The Voice of Podiatrists

October 29, 2006 #2,726 Editor-Barry Block, DPM, JD

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HF “Bunny” Brown Receives Two Appointments

H. F. “Bunny” Brown, III, DPM of Little Rock, AR has recently received two significant appointments. On Wednesday, Governor Mike Huckabee reappointed him to the Arkansas Board of Podiatric Medicine. His term will expire on Sept. 1, 2009.

Dr. H.F. "Bunny" Brown III

Bunny has also been appointed protocol officer for the 2007 APMA House of Delegates, which will convene March 23-26, 2007 in Washington, DC. Brown is a past president of APMA and was recently renamed to PM list of America’s Most Influential Podiatrists.

IN Podiatrist Runs Shoe Drive For 4th Straight Year

Noblesville podiatrist Gad Flaumenhaft wants to see more people up and walking for the health of it, so he’s bringing back a program that’s not only a hand-out, but gives people a leg-up to get back on their feet – literally. Flaumenhaft aims to collect 500 pair of shoes by the end of November to distribute to people who need them.

Dr. Gad Flaumenhaft

There is a big push to encourage people to walk for exercise, Flaumenhaft said. Comfortable shoes, which keep the feet warm and dry, are necessary for healthy feet and ultimately affect a person’s health in general. But some people in the community Flaumenhaft serves with his practice at Noblesville Foot Clinic can’t afford shoes. So, teaming up with doctors of the Indiana Podiatric Medical Association, he is taking in donations of shoes that will be distributed through Good Samaritan of Hamilton County.
Flaumenhaft has been taking to the streets himself, passing out flyers to businesses, churches and civic groups asking for their unwanted footwear.

“People are very generous,” he said. “They stop by and drop off new or slightly used shoes, and we try to coordinate with church programs and civic societies to have fundraisers where they collect shoes, and then they drop them off here.” This is the fourth year Flaumenhaft has spearheaded the program. Last year, he collected about 400 pairs of shoes. “A lot of times people who can’t afford shoes are then prohibited from going to work or exercising for better health care,” he said. “It’s such a small thing to do to get people back on their feet.”

Source: Rebecca L. Sandlin, Noblesville Daily Times [10/27/06]

Providers Push to Limit Whistle-Blowers

The American Hospital Association and three other provider groups urged the U.S. Supreme Court to limit the definition of who qualifies as a whistle-blower plaintiff in False Claims Act lawsuits. The high court is considering a ruling by the 10th U.S. Circuit Court of Appeals in a case involving Rockwell International.

Whistle-blower law requires plaintiffs to be the "original source" of information in a complaint. In a friends-of-the-court brief, the provider groups argued that the 10th Circuit accepted too broad a definition of "original source." "A clear, consistent and strict 'original source' rule" could "ward off illegitimate qui tam strike suits," the groups said in the amici brief. In addition to the AHA, the groups include the Federation of American Hospitals, Association of American Medical Colleges and American Health Care Association.

Source: Mark Taylor, Modern Healthcare [10/17/06]

Query: Closing a Satellite Office

We are thinking about closing one of our satellite offices which, although lucrative, is taking better spent time away from our main offices because it is too far away and we need the time in our two main practices. I would like to know if there is a protocol in closing an office as far as patient notification and education.

Name Withheld

Editor’s Comment: PM News does not supply legal advice. The primary concern in closing a satellite office is to notify all of the patients using that office of the closure by providing them timely notice in writing. This helps prevent any potential for a charge of patient abandonment against you. Particular attention should be given to post-op patients, diabetics, and the elderly.

Query: Saving X-Rays

Once the scanning of x-rays are done, can the original films be disposed or they still must be saved?

Charles Spatz, DPM, Middletown, NJ, DrCharles57@aol.com

Editor’s Note: PM News does not provide legal advice. Assuming that the scanned copies are comparable to the original in quality, there does not appear to be any logical reason for a requirement that they be maintained. It is important to keep multiple copies of any digital data, and to store at least one copy off-site. HIPAA and applicable state laws regarding privacy and security must also be complied with.

Query: Explaining Routine Care Codes

Can anyone explain to me the difference including when to use and how often I can get reimbursed) between using the LOPS (loss of protective sensation) codes G0127, G0246, G0247 versus CPT 11719, CPT 11720, and CPT 11721?

Peter Wilusz, DPM , Warren, MI

Response: The routine foot care code numbers, CPT 11719 and G0127, are defined as follows:
CPT 11719 - trimming of non-dystrophic nails, any number; G0172 - trimming of dystrophic nails, any number. The definitional differences are based on the pathological (or non-pathological) character of the nails, CPT 11719 being "normal" nails.

If the patient qualifies for routine foot care, but the nails require debridement because their thickness is such that trimming (reduction in length) is not sufficient, and they need to be reduced in bulk toward a normal thickness, then you would use either CPT 11720 or CPT 11721, depending on the number of nails requiring debridement.

CPT 11055 through CPT 11057 are used when "paring or cutting of benign hyperkeratotic lesion(s) (e.g., corn or callus)" are performed. Each of these requires the patient to have met Medicare's routine foot care criteria for "at risk" status. Each requires you to document that fact. Routine foot care codes have a 60-day cycle of payment (edit).

