The Voice of Podiatrists

Serving Over 9,800 Podiatrists Daily

October 06, 2007 #3,059 Editor-Barry Block, DPM, JD

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We've just mailed the latest issue of Podiatry Management. At 236 pages, this is our largest October special footwear issue ever, and is filled with interesting, informative, and useful articles. You'll also find our usual assortment of features, including our columns, and a CPME-approved CME.

October 2007 Podiatry Management

TX Podiatrist Defends Special Native American Athletic Shoe

When Nike recently introduced a shoe designed specifically for American Indians, the company said it was to promote a healthy lifestyle on reservations. But along with its trademark swoosh, the Nike Air Native N7 features feathers and arrowheads, which bloggers have found off-putting.

Drs. Eugene Dannels and Rodney Stapp, Nike Consultants

One of those consultants, Rodney Stapp, a podiatrist and a member of the Comanche Nation of Oklahoma, begs to differ. “There are always going to be negative comments,” said Dr. Stapp, who is director of the Dallas Urban Indian Health Center, “but most of them are saying that because they are not really familiar with the whole process that Nike went through.”

“Indians tend to have a wider forefoot,” he said, “but their heels are about average,” which means that when shoes fit in the front, there can be “heel slippage” in the back.

Doctors who serve American Indians may have even more cause to nag their patients to exercise than doctors elsewhere. Along with a higher incidence of diabetes, deaths from heart disease are 20 percent higher than in the American population over all, while deaths from strokes are 14 percent higher, according to the Centers for Disease Control.

Source: Andrew Adam Newman, New York Times, [10/3/07]

NJPMS Elects Officers

The New Jersey Podiatric Medical Society has announced its new officers who will be formally installed on October 27, 2007. They are:

Dr. Marc Haspel

President - Marc Haspel, DPM, Clifton
President-Elect – John DePalma, DPM, Medford
Vice-President – Steven Maffei, DPM, Mercerville
Treasurer – James Ricketti, DPM, Hamilton Square
Secretary – Terry Spilken, DPM, Livingston

Dr. Haspel also serves as Senior Editor of Podiatry Management Magazine.

NY Podiatrist Wins First Prize For Tomatoes

Dr. Elliot Udell of Hicksville, NY has won first prize in the tomato category at the September, 27-30th, 2007 Long Island Fair held at the Bethpage Village Restoration. Dr. Udell also won a second prize ribbon for a Lantana flowering plant he raised.

Dr. Elliot Udell show off his prize-winning tomatoes

This fair, an annual event since 1841, is sponsored by the Queens, Nassau and Suffolk county agricultural societies. Farmers, horticulturists and home gardeners come from all over the three counties and enter their annual produce as well as hobbies categories such as best needle point, baked goods and pickles.

Udell is president of the American Society of Podiatric Medicine and is a frequent lecturer on podiatric medical topics at seminars throughout the country.

Query: Restrictive Covenant

I recently finished my residency and am about to accept an associate position in a successful group practice. The contract that I was given to sign has a restrictive covenant which says that if I leave the practice, I cannot practice within five miles of the practice for three years. Is this the norm for podiatric practices? Is it enforceable?

Name Withheld

Editor’s comment: PM News does not provide legal advice. Whether a restrictive covenant is valid and enforceable generally depends on the area in which you practice. In an urban setting, such as Manhattan, even a 20-block (1 mile) covenant may be enforceable, whereas in an rural area, a 10-mile covenant would be more appropriate.

The best way to determine the enforceability of a particular covenant is to check with a healthcare lawyer, who can research how the courts in your jurisdiction have ruled in the past on restrictive covenant cases. These prior rulings set a strong precedent as to how these courts would rule if a dispute arose.

Query: Billing For Covering Physician

I will be out on disability for an indefinite period of time. I am fortunate to have two doctors who will cover for me in my office during this time. Would this be an employer/employee relationship? Or Independent contractor relationship? Or could it be either?

I do have a NPI and group number for my practice. When billing Medicare (and others), is it simply a matter of billing the covering doctor's individual NPI (and other individual numbers) along with my group identification number? Do all insurance carriers need to be notified in advance that this new relationship exists?

Robbin Frost, DPM, Windham, ME

Response: I am assuming the covering physicians are not currently members of your practice. You also did not define what amount of time you would be out. If you will be out 60 days or less then "Reciprocal Billing" would work well for you for Medicare patients. "Locum Tenens" is probably not appropriate (if my assumption is correct) since in those situations the covering physician(s) "generally do not have a practice of his or her own."

You can find the details for Reciprocal Billing Arrangements in the Carriers Manual on pages 55-57 at the following website address:
http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf

The process is quite simple. The covering physician simply performs the work and all billing is done in your name and billed by you using the "Q5" modifier. The only caveat is that this cannot exceed 60 days of continuous service. A new period of covered visits cannot begin until you have returned to work. Once you return to work, if you needed to be out again, then the arrangement could begin again for another 60 days. If the time exceeds 60 days, all billing must be done in the name and under the provider number of the substitute physician(s).

