The Voice of Podiatrists

Serving Over 10,000 Podiatrists Daily

October 26, 2007 #3,076 Editor-Barry Block, DPM, JD

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No Such Thing as a Simple Ankle Sprain: NY Podiatrist

“I'M going to say something that could come as a surprise, but here goes: There's no such thing as a simple ankle sprain. Nope, no such thing.” Says Dr. Rock Positano, director of the Non- surgical Foot and Ankle Service at the Hospital for Special Surgery in Manhattan.

Dr. Rock Positano

Every year at marathon time, runners start to test themselves unnecessarily. They're thinking of the finish line - whether or not they're actually competing in the race or just pounding it out on the treadmill. They're not focused on taking care of their ankles and joints; they're thinking about achieving runner "rock star" status. And then another season goes by, and another one comes - and the ol' ankle isn't feeling so good.

“Please, whatever you do, don't self-diagnose”, says Positano. “When the ankle becomes swollen, hot, tender to the touch, discolored and painful when any weight is placed on it, that could mean there's been trauma to the soft tissues (that's tendons, ligaments and muscles) and bones of the ankle and foot. In this case, you need to, ahem, hotfoot it to your foot health professional - a podiatrist or orthopedist - and get X-rays to rule out a fracture or joint dislocation.”

Source: New York Post [10/23/07]

More Education Needed About Charcot Foot: ACFAS Podiatrists

"More people with diabetes, their families and their care providers need to know about Charcot foot,” says J. T. Marcoux, DPM, FACFAS, one of only a handful of Massachusetts foot and ankle surgeons who performs Charcot foot reconstructions. "When I diagnose a patient with this complication, I telephone their primary care doctor and educate them about it as well.”

Dr. J. T. Marcoux

But educating patients and their care providers is only half the battle. Keith Jacobson, DPM, FACFAS, a Houston foot and ankle surgeon. He and Marcoux say there's little they can do when patients are apathetic or in "diabetic denial.” "I've had patients who are literally blind, on dialysis and neuropathic who refuse to admit they have diabetes,” says Jacobson. "I have seen horrific deformities with this condition.”

Dr. Keith Jacobson

Marcoux tells of a middle-aged woman he diagnosed with Charcot. Typically the first order of business is to immobilize the foot by putting the patient in a boot or cast, and to keep the patient off the foot by using crutches or a wheelchair. Marcoux says his patient was "in massive denial” about her Charcot diagnosis.

NJ Revokes License of Ming C. Tung, D.P.M.

The New Jersey State Board of Medical Examiners on September 26, 2007 revoked the podiatry license of Ming C. Tung of East Brunswick, NJ. Dr. Tung was the subject of a federal civil and criminal investigation involving Medicare fraud. By settlement agreement, Dr. Tung agreed to pay $868,313.38 in settlement of civil claims alleged by the Department of Justice and the Office of the inspector General of the Department of Health and Human Services.

Dr. Tung offered to surrender his license to practice podiatry, to be deemed a revocation, effective immediately

Source: The New Jersey Board of Medical Examiners

Query: OTC Dispensing for Chemical Nail Post-Op

I am wondering what other podiatrists are using for “post-op kits” dispensed in-office over the counter available to patients after phenol or sodium hydroxide nail procedures. What and how much do you put in these kits Amerigel, Band-Aids, Poly-Mem, gauze, Betadine, etc.? How much do you charge patients?

Michael B. DeBrule, DPM, Marshall, MN

Query: Office-Made Night Splint

If a physician makes his own custom night splint (does not order one from a supplier), is it a billable service?

Susan Doerner, Billing Manager, Office of Richard Goldstein, DPM, New York, NY

Response: Night splints are a covered service subject to Ankle Foot Orthosis (AFO) local carrier determination (LCD) policy. This may be found on the www.tricenturion.com website. The question is whether or not the custom (as opposed to the garden variety pre-fabricated) night splint you dispense would pass the SADMERC requirements, whether the materials you use qualify the item as a DME, and whether or not you must have a letter of verification from SADMERC to dispense your night splint.

CMS does not require a SADMERC verification letter for the reimbursement for most DME products. The most notable exception, at least for podiatrists, is diabetic therapeutic inserts (both custom and pre-fabricated). The exception to this exception is if the supplier is fabricating their own qualifying diabetic inserts. However, the product dispensed must qualify by meeting SADMERC requirements.

