The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

October 02, 2010 #3,973 Publisher-Barry Block, DPM, JD

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Keep Feet Younger-Looking By Preventing Bunions: CA Podiatrist

The saying goes that you can tell a woman’s true age by looking at her hands—but the feet tell a story of their own. Years of walking in high heels, flip-flops, and other unsupportive shoes can take their toll in the form of bunions. “It’s a wear-and-tear phenomenon,” says Colleen Schwartz, DPM, a podiatrist in Pleasanton, CA and a spokesperson for the American Podiatric Medical Association.

Dr. Colleen Schwartz

Turn back the clock: Keep your feet youthful by taking steps to avoid a bunion in the first place, especially if they run in your family. Because the problem is created by a muscular imbalance, try feet-strengthening exercises such as Pilates or yoga. And rethink your footwear, especially if you’re going to be doing a lot of walking. If a bunion does start to develop, see a podiatrist.

Source: Yahoo Shine [9/28/10]

Scholl Student Wins a NSF-Sponsored Student Poster Award

Lydia Regis, a second-year student at the Scholl College of Podiatric Medicine has received an ‘NSF-Sponsored Student Poster’ award for her  research project during last summer, entitled ‘The Effect of Motor Learning and Spaced Training on Balance Control’. During this innovative study, she demonstrated that a combination of virtual reality and an innovative motor learning paradigm allows for improved balance and postural compensatory strategy during sensory-altered conditions.

Lydia Regis performing science experiment

This innovative finding could be used for neuro-rehabilitation of patients with altered sensory feedback like in diabetic peripheral neuropathy. Lydia has been invited to present her study at ASME-IMECE 2010 (International Mechanical Engineering Congress and Exposition) in Vancouver this November.

Query: Midmark Repair

I have a 1989 Midmark 416 podiatry chair. Apparently, it had a power surge and may need a "main board." Does anyone know of any used parts or where I can get this repaired for a "reasonable" price?
 
Pau Galluzzo, DPM, Rockford, IL

Query: Liability Issue

I had an elderly patient come in with his wife for nail debridement. He is fairly immobile and is unable to get up into our exam chair, so my assistant used a stool on which to prop his feet up. As she was placing his leg up, his wife decided to help, unbeknownst to my assistant.  As my assistant placed his leg on the padded stool, it landed on the wife's hand. The wife did not detail any of this to me, but called the next day to complain to my assistant. She now states it is fractured and may need surgery. My question is who do I need to contact if she calls asking us to cover her medical expenses? She was not asked to help my assistant, so what is our liability?

Joe Gonzalez, DPM, East Lansing, MI

Query: Modifier for Cast Removal

A new Medicare patient presented with metatarsal fractures diagnosed by another doctor out of state. The patient had a broken-down fiberglass cast that was removed. X-rays were taken and a new fiberglass cast was applied. We billed a new office visit (CPT 99203-25), x-rays (CPT 73620-LT), and cast application (CPT 29405-LT). Payment was received.

I also billed for removal of the broken-down cast (CPT 29700 - removal or bivalving; gauntlet, boot or body cast) since the original cast was applied by another doctor. CPT 29700 was denied (reason B15: "This service/procedure requires that a qualifying service/procedure has not been received/adjudicated.")

When I spoke with Medicare, they said a modifier was needed for the CPT 29700 procedure code. I resubmitted the claim with a "-77" (repeat procedure by another physician) modifier, and was again denied for reason B15. It is my understanding that I should be reimbursed for the initial cast removal (since it was applied by another physician), but that subsequent cast removals are included in with any future casts I apply. Am I using the incorrect modifier?

Nancy Hayata, DPM, Huntington Beach, CA

Response: You billed for a procedure for which you cannot be reimbursed. CPT 29700 - removal or bivalving; gauntlet, boot or body cast - falls under the description of CPT as "casts applied by treating physician." This is why it is being denied. You did not originally apply the cast.

