl in the bathtub, dead ... a needle floating beside her. Today, Mann Spitler is everybody's dad. Manda Spitler, a beautiful young lady with everything to live for, had died of a heroin overdose. But even before the grief could begin to subside, her father vowed to do all he could to prevent this from happening to someone else's child.

Dr. Mann Spitler, III

Six years later, Dr. Mann Spitler III is coming to Wabash to tell students here his tragic story. Spitler, a successful podiatrist from Valparaiso, will be at the Honeywell Center Ford Theater on Tuesday to speak to Wabash and Metro students - middle and high schools. The program is being supported by the Wabash Elks Lodge. However, donations are needed to assist in the schools' transportation costs.

Somehow Spitler turned his sadness into an ability to talk to teens in a way that makes them think - long after he is gone. He travels from school to school, but also speaks to church groups, clubs and anyone else that will listen to him. He encourages drug testing your children at home and suggests visiting a Web site which makes all kinds of testing kits available for purchase (TestCountry.com) He said drug testing at home also gives your child an "out" because they can tell their peers they really can't use drugs because they could be tested when they get home.

Spitler thought a moment about how Manda would feel if she could see what has transpired. "I think Manda would have a feeling of gratification," he said. "I think she would be honored and proud to know her dad is giving her death some meaning and purpose.

Source: Sheila Rhoades, Wabash Plaines Dealer [9/26/08]

Medicaid Rolls Grow, Threaten State Budgets

A limping economy and increasingly gloomy financial outlook has led to a 2.1% increase in Medicaid enrollment, erasing a downward trend in enrollment and threatening the fiscal well-being of more than 30 states, a report by the Kaiser Commission on Medicaid and the Uninsured has found.

States also experienced higher Medicaid spending. In fiscal 2008, spending grew 5.3%, up significantly from 1.3% and 2% in fiscal 2006 and 2007, respectively, according to Kaiser's report. Medicaid directors from almost every state and the District of Columbia project even higher enrollment and spending for fiscal 2009.

Ongoing state efforts to address the uninsured—including expanding eligibility, improving outreach and simplifying enrollment—were also a factor in the bump in enrollment. The survey found that many states have had to limit their expansion of children’s health insurance coverage due to uncertainty over future funding and have struggled with new documentation requirements.

Source: Matthew DoBias, Modern Healthcare [9/29/08]

Speak Up and Be Noticed

Would you like to become the type of doctor who commands attention? Remember the following guidelines to increase your profile:

• Start Strong. Conventional wisdom says that you have 30 seconds - or even less time than that - to make a first impression. The clock starts ticking as soon as you meet patients. Appearing friendly, open, and approachable sets the stage.
• Make it personal. Maintain patients' interest by using their names frequently. As soon as you are introduced, shake hands, make eye contact, and repeat the new patient's name. Throughout the conversation, use that name periodically to show respect and to recapture your new patient's attention and personalize the relationship.
• Show interest. When you take interest in patients - asking questions and remembering important details from their stories - you create a natural bond. The best strategy for commanding attention is not to dominate but to reciprocate.

Source: Adapted from Communications Tips by Susan Fee

Query: Skin Discoloration over Post-op Site

I operated on this 43 y/o female about 17 years ago for bilateral bunions. She had a distal metatarsal osteotomy with two-screw fixation. I saw her recently because she was concerned about discoloration over the incision of her right foot. She noticed this discoloration three years ago, but did not tell anyone about it. The discoloration has not changed in size since she first noticed it. She has no pain in her feet and wears 3" heels routinely.

Discoloration of skin, 17 years Post-op

Foot x-rays taken a few weeks ago show that the screw heads are not prominent and are countersunk into the metatarsal. The discoloration on the skin is located over the screws. I have performed thousands of osteotomies with internal fixation and have not seen this type of discoloration before. Has anyone encountered this and could the discoloration be a result of something else.

Josef Geldwert, DPM, NY, NY

Query : Obligation to Assist Nursing Home Patients Seen in Office
From: Jennifer B. Ryder, DPM,

Nursing homes will send patients to me for routine foot care (to be done in my office) who are sometimes not able to take care of themselves during their visits ( .i.e., they need assistance using the bathroom, can't put support hose back on themselves, need help if they start to fall from their wheelchair, etc.). Am I legally obligated to have my assistants provide their nursing care while in my office or can I refuse to see them and reappoint them if they do not have someone to help them with their care? My staff is too busy to take twenty minutes to walk them to the bathroom and/or help them with other personal care (other than assisting with shoes and socks).

Jennifer B. Ryder, DPM, Rapid City, SD

Editor’s comment: PM News does not provide legal advice. We are not sure whether any of the nursing home patients qualify under the Americans with Disabilities Act. We suspect some do, in which case you would have a legal obligation to provide “reasonable” assistance to them.

Even if they didn’t qualify, it seems that you would have an ethical responsibility to assist them. The best course of action is to request that they bring an aide to assist them for future visits. Even if they don’t, successful practices thrive on providing exceptional service. It’s probably worthwhile to schedule these patients on a designated afternoon, and then hire a college student to assist in such tasks.

Query: Patient with BKA & Mycotic Nails

I have a patient that has a left below-knee amputation (BKA). I see her for debridement of mycotic nails and a callus. All of her nails are not mycotic, only 2 of 5 on her right foot.