You would not be required to have a verification letter from SADMERC in order to receive reimbursement for L4396 (pre-fabricated night splint) or a custom night splint, but the DME device you fabricate could/would be subject to a SADMERC scrutiny if you were ever audited. You may call either call SADMERC on the phone, or look up similar devices on their DMECS (web-based code listing) system. The safest and most assuring process is to submit your custom device to SADMERC for a code verification review, and have it listed on the SAMDERC DMEC list.

You may choose to ask to have your device coded similar to other custom night splints/braces, or have it assigned its own new HCPCS code. In either case, this is not an easy or inexpensive process. Should you choose to obtain a verification letter, personal experience with salvaging other manufacturer’s applications would suggest you hire a consultant to assist you in this process.

You can find more contact information about SADMERC and the product code verification process on the web at: http://www.palmettogba.com/palmetto/other.nsf/Home/Other+Medicare+Partners+SADMERC+Home?OpenDocument Or follow the links located on the www.palmettogba.com home page.

Paul Kesselman, DPM, Woodside, NY

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

RE: Medication Use for Diabetic Peripheral Neuropathy (Neil H Hecht, DPM)
From: Multiple Respondents

Some of the medications we have found helpful in my office are Metanx 2 tablets daily plus the topical use of Neuroez (an l-argine cream similiar to diabeta-derm), Cymbalta, once daily and in severe cases, Cymbalta and Lyrica. On occasion, low doses of Mirapex is also helpful. I also frequently do nerve blocks using just 1-2 cc of lidocaine on the tibial nerve. Also, don't underestimate the power of some physical modalities out there. Anodyne and neuromuscular stimulators can be effective as can home use of TENS.

Greg Mowen, DPM, Margate City, NJ, gregmowen@comcast.net

I have had success with Cymbalta (duloxetine) and Lyrica (pregabalin). I was fortunate to be a member of the American Professional Would Care Association when Cymbalta became the first drug to get the FDA indication for painful diabetic neuropathy. When I read the APWCA email alert, I started writing for Cymbalta immediately. It has been well tolerated. And, off the top of my head, I cannot remember a patient who did not get significant relief of pain. (I have also noted other benefits that patients have related to me. I have also used Lyrica with similar results. I simply prefer Cymbalta because it is qd. Both drugs take a month or so to work. Lyrica cannot be stopped abruptly because this may induce seizures.

To my knowledge, gabapentin, the tricyclics, and anticonvulsants have not gotten the FDA indication for diabetic neuropathy. Although I try to be a good citizen in the healthcare system by writing for generic drugs, I think it is not reasonable to write for these drugs now that Cymbalta and Lyrica are indicated.

Richard Gosnay, DPM, Danury, CT, beautifulbaldhead@hotmail.com

My experience is that gabapentin (Neurontin) has had demonstrable effect on perhaps two of the 120 patients in my practice that have tried it. Second only in poor effectiveness to Lyrica, where, to date, I have not encountered a single patient who relates relief of pain secondary to peripheral neuropathy. I have had wonderful results with Cymbalta (16 patients, all relating complete relief of pain at 60mg QD dosing, with one patient relating no effect) and have always had very good results with oral Elavil (titrating up from 10mg to as high as 125mg QD, seeking a balance between effectiveness and anti-cholinergic side effects).

Metanx has also worked well for many of my patients, although nobody’s insurance wants to pay for it. For my patients whose insurance will cover a compounded Rx, I use AMI-BAC (amitriptyline-baclofen 2%) gel topical. Most patients relate near 100% relief of their pain after applying it before going to bed, with very few relating only partial relief and perhaps 2 patients telling me it didn’t work at all. Oddly, this effectiveness is mostly in diabetics and not in other forms of neuropathy. The effectiveness of the AMI-BAC (amitriptyline-baclofen 2%) gel is closer to 80% or less, with as much as QID application in those patients with heavy metal poisoning, idiopathic, hereditary and acquired forms of peripheral neuropathy.

David Secord, DPM, Corpus Christi, TX, David5603@pol.net

My opinion regarding neuropathy is that pretty much all of the drugs that you mentioned are poisons. They mask the problem and often lead to significant side-effects. They do not address the patient’s deficiency, the root of the problem. The U.S. is way behind other countries in the practice of treating the cause not the symptoms. The drugs are promoted by Big Pharma as are many drugs and patients tend to get sicker and sicker as more drugs are added to their burdensome medication list. The other problem is that multiple specialists are not aware of other drugs being prescribed.

I have had excellent success using a blood test known as Spectracell, which evaluates nutrients and antioxidants in the patients system.If you use vitamins that are considered "whole food" vitamins you can supplement these people with B vitamins and folic acid as well as alpha lipoic acid and inositol. When these are used in their cheap synthetic form they are useless. Some excellent companies include for high grade supplements include Newmark, Standard Process, Metagenics, Xymogen and Orthomolecular.