You performed a complete evaluation of the patient only by removing the cast. I believe that removing the cast was not a billable event, and that it would be included in the E/M component of the encounter. You stated that you billed for application of a cast. Was the applied cast a walking BK cast (CPT 29425) or a non-weightbearing BK cast (CPT 29405)? Did you bill for the cast supplies used? If you used plaster or fiberglass rolls, they would be reimbursed with A4590 (per roll) or the appropriate "Q" code, depending on payer:

Medicare, for example, would be billed "1" unit using:
Q4037 - Cast supplies, short leg cast, adult (11 years +), plaster; or
Q4038 - Cast supplies, short leg cast, adult (11 years +), fiberglass; or
Q4039 - Cast supplies, short leg cast, pediatric (0-10 years), plaster; or
Q4040 - Cast supplies, short leg cast, pediatric (0-10 years), fiberglass.

A number of non-Medicare payers reimburse A4580 (cast supplies [e.g., plaster]) or A4590 (special casting material [e.g., fiberglass]). The units billed with these codes are based on the number of rolls of materials used.

David J. Freedman, DPM, CPC, Silver Spring, MD

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RE: Wound VAC with HBO (Doug Mason, DPM)
From: Bhavin Mehta, DPM , Robert Wunderlich, DPM

Never use the wound VAC inside a hyperbaric chamber due to the electrical components of the VAC being a fire hazard. Disconnect the VAC, cover the unclamped end of the VAC tubing with a saline-moistened gauze and a moist towel around the entire VAC dressing. Or, you can simply remove the entire VAC dressing, cover the wound with saline moist gauze and dry Kling inside the chamber, and then replace the VAC dressing after the hyperbaric treatment.

Bhavin Mehta, DPM, Newnan, GA, tarheel72@hotmail.com

In my experience, this has not been a problem.  However, any potential issues with periwound maceration in this scenario can be avoided simply by planning to perform a VAC dressing change immediately prior to HBO therapy. The VAC dressing is removed, a temporary dressing such as a Kerlix roll is placed on the foot, and the patient undergoes the HBO treatment. After HBO treatment, the VAC dressing is replaced. Obviously, this approach would essentially eliminate the need for a home healthcare nurse (at least on the days the patient undergoes HBO therapy). Check with your HBO center to ensure they have the materials and staff necessary to do a VAC dressing change.

Robert Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com

RE: Rotation Flap for Squamous Cell Cancer (David E. Gurvis, DPM)
From: Multiple Respondents

I have had a few patients in the past with squamous cell carcinoma in situ, i.e. Bowen's disease who have responded with the utilization of imiquimod topically to the area five days a week for up to two months. This may be an option for a toe lesion that would be difficult to close primarily. 

Brent Rubin, DPM, Bradenton, FL, brentlrubin@hotmail.com

I would remove the lesion, make sure you get clean margins, and then either use an allograft for coverage, or just let it granulate and heal by secondary intention. This is not a great place for a flap, and it does not look like you need it.   

Robert P. Thiele, DPM, Hillsborough, NJ, drthiele@comcast.net

I have never done a rotation skin plasty across a flexion crease and would be nervous to do so. Another option would be a pedicled flap-based off the plantar lateral digital vessels of the great toe (nerve is optional). The skin flap obtained would be big enough to cover the defect, but you would have to dissect the vessels proximal to the MPJ and re-route them towards the 2nd digit. The hallux is primarily closed. There would be less chance of a flexor contracture of the toe than with the rotational skin plasty. There are good pictures and details for the procedure in Surgical Reconstruction of the Diabetic Foot and Ankle by Thomas Zgonis. I hope you will keep us updated and let us know what you decide to do.
 
Samantha E. Bark, DPM, Mountain View, CA, krabmas@yahoo.com

RE: Ethical Dilemma (Ivar Roth, DPM, MPH)
From: Jeffrey Kass, DPM, Jeffrey M. Kittay, DPM

Dr. Roth brings up an interesting question. My thoughts on the subject are: 1) treat the patient's chief complaint. 2) Never bad mouth a colleague or another doctor. 3) Don't look to start trouble that is not there.