If the patient had both extremities, I would bill it as

CPT 11055-Q7 (ICD-9 700; ICD-9 440.20)
CPT 11719-Q7 (ICD-9 440.20)
CPT 11720-Q7-59 (ICD-9 110.1; ICD-9 440.20).

My question is, can I bill both CPT 11720 (debridement of nail(s) by any method; one to five) and CPT 11719 (trimming of nondystrophic nails, any number) for a patient who has only one foot (and 2 mycotic nails)? I know if all 5 nails were mycotic, I would only bill CPT 11720, and not include CPT 11719.

Mark Gasparini, DPM, Massapequa, NY

Response: The description of CPT 11720 is "debridement of nail(s) by any method(s); one to five." This covers reduction of nail mass up to 5 nails. It would be inappropriate to bill both CPT 11720 (which would include in its value 'trimming') and CPT 11719 or G0127, both of which are defined to include "any number" of trimmed nails.

This is no different that a patient who is not a BKA, and has 7 thick mycotic or dystrophic nails and three "normal" but long nails. In this case, only CPT 11721 would be billable - covering a minimum of 5, but up to 10 nails, if debrided.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here

RE: Painful. Stiff Toes (Harry Cotler, DPM)
From: Paul Kruper, DPM, Judith Hopkins, DPM

Investigate seronegative arthropathies: ankylosing spondylitis, Reiters, psoriatic arthritis, enteropathic arthritis. The sausage toe can occur with these entities with no history of trauma.

Paul Kruper, DPM, Kingsburg, CA , prkruper@yahoo.com

I would add CRp and ANA in the labwork, also check for family history of arthritidies. Considers Saids for short-term treatment and see how she responds. Lastly, sometimes patients have arthritis i.e., rheumatoid, long before their bloodwork becomes positive, consider a rheumatological consult even if labwork is negative.

Judith K. Hodgins, DPM, Dunn, NC, judy.hodgins@onsightseniorcare.com

RE: Nerve Conduction Testing In Office (Marc Katz, DPM)
From: Steven H. Goldstein, DPM, Carl Ganio, DPM

About 2 years ago, I was interested in using the Neurometrix system in my office as my practice became more focused on nerve-related pathologies. I called the Neurometrix company to inquire about purchasing a machine. I was told that they would no longer sell this machine to a podiatrist as they felt it was not in the scope of our practice. Needless to say, the company refused to sell me a machine.

Steven H. Goldstein, DPM, Royal Palm Beach, FL, stevefootdr1@cs.com

In response to Dr. Katz' post regarding automated NC tests, I would like to clarify and update my position. Medicare has looked at these diagnostic tests, and in particular at the NC-Stat testing provided by Neurometrix. I reviewed the final LCD's on this topic. In the LCD A45698, dated 7-10-2007, the CMS website stated that "on or after June 30th, 2007 the use of the nerve conduction study codes (95900, 95903, and 95904 could be billed...pending clarification...) The LCD also indicated that a physician could perform the testing, with appropriate post-graduate training (As I indicated in my posts last year, and earlier this year).

The latest LCD on this topic A43443, dated 8-01-2008, was updated to address the NC-Stat/Neurometrix issue. The update was not favorable, and states..."nerve conduction studies performed with this (NC-Stat) device should not be billed to Medicare with the current CPT codes 95900, 95903, 95904...and should be billed with the procedure code 95999 (unlisted) code. The LCD further stated, that those performing the test have residency or fellowship training in neurology or rehab. medicine. This should really bring the issue, and use of these codes to an end for podiatrists, even those of us who obtained the comprehensive postgraduate hours that were acceptable in last year's LCD. I still stand by the reliability of the tests, which often correlated with MRI findings in the lumbar spine.

Carl Ganio, DPM, Vero Beach, FL, drcarlganio@bellsouth.net

RE: CaerVision Podiatry TV Network for Waiting Room (Eric Arp, DPM)
From: Larry Kosova, DPM

These are the same fine people that bring you Atlantic diagnostic ultrasound machines. They are pro-podiatry, active in meetings and webinar's and basically just get it. I am in the process of getting one of these "Podiatry Networks" for our new office that we are moving in to now. Patients can learn about you and your practice, and tend to buy or use the services shown. Go to most dental clinics these days and you will see this type of marketing educating their patients on new and old services and products. This will make your office seem more "high tech" and patients do respond to this. This is one of the products that will set you apart from your "competition."

This is just one of the first companies to make this product at a price point that you can afford with a 32 inch TV to boot. I have seen similar products for over 10 times of the intro price of less than $1,000 that they are currently offering. Jack ,the owner, is wonderful to deal with and is very open to your ideas and suggestions.

Larry Kosova, DPM, Chicago, IL, lkosova@yahoo.com

RE: A Pyrrhic Savings (Marc Greenberg, DPM)

For the sake of comical accuracy: a metatarsal fracture is coded 825.25, but correct coding for a metatarsal stress fracture would be 733.94, thus resulting in even “greater savings.”

Keith Gurnick, DPM, Los Angeles, CA

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 information 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

TIMESHARE – MOTIVATED SELLER

Golfer's paradise in Myrtle Beach, S. Carolina! Click here for details! Great for family vacations. Fixed deeded week. Beachfront resort, RCI Exchange, price reduced...DPM special...must sell! $13,500/or bo. Timeshare points also available. Contact footfixr@consolidated.net or 1-800-366-8397

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

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

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