The Voice of Podiatrists

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October 04, 2007 #3,057 Editor-Barry Block, DPM, JD

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Podiatrists a Critical Part of Limb Salvage Team

Many of the 80,000-plus amputations of toes, feet and lower legs that Americans diabetics undergo each year are preventable, say specialists who brought more than 900 health providers to a meeting last week to figure out how to do just that. One recommendation: For hospitals to create diabetes limb-salvage teams.

Dr. John Steinberg operates live before Georgetown audience

It sounds simple. But it involves pairing specialists who seldom work side-by-side — like podiatrists and vascular surgeons — to shave weeks off the time it can take to get proper care for a festering foot."It gets them everything they need right away, without months of waiting (between doctor appointments) while the wound is going downhill," says Dr. John Steinberg, a podiatrist with Georgetown University Hospital 's limb-salvage team.

That's one reason that last week's meeting urged a team approach to saving diabetics' limbs: Whatever foot surgeons apply to heal a nasty ulcer won't work unless a vascular surgeon has first cleared clogged leg arteries. "We are hostage to the blood flow," is how Dr. David G. Armstrong, a podiatrist at Chicago's Rosalind Franklin University of Medicine and Science, puts it.

Source: Lauran Neergaard, Associated Press [10/1/07]

Michigan Podiatric Medical Association Elects New Officers

On Friday, September 28, 2007 The Michigan Podiatric Medical Association installed the following officers for two-year terms at its annual business meeting:

Dr. Jeffrey Frederick

Dr. Jeffrey Frederick, President
Dr. Jodie Sengstock, President-Elect
Dr. Joseph Silver, Secretary
Dr. Bruce Jacob, Treasurer
APMA Delegates: Dr. Marc Borovy, Dr. Irv Kanat, Dr. Randy Kaplan, Dr.
Craig Gastwrith, Dr. Marie Delewski

KY Podiatrist Enjoys Golden Years Cleaning Up at The Golden Arches

Tom McCay was a podiatrist for 43 years when he retired. Then, for a year, he stumbled through the house looking for something to do. He'd clean and fidget, always trying to find something to keep him busy. But the only thing he did was make his wife mad. His six children teased him because he liked to clean so much, and they said he should just go and apply for a job at McDonald's, where he could clean all he wanted.

Dr. Tom McCay (Photo Partick Reddy)

On a whim, McCay went up to the local McDonald's and asked if they had a job for a self-described "antsy-pantsy old man." Turns out they did. For the past 13 years, Tom - known as Mr. Clean to his family - has been cleaning up after people for three hours a day on Mondays, Tuesdays and Thursdays at the Edgewood McDonald's on Dixie Highway. Now at age 89, he doesn't see himself stopping.

"It keeps me active, and I like the people," says McCay, who lives in Fort Wright but was born and raised in Covington. "Plus, my wife loves that I'm out of the house." McCay says that after having to care for patients who were in pain and needed help, it's now nice to deal with people who are in good moods.

Source: Ryan Clark, Enquirer [10/1/07]

Query: Holding Patient Records Hostage

A patient became disgruntled about a $15 co-pay and asked for his records. What is the amount we can bill for copies of records? Can we refuse to send the records until we receive payment?

Edward Orman, DPM, Perry Hall, MD

Editor’s comment: PM News does not provide legal advice. Under HIPAA, patients have an absolute right to their records. You must provide them in a reasonable amount of time. State rules vary on what you can charge. In NY, for example, podiatrists can charge up to seventy-five per page.

Holding records up until payment is made is an easy way to subject yourself to professional misconduct charges. You can and should bill patients for the records you have provided to them. If they fail to pay, you then have the option to send the bill to collections or to commence a small claims option, if you so desire.

RE: Measuring Device For Pad Placement (Frank DiPalma, DPM)
From: Multiple Respondents

To help locate a met pad, met bar, or accommodation on an orthosis, mark the corresponding area of the foot with lipstick and then press the orthotic device against the plantar surface of the foot. The lipstick will transfer to the surface of the orthosis to indicate the location of the modification or pad. I recommend cherry red! Outline area on orthosis and remove greasy lipstick before gluing. Credit for this simple trick goes to Ron Hetman, DPM who taught me it many years ago. If you are casting for an orthosis, mark the foot with an indelible ink pencil which will then transfer to the negative cast. If using an STS resin sock, after casting remove plastic bag from sock, mark foot with indelible pencil and place cured, damp sock back on the foot and ink should transfer to the resin sock.
Jeff Root, President, Root Laboratory, Inc., jroot@root-lab.com

The easiest and most accurate device for this is a Harris Mat a.k.a. Pedograph. This device is an oversized ink pad that has a built in grid within grid that will show a darker impression in high pressure areas and a lighter impression in lower pressure areas. All that needs to be done once you imprint the patients foot, is to take that piece of paper, put it on a table, put the shoe or innersole over the paper and see where the dark area on the paper comes out and simply place a finger with one hand on the area, and with the other hand make a small mark with either a pen or something else, even a sticker, proximal to that area. Another way, is by taking some lip stick and marking the area on the patients foot, then having them put their shoes on and taking one step. The area will be clearly marked inside the shoe for you to know where to place the pad.

