The Voice of Podiatrists

Serving Over 9,800 Podiatrists Daily

October 10, 2007 #3,062 Editor-Barry Block, DPM, JD

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David Gutierrez, 46

PM News mourns the untimely death of David Gutierrez, DPM of Bronx, NY. Dr. Gutierrez, a 1988 graduate of The new York College of Podiatric Medicine, previously served as president of the Bronx Division of the New York State Podiatric Medical Association and was a frequent contributor to PM News. He leaves behind a wife and two children.

Dr. David Gutierrez

PM News policy is to recommend that memorial donations be made to the APMA Educational Foundation's Student Endowment Fund, 9312 Old Georgetown Rd., Bethesda, MD 20814.

FL Podiatrist to Serve as HVO Program Director in Peru

Health Volunteers Overseas (HVO) has announced the establishment of the new wound care management program area with program sites in India, Peru, Phnom Penh, Cambodia and Siem Reap, Cambodia. These programs are the result of a partnership with the Association for the Advancement of Wound Care (AAWC) and its global initiative, the World Wound Care Association (WWCA). The main objective of these programs will be to increase student and staff knowledge of appropriate and effective management of wounds.

Dr. Nicholas Przystawski

Nicholas Przystawski, DPM of Leesburg, FL will serve as the program director in Peru. "The best way to help Peruvians with wound care is through education," states Dr. Przystawski. "This experience will give volunteers the chance to be in the hospitals with the staff and show them, hands-on, how to improve their skills. I hope that this can be a growing trend within the health care system in Peru."

Volunteers fulfilling assignments in Peru will educate staff at Hospital Nacional Guillermo Almenara in Lima, Peru. Specific training areas at this site include wound healing, wound management, infection control, creative offl-oading, bedside debridement, moist wound healing, wound bed preparation and other areas of general wound care. There will also be an emphasis on supportive care, wound bed preparation, early diagnosis and differential diagnosis

Hospital Can Be Sued For Credentialing Doctor with Questionable Qualifications, Minnesota High Court Rules

Physicians fear that a recent Minnesota Supreme Court decision could compromise statutory peer review protections and taint physicians in medical liability cases that are tied to negligent credentialing claims.

For the first time, the high court recognized that patients can sue hospitals for allegedly granting privileges to doctors with questionable credentials. The unanimous decision adds Minnesota to a list of at least 25 other states that recognize negligent credentialing claims: Alabama, Alaska, Arizona, California, Colorado, Florida, Georgia, Hawaii, Illinois, Indiana, Michigan, Minnesota, Mississippi, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, Washington, West Virginia, Wisconsin, and Wyoming.

In their opinion, justices looked to some of those states when they concluded that hospital peer review committees have a duty to protect patients when they make privileging decisions. Existing peer review confidentiality measures can continue to protect those discussions, but nothing in the law prevents patients from using other outside information to make their cases, the court said. Attorneys say that could mean anything from prior lawsuits and state disciplinary records to divorce papers.

Source: Amy Lynn Sorrel, AMNews [10/15/07]

Query: Telephone Inquiry for Nail Care

A patient calls your office and says, “I want to make an appointment to have my nails cut. I have Medicare and XYZ as a secondary. Will I have to pay anything?” Please let me know how your staff is trained to respond to this question.

Ken Malkin, DPM, Caldwell, NJ

Query: Initial Visit Medicare Denial Code M13

Medicare has rejected a few of my claims with the following reason code, M13 - "Only one initial visit is covered per specialty per medical group."

Does this mean the patient is seeing another podiatrist...or what exaclly does this phrase mean? Is there a modifier to get around it?

Vicki Hicks, Office of Daniel Brown, DPM, Herrin, IL

Response: A new office visit can only be billed once every three years by a doctor or a doctor of the same specialty within a group. Unless your carrier erred, there must be a podiatric colleague from your group who, within the past 3 years, saw the patient and billed Medicare. It would be based on the group provider number.

If you are not, and have never been part of a group, then you should contact your Medicare carrier, and get a clarification. In that case, this could be a clerical error/computer glitch....or some has billed under your provider number.

Tony Poggio, DPM, Alameda, CA

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RE: Choice of Bunionectomy (Dennis Shavelson, DPM)
From: Multiple Respondents

I recently had a similar case. I chose to do a reverse Reverdin-Laird and had an excellent result, both cosmetically and functionally. Looking at your film, it could very well be a good procedure for your patient as well, since it would help in rotating the metatarsal head medially in addition to being able to distract it. Make sure you lengthen the EHL tendon, however, since there will be some shortening as a result and you don't want to end up with a cocked-up hallux.

Andrew Schneider, DPM Houston, TX ajsdpm@aol.com

I think you really have to address the problem with this patient and explain to her, the negative IM angle has to be corrected. You will might have more problems if you attempt a reverse Austin or Keller including increasing problems with transfer lesions.

Recent advances in graft material as well as locking plate technology have made the Lapidus-type procedure more stable and predictable. I might suggest considering removal of the screws and correcting the problem where it is with another osteotomy. I have been using the Hand Innovations F3 locking plate for this procedure as well as bone graft material with excellent success. Another alternative to consider is external fixation with a mini rail type fixator. Neither of these methods truly requires casting if done correctly and toe touch weight-bearing is allowed within 2 weeks.

Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

I do not think just dealing with the hallux varus will be sufficient. Although there is only an AP radiograph and assuming it is weight-bearing, it appears that the second and third MPJ’s are subluxing medially. It has been my experience that without dealing with the deviation of the second and third toes at the MPJ’s, it will be very difficult to get the hallux into an acceptable alignment for shoe fit, let alone have it functional to a degree so as to relieve lateral transfer pains.