For other insurers, you need to contact their Provider Services Department and ask how they want this handled. Get as much as you can in writing, of course, and save it so it can be retrieved if you are ever audited for services provided during this time.

Richard Papperman, MBA, CHBME, Cape May Court House, NJ

Codingline subscription information can be found at:
http://www.codingline.com/subscribe.htm

RE: Measuring Device For Pad Placement (Frank DiPalma, DPM)
From: Brandon Macy, DPM

I have a device called the “Metatarsal gauge #14” put out many, many years ago by Dr. Scholl’s. I inherited it from a small practice I took over when I got my start 26 years ago. Essentially it is a caliper device with one end to cup the posterior aspect of the heel and the other in the shape of a metatarsal pad. Measure it against the foot directly, and then transpose it onto the device of your choosing.

Scholl Metatarsal Guage

In all honesty, I’ve kept it as a collector’s item and novelty as opposed to actually using it.
Brandon Macy, DPM, Clark , NJ, bmacydpm@comcast.net

RE: Mixed Fungal Infections ( Greg Caringi, DPM)
From: Bryan Markinson, DPM

Dr. Caringi states that lately he has been getting back culture reports indicating mixed fungal infections when clinically he was expecting dermatophyte onychomycosis. I'll bet his clinical suspicion is correct, and that what he is experiencing are reports of contaminants, not pathogens. This contamination is probably happening right in the mycology laboratory. In any case, there are some reports of mixed infections and the use of Lamisil. Here is one: Lebwohl, M.G., Daniel, C.R., Leyden, J., et al. (2001) Efficacy and safety of terbinafine for nondermatophyte and mixed Non-dermatophyte and dermatophyte toenail onychomycosis. International Journal of Dermatology 40(5), 358-360.

Beyond this phenomenon, I believe that poor technique in taking specimens is the major reason for negative dermatophyte results on culture. Proximal subungual skin is necessary, not distal nail clippings. The PAS stain, which will reveal dermatophytes more reliably than fungal culture, may reduce some of the treatment questions surrounding the questionable culture reports.

In most reports that I have seen, itraconazole is clearly the drug of choice for non-dermatophyte molds, but this represents less than 5% of infections in my experience.

Bryan C. Markinson, DPM, New York, NY, Bryan.Markinson@mountsinai.org

RE: Slides for Rheumatology Presentation (Thomas Brant, DPM)
From: Raman Sinha, DPM

Go to http://images.google.com and type in "rheumatoid arthritis foot" in the search textbox (without the quotes).

Raman Sinha, DPM, Overland Park, KS, dr.raman.sinha@gmail.com

RE: Billing an E/M code for Recurring Plantar Fasciitis.(Ken Malkin, DPM, Simon Young, DPM)
From: Jon Hultman, DPM, MBA, Ken Meisler DPM

Regarding E/M coding being warranted when a problem recurs, Ken Malkin’s response (“I would re-assess my original diagnosis. I think an E/M code could be warranted since you need to re-examine the patient to see if the original diagnosis was correct”) reminded me of a recent TV episode of “House” in which a medical student challenges Dr. House by stating, “I thought you said that the Buddy Epson didn’t get the Tin Man role in The Wizard of Oz because he was allergic to aluminum.” House replied, I never said that he was allergic to aluminum, I said that he was diagnosed as being allergic to aluminum.” Whenever a condition is not responding to treatment, isn’t it is good medicine for a physician to take the time to re-evaluate the diagnosis?

Jon Hultman, DPM, MBA, Los Angeles, CA, jhultmaned@podiatrists.org

I very much appreciate Dr. Malkin and Dr. Young's comments. I agree with both of them to some degree. The original posting was about a patient that was discharged 3 months earlier after having been diagnosed with plantar fasciitis, treated successfully and discharged. The patient returned with what was diagnosed as a recurrence of the same condition and injected again. The doctor wanted to know if he could bill for another e/m code in addition to the injection at the 3 month visit.

I was concerned that some practitioners might think that every patient with plantar fasciitis who develops a recurrence should be billed for an E/M code in addition to a procedure, injection or strapping). I think that in some cases there will definitely be patients who had classic plantar fasciitis who will get relief from injection, p.t., orthotics etc. and will still have a recurrence a few months later whether it be from increasing their mileage when running, new shoes, or many other causes. I think it is important for each case to be billed individually. The ones that are obviously just a recurrence and do not warrant an extended workup at a follow up visit may not warrant an E/M code.

I agree with Dr. Malkin, having reviewed many insurance company claims, that sometimes there are practitioners who produce a lot of "medical record fluff" in order to justify billing for a code. When you treat patients with this type of condition and recurrence there are going to be some that require all level of E/M codes but probably also some that do not require an e/m code. You should not be doing the extended workup just to get paid for the E/M code unless you think it is medically necessary.

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

Editor's Note: This topic is now closed.

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