How do you know the doctor cut the sural nerve? Did he admit this to the patient or is this an assumption based on clinical presentation? Even if it was cut during the surgery, which is a possible inherent risk, I still don't feel it is your place to turn this into a "situation."
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

Is Dr. Roth suggesting that the original surgeon also be publicly flogged for his mistake? His indignation about the long-term disability payments is misplaced. If the PATIENT, not a subsequent treating doctor, is sufficiently unhappy with a result that she wants to bring a malpractice case against the original surgeon, that is her prerogative. She is not obligated to undergo further surgery, even if it would improve her condition. This doctor made a surgical error and did his best to help his patient in the resulting difficult situation, not cover it up or "avoid the hit," as is stated.

Should the surgeon personally be forced to pay the patient's disability claims until her death because he made the mistake? We pay for malpractice insurance to protect us from damages from both legitimate and spurious claimants, not from self-righteous zealots who happen to be our colleagues. Here's hoping that when Dr. Roth makes his eventual surgical mistake, one of his peers is not so anxious to throw him under the bus. 

I have no problem with peer review and for appropriate disciplinary action when necessary. Careless and reckless doctors hurt patients and paint us all with the same broad brush. But I would like to know just who would be proffering charges against the surgeon? And where and to what body would these charges be presented? Let's not be so quick to condemn our fellows. Podiatry has enough issues to contend with without being devoured from within.
 
Jeffrey M. Kittay, DPM, Boston, MA, twindragons2@verizon.net

RE: Extortion By Patient (Name Withheld)
From: Gino Scartozzi, DPM

My recommendation is that you contact your malpractice carrier IMMEDIATELY. Any form of "payment" to dispose of this case may be viewed as an admittance of guilt in a pending court case. Any waiver that this patient signs in exchange for payment may be contested by an attorney which places you "in worst light" with a prospective juror. No doubt, an attorney will argue that he did not understand he was signing away his rights for redress and that he was taken "advantage of" by you. Indeed, it is possible the waiver may be "tossed out" after motions made to court. The "payment" you provided would still be admissible in a court case. You express a concern that the patient may "sue"; well, he probably will anyway.  I cannot imagine that an attorney would proceed to court with a case as weak as you described. In fact, cases such as you describe usually pass from one attorney to another.

Even if an attorney would take this case, having an "expert" testify for the plaintiff would be problematic. Here, you describe a patient as being non-compliant, removing a cast to "play softball" in a critical post-operative period. He contributed to his surgical complication. Despite the patient's non-compliance, follow-up with a bone stimulator and discussion for revision was provided to the patient. In light of this case as described by you, I can't imagine an insurance carrier charging for an increase in premium if the case is dismissed. However, lack of timely reporting of pending litigation to your carrier may lead to financial consequences by the carrier against you that you fear (either in the form of increased premiums or being dropped as an insured.) 
 
Gino Scartozzi, DPM, New Hyde Park, NY Gsdpm@aol.com

NO, NO , NO! Do not pay this patient anything. I do not think this is novel at all. Name withheld needs to get in touch with his/her malpractice carrier and his/her own counsel. In my state, any payment to a pt in this situation needs to be reported to our version of the databank. My advice: secure your chart, don't change anything, hope you have documented all that you indicated in your query, continue to document every conversation and interaction, stay polite no matter how hard it seems, and do not pay extortion. We pay for representation. It's time to use it and not be your own lawyer.

Andrew Levy, DPM, Jupiter, FL, rcpilot48@gmail.com

ASSOCIATE POSITION - NYC, NY

Part/time, full/time associate for busy, well established multi-doctor, multi-office NYC group. Seeking motivated, ethical, NYC licensed DPM with excellent office management and clinical skills in all phases of Podiatry. Board Qualified/Certified preferred. Salary plus incentives, pension/medical/dental. Partnership potential. Fax CV to 631-369-6570.

ASSOCIATE POSITION - FREDERICK, MARYLAND

Well-established group practice is located only 45 minutes from both DC and Baltimore. Immediate opening for a minimum PSR 36 Podiatrist for full time position. We have it all: EMR, digital x-ray, ultrasound, ASC, etc. Excellent salary with bonus structure and benefits. Please email resume to docsbnb@aol.com

ASSOCIATE POSITION - WEST COAST, FLORIDA

Outstanding opportunity for PSR-36 graduate to join successful group podiatry practice in Summer 2011. Seeking a sociable, articulate graduate who is confident in rearfoot and ankle reconstructive cases but also enjoys all phases of podiatry. Long-term opportunity for the right candidate with generous pay and benefits. Reply to jwicks@cortezfootandankle.com

ASSOCIATE WANTED - DELRAY BEACH FLORIDA AVAILABLE IMMEDIATELY

Rapidly growing well established practice seeking part-time leading to full-time. PSR 12-36. Great opportunity for highly motivated, personable individual. Please reply by emailing a CV to nursebsf@aol or fax (561) 498-9068.