MPJ releases with or without Weil osteotomies of the second and third need to be performed along with an arthrodesis of the 1st MPJ. Given the advanced degeneration of the plantar plate (negating the attempt to realign the sesamoids) and the medial aspect of the 1st MPJ and short 1st metatarsal(probably negating a head procedure), arthrodesis may be best. A lot of surgery for a 63 y.o. Is this person active? What about custom shoes? It might be a better way to go.

Vince Marino, DPM, San Francisco, CA, drmarino@marinofootandankle.com

Bear in mind, with the "wind-swept" appearance of the forefoot, unless you deal with the transverse plane malposition of the lesser digits, you won't have a place for the hallux to sit, let alone deal with a multitude of digital lesions. Having said that, in addition to digital stabilization procedure(s), 1st MTP fusion would be the easiest, less heroic and would solve the lateral forefoot pain. Pending patient acceptance, if fusion is not an option, then my second choice, would be a reverse head osteotomy (of choice) to re-establish the IMA, capsule re-balancing (the deformity has been there along time) in combination with a split EHL tendon transfer. A Keller or implant would not be an option.

S. Jeffrey Siegel, DPM, Philadelphia, PA, heeldoc1@aol.com

RE: Practice Advisors (Robert Lagman, DPM)
From Hal Ornstein, DPM

For advice on buy-ins, I highly recommend Mike Crosby, CPA (www.providerresources.com). I hired him to do recent associate buy-in and have recommended him to many who have used his services.

Hal Ornstein, DPM, Howell, NJ, toetoe@optonline.net

RE: Service Dogs and the ADA (Michael Cohn, DPM)
From: Stephen R. Matlin, DPM,MS, David Arkin, DPM

As a disabled person with a service dog – I suggest that medical office personal be fully briefed on this issue. While a disability may not be obvious or considered significant by an onlooker – nevertheless – denial of equal access to a disabled person’s service dog can turn into a federal case. Really,

You may not request any certification or licensing of the dog, nor may you request the medical condition of the person (regarding the use of his dog). Many conditions that permit him to have a service animal are “hidden” or invisible to many people. Not all conditions are physical or apparent. He does not have to justify or explain anything to you. In fact, your request for a medical reason can be taken as an act of invasion of privacy and a violation of his civil rights. Be careful.

The Department of Justice has no sense of humor regarding this matter and excuses such as allergies, fear of dogs, or local and state laws are trumped by federal law. A CIVIL OR FEDERAL LAWSUIT could be filed against you and your place of business as the result of noncompliance with the ADA, as well as, State Statute

My dog Peter goes everywhere with me, including restaurants, museums, temple, movies, hospitals (during my MRI, and colonoscopy) and medical and dental offices. His behavior is envied by most parents. Service dogs are partnered with a specific individual for the purpose of helping that individual with a disability. When service dogs are admitted to places that exclude other dogs it is not the dog that is getting a special privilege. The special privilege belongs to the person who relies upon the dog.

For more information – contact the Department Of Justice Hotline 800-514-0301

Stephen R. Matlin, DPM,MS, Beverly Hills, CA stevematlin@yahoo.com

If I were advising the podiatrist, I would suggest that he tell the patient that he's aware of the patient's rights under the ADA and that he is allergic to the dog. I further would suggest that he then ask politely if the patient would mind very much if he referred her to another podiatrist in town who is not allergic.

If the patient insists on being treated by the allergic podiatrist, then he can wear a mask or take an antihistamine/decongestant or set up a window fan, and treat her because the law gives her that right. But I'd suggest he put his needs "on the table" too and see if she'd be gracious enough to accomodate him, even if she does not have to.

David Arkin, DPM, Big Flats, NY, docarkin@stny.rr.com

RE: Restrictive Covenants
From: Brian Kashan, DPM

The employing doctors are supposed to transition patients from them to the new associate. This is the purpose of the relationship, to reduce the employers patient load and increase productivity. The associate comes to the practice without a single patient. They are, literally, given patients from the get go. These are patients that are referred to the practice because of the employer. As a result of the employer giving the associate patients to see, the associate will eventually build up their clientele.

Associates see this as their practice, when the fact is that their practice is 100% the result of the employer giving them patients to see. They would never see those patients if they opened across the street. As stated previously, the employer needs to protect their practice, so that the associate does not actually take away what was given to them. This would be paramount to any business, equipping, educating, developing, and then giving patients to their competitor.

I suggest that every associate hire a lawyer to review their contract, but also realize that, except for their training and skills, they are coming to the practice with empty pockets. They have alot of potential, but no patients to use it on.

It is a fact of life that things don't always work out. The associate stands to lose his time and energy. He has gained a lot of knowledge about running a practice, a lot of practice "pearls", and invaluable experience in treating private patients. The employer stands to lose a portion of his practice that he has developed for years. It seems to me, that is a lot more on the line. All parties need to be protected, but without the restrictive covenant, I doubt that there would be many associates working at all.

Brian Kashan, DPM, Baltimore, MD, drbkas@worldnet.att.net

Editor’s Note: This topic is now closed.

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ASSOCIATE POSITION - NORTHWEST PENNSYLVANIA

Multi-specialty group is looking to add another Podiatric Surgeon or General Podiatrist to our well-established group. Office locations in northwestern Pennsylvania. Unlimited opportunities exist for the right Associate, wound care experience is a plus. Please forward your CV to adminsec@ips-mso.com

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 -- www.homephysicians.com

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ASSOCIATE POSITION – CENTRAL FLORIDA, ORLANDO AREA

Exceptional opportunity for qualified candidates. Associate position available in a rapid growing, well established multi-office practice. Applicant must be bilingual in English and Spanish, well trained (PSR-24 or more). Compensation includes excellent salary plus incentives and benefits. Please e-Mail CV, letters of reference to CF_resume@hotmail.com

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