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

I have also found that an "eyeballing" technique leads to proximal placement. Since we order our orthotic devices and prefab arch supports with the covers glued down only on the heel area, I can mount the met pad or bar under the top cover with some tape.. After the individual walks around with the taped down met pad or bar, I find that I usually need to reposition the device once or twice until the individual responds positively to a placement. I encourage the use of the orthotic for a week to ten days before I glue the met pad/bar to the orthotic and glue the top cover over the met pad/bar.

Sometimes a slight medial or lateral or angling placement finds the sweet spot when the correct distal position appears to be found but the individual's response is still not 100% positive. And sometimes I have to go to a different size or durometer.

I believe at one time that one of the better orthotic labs, Prolabs in California, recommended to its customers not to have their personnel place met pads or bars on custom orthotics at their lab but for their customers to stock various sizes and densities of the devices at their office and request that the top covers be left unattached at the distal half of the FO.

We stock about 12 different sizes, shapes, and durometers of materials in our met bars and met pads. Picking one design or material over the others is more art than science, but with some patience and perseverance, I like to think that we optimize the outcomes for our clients with this process.

John Mishasek, CPed, Colorado Springs, CO, jmishasek@earthlink.net

RE: Mixed Fungal Infections (Greg Caringi, DPM)
From: Randy H. Bernstein DPM

Even though we have been told by a great deal of the literature that dermatophytes make up 90% of the fungal pathogens in the skin and nails, I have found this not to be true. Since the days before CLIA and OSHA regulations stopped allowing doctor's office labs, I have been doing my own fungus cultures. Often when you send a culture to a lab, they plate it on DTM agar plates. DTM stands for dermatophyte testing media, and it contains chloramphenical which kills the majority of other organisms. Instead of using DTM agar, I request the use of Saboraud dextrose agar plates or Potato Dextrose Agar plates from the lab that I now use.

I find that dermatophytes make up about 60% of all fungal infections, with yeasts like Candida, Cyrptococcus, and Rhodoturla, making up 10% and non-dermatophytes like Penicillium, Alternaria, Aspergillis, Mucor, etc. making up the remaining 30% of fungal infections. Lamisil and GrisPeg are primarily used only on dermatophytes, Diflucan can be used on Yeasts (but it has not been approved by the FDA for use in onychomycosis), and Sporonox is more of a broad-spectrum antifungal which could be used on many non-dermatophytes. None of the oral antifungal agents are 100% effective towards all of the organisms in their group, but you will be more successful if you know which fungus you are treating.

Randy H. Bernstein DPM, Dearborn Heights, MI foottdude@aol.com

RESPONSES / COMMENTS (NON-CLINICAL)

RE: Performing Live Podiatric Surgery Before an Audience
From: Sheldon Marne, DPM

The first podiatric surgical case live was performed at a New York State convention in 1960. It was a hammertoe surgery. There may be others who are still around who can verify the case.

Sheldon Marne, DPM, Hendersonville, NC, ncmarnes@msn.com

RE: Billing an E/M code for Recurring Plantar Fasciitis
From: Ken Meisler, DPM

Having treated many thousands of patients with plantar fascitis over the years. I have had many who return after 3 months of relief for recurrence of the symptoms. Usually the first words they utter are "it was better and then the pain started to come back." I find it hard to believe that you can justify billing for an e/m code in addition to the injection. What kind of history and examination does it require to determine that in fact it is plantar fasciitis recurring? Obviously there may be the small percentage of cases where the patient presents with other factors that make you spend the extra time with the patient, for example if the patient states he was fine and then accidently missed a step going and landed hard on the bottom of his heel, the symptoms are different (hurts least in AM and then gets worse during the day) and you are trying to rule out a compression fracture or bone contusion vs. plantar fasciitis, then I think an E/M code is indicated.

In most cases, however, I think it would be hard to justify and E/M code for recurrent plantar fasciitis after 3 months in addition to an injection after 3 months. I would be curious to see what % of the time the experts feel a recurrence of plantar fasciitis after 3 months warrants an e/m in addition to an injection. Maybe I have been under-coding.

Ken Meisler, DPM, New York, NY, kenmeisler@aol.com

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