I believe it is time for podiatry to embrace natural medicine. These products work as well or better than any of the drugs you listed. You can better yourself as practitioner as well. Many will bash this practice, but ignorance is the only obstacle in their way.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

RE: Phones and Multiple Offices (Daniel Reznick, DPM)
From: Vince Marino, DPM, David O'Brian

I have had two office locations for over 15 yrs. The main office receives all phone calls and the satellite has a “blind” phone number that when dialed, transfers blindly to the main office and is answered by the staff. The phone co. can easily set this up and the cost is nominal. The “blind” number will have the loc al area code for that region. It works quite nicely.

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

A good solution is the call forward service offered by AT&T. Calls to one office are forwarded to the office you are currently at. You can also request remote call forwarding which allows you to activate call forwarding from a remote phone. This comes in handy if you forget to activate the service before leaving the office.

David O'Brian, DPM, Toledo, OH, dwobrian@comcast.net

RE: PM Jury Verdict Reporter
From: Elliot Udell, DPM, Allen Jacobs, DPM

What infuriates many of us about unscrupulous expert witnesses in med mal cases is not so much that colleagues of ours are willing to testify against us. It's that the person taking the oath and testifying may be believed by the judge and jury solely because he or she holds the same medical degree as the defendant and may present some beefed up credentials as well. The person may also have some good acting ability as well. At a medical conference no doctor can say what he or she says in court without proving that there is evidence to support what is being said.

We as doctors no longer blindly listen to what colleagues say or write just because they have good reputations or are good speakers. They have to present proof. After all, we practice in the era of evidence-based medicine. The tort system also has to jump into the 21st century just as the medical profession has and not allow verdicts to be decided on testimony from "bully of the block" doctors who get up in court and say "this is the way it is because I'm an expert and I say that's the way it is."

If this could be changed, we would come a long way in the direction of reforming the tort system.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

Dr. Rosenblatt's recent lament regrading the broken legal system is with merit. Without plaintiff's there would be no defence lawers making money. That is a fact. They all know each other and NEVER go after each other. It is a business and YOU are the commodity being traded and sold.

I just finished a deposition in an active case in which our recently exposed expert Dr. David Widom is the plaintiff expert. The PM readers might be curious to know that the standard of care for an ulcerated fouth toe soft corn absent any infectious changes includes (according to Dr. Widom) probe to bone test, X-rays, culture, MRI, ID and/or vascular surgery consultation, and likely immediate hospitalization. One more thing...he can even state that drainage was present even though the office note clearly indicates the absence of any infectious changes, based upon his "vast experience."

The defendent doctor is board certified and quite experienced in wound care.

Fact is, nothing is ever going to change with tort reform. Document well, and try to answer in your chart potential areas of concern. Both sides are making lots of money in these cases, and there is no incentive on either side for REAL change

Allen Jacobs, DPM, St. Louis, MO, Allenthepod@sbcglobal.net

RE: Shorten My Feet So I Can Wear These Fabulous Shoes

Today a 67 year old female came to my office. She was carrying a large bag of shoes and told me that her feet did not fit into these shoes and that she wanted my help. I checked the shoes and then her foot and realized that the shoes were a size 6.5 and her foot was an 8. I told her that these shoes were the wrong size. She told me she knew, but wanted to fit into them any way.

She told me that recently got married to an nice 81 year old man whose wife died 6 years ago. When she moved into his home she found a closet specifically designed for ladies shoes which contained 400 pairs of Manolo Blahniks and Jimmy Choo shoes worth over $100,000. She was willing to have surgery to shorten her feet just to wear them.

I told her the surgery could be done to shorten each of her metatarsals, but there would be very serious risks involved. She said, "I'll take the chance." Then I told her I would charge her $ 100,000 dollars for the surgery (thinking this would change her mind). She said she will talk it over with her husband and let me know. I then suggested that she use the $100,000 to buy new shoes, She said she will think about it. Only in Boca Raton.

Bret M. Ribotsky, DPM, Boca Raton, FL

IMMEDIATE ASSOCIATE NEEDED - SOUTH MIAMI

Approximate $100,000 position available now. 6-doctor, 8-office group
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PRACTICE FOR SALE - BUFFALO, NY

Part Time Practice with full growth potential. Mix of conservative, biomechanics and diabetic foot care. Great surgical potential. Gross 170K. Willing to stay through transition. Call 716-432-7092.

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