ASSOCIATE POSITION - WEST CENTRAL FLORIDA 
 
A great opportunity to join a  very busy, well established, diversified practice in Clearwater, Florida. We are seeking an Associate who is BC/BE and highly motivated, minimum PSR24+. We offer a competitive salary and benefits. Please send your resume to Jaye@fdn.com

PART-TIME PODIATRIST NEEDED ASAP CHICAGO

Part-time podiatrist needed for 2 offices in Chicago with an average of 20 hours/week. Must have Illinois license. Must have completed 2 years of surgical residency. If qualified, email to f-massuda@footexperts.com

NORTHEAST OHIO PODIATRY OPPORTUNITY

Western Reserve Senior Care, an innovative home visit practice that makes visits to seniors in assisted living facilities and SNF’s, is recruiting for a Part-Time Podiatrist. Make a true difference as you make visits to homebound seniors while managing the full scope of podiatric disease. This opportunity offers a perfect balance of superb lifestyle and excellent compensation. Practice is affiliated with world class health systems in Cleveland, OH. Email CV to wmills@westernreserveseniorcare.com

IMMEDIATELY AVAILABLE- ASSOCIATE POSITION -CT (FAIRFIELD AND NORTH HAVEN)

Great opportunity. Join one of the largest podiatric groups in Connecticut. Well-established and progressive offices. Electronic medical records, digital x-ray, diagnostic ultrasound, Padnet vascular studies, nerve conduction studies, pinpoint and CO2 lasers, electrical stimulation and ultrasound therapies. Seeking a well-trained, personable, and highly motivated individual. Please send resume and current photo to dr.kassaris@yahoo.com

ASSOCIATE POSITION – LONG ISLAND, NY

Associate full-time. Well-established, busy, well-rounded podiatry practice looking for a motivated podiatrist. Suffolk Co. LI NY. Board eligible, Board certified PSR-24/36 trained. Fax resume to 631-581-0857

PRACTICE FOR SALE - NORTHEAST COLORADO/SOUTHWEST NEBRASKA 
 
Practice is a good mix of biomechanics, diabetic care and surgery.  Revenue could be increased by well-trained surgeon. No HMO's. Low overhead. Only podiatrist in the area. Please contact mld9439@live.com for more information.

PRACTICE FOR SALE - MARYLAND, DC SUBURB

Great opportunity. Retiring after 38 years in practice at the same location. Practice is fully equipped with digital x-ray, diagnostic ultrasound, computer network, orthotic scanner and state licensed ambulatory surgical center that is fully equipped. Owner will stay on as needed for easy transition. dpmpracticeforsale@yahoo.com

AMBULATORY SURGICAL CENTER PRIVILEGES AVAILABLE - NJ

Privileges available in a new 2 ORs. New certified multi-specialty ambulatory surgical center in Fairlawn, NJ - 8 minutes to the George Washington bridge. Specializing in podiatric surgery. Center will pick up and return patient home. Syndication is available. Center will accommodate doctors in Manhattan, Queens, Brooklyn, Bronx, Staten Island, and long Island. Will assist in getting NJ License. Call for information (516)476-1815 e-mail podo2345@aol.com. To view center, go to FAIRLAWNASC.SHUTTERFLY.COM

MEDICAL SPACE AVAILABLE- MANHATTAN

Multispecialty Medical Building with 24/7 doorman. Prime Luxury Building and Location, Gramercy, Stuyvesant, Peter Cooper Area. 305 Second Avenue (17th-18th). Prior tenants past 23 years; podiatrist, dentist (plumbing/electric intact), internist. Ideal for podiatry, co-share with dentist, MD, etc. (flexible lease terms). E-Mail; jbdrun@aol.com

PM News Classified Ads Reach over 12,000 DPM's and Students

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