The LOPS system is for evaluation of patients for diabetic neuropathy only with different rules and requirements. These code are billed for the initial evaluation G0245 and for follow-up visits G0246. In addition, you must bill G0247 in addition to either G0245/G0246 for care of nails and calluses. Under G0247, nail and callus care are lumped into one code much like the old M0101 code. These codes can only be billed, however, if the patient has not been seen by a foot care specialist (?) within the past six months. Hence, they can only be billed twice a year.

Tony Poggio, DPM, Alameda, CA

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

RE: Dropfoot While Running (Stephen Kinard, DPM)
From: Michael M Cohen, DPM, Jay Goldstein, DPM

It appears that this runner is most likely suffering from exertional compartment syndrome in the anterior and/or lateral compartments of the leg. He would benefit from having compartment testing at baseline and after being challenged. A Stryker hand-held pressure monitor is usually employed with a technique that is analogous to testing of the acute compartment syndrome. Unfortunately the treatment is limited on the conservative side to reducing running intensity or discontinuing running completely.

Orthotics and physical therapy have not proven to be effective. Definitive treatment requires fascial releases, whereby both anterior and lateral leg compartments are performed simultaneously through a common incision. The prognosis is usually very good with this approach.

Michael M Cohen, DPM, Miami, FL, Michael.Cohen1@va.gov

Check your hypothesis by having the patient run 1.5 miles, ending at your office at exactly the time of his appointment. Then check his circulation (skin color, pulses, CFT), muscle function, and sensorium (sharp and light touch--especially over the area innervated by the deep peroneal nerve).

Jay Goldstein, DPM, Portland, OR, jcgdome@hotmail.com

RE: Screening For Hypertension (Alex Kor, DPM, MS)
From: Multiple Respondents

While I am pleased that Dr. Kor asked the question about the need for podiatric physicians to take blood pressure readings on patients, I am amazed that this is even an issue today. Prior to performing a surgical procedure and often in the process of trying to diagnose a patient’s problem, DPMs have been taking or ordering blood specimens for decades. This often helps lead to the diagnosis of systemic diseases (e.g., diabetes, rheumatoid arthritis, SLE, etc.) which we do not manage. In addition, while our specialty involves the diagnosis and treatment of problems affecting the pedal extremity, as health professionals we also have an obligation that makes us part of the army of those with responsibility for the health of the public.

We also have always liked to indicate to the public that many signs and symptoms that our patients experience are manifestations of systemic disease. Performing simple, non-invasive screening examinations such as assessing the status of an individual’s blood pressure is an invaluable public health service that can identify people with undiagnosed hypertension or hypertension that is not adequately managed. While we may not treat such a disorder, referral to the appropriate physician can save a person from significant complications.

Podiatric physicians sometimes see patients more frequently than other physicians involved in primary care. As a result, DPMs sometimes find themselves in a position to help monitor the blood pressure status of patents and identify those who may be at risk for serious medical problems (e.g., stroke, heart, and kidney disease) and require follow-up care by other physicians. Remember, we like to call ourselves physicians. That means or should mean that we do not take care of feet or ankles but people who come to us for podiatric problems.

Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL, levyleon@nova.edu

I disagree with the editor. Blood pressures’ are most frequently taken by RN's, LPN's or CNA's. It can be dangerous procedure, i.e. in a female who has had breast surgery with lymph node dissection. Should podiatrists take serum glucose on their diabetic patients? No.

If a patient has a history of HTN, and you are going to perform a procedure in the office requiring an injection, then perhaps a blood pressure reading may indicated. The reading will be elevated. Should the procedure then be cancelled? Use your judgment and ask the medical director of the clinic if there is a specific protocol for the measurement of pressure (most manual readings are too high due to a too rapid decrease in the cuff pressure...the pressure should be decreased only 2-3 mm. Hg / heartbeat).

Marty Lynn, DPM, Kent, WA, mlynn@wport.com

I have been taking vitals since the 1997 E&M coding guidelines have started. Staff does this, patients like it, and I earn a "bullet point" to add to my documentation.

Bret M. Ribotsky, DPM, Boca Raton, FL, Ribotsky@doctorbret.com

My office screens for blood pressure, O2 %, Temp, HR, using a machine at every visit except routine nail care. We have to do this to bill for appropriate E&M codes. Not only that, if you want to be part of the physician community, you need to start acting like one doctor. Many times my office has caught uncontrolled blood pressures which were referred to their PCP who was appreciative. It only takes a few minutes. Train your MA or back office.

Michael Cosenza, DPM, Ukiah, CA, michaelcosenza@yahoo.com

RE: Lapidus on Down's Patient (David Gurvis, DPM)
From: Charles Morelli DPM, David E. Gurvis, DPM

Placing the obesity and Down’s concerns aside for a moment, there is a small bone fusion implant plate that may be of some use in this patient. It is extremely strong (according to the manufacturer), relatively simply to perform and allows an earlier return to weight bearing (www.reileyorthopedic.com). I have not used this plate-fusion system, and can not comment on it's effectiveness.

I would think twice before performing a mid foot fusion on this type of patient. The list of potential complications is extensive. That being said, You may want to consider an biplane opening wedge osteotomy in the cuneiform (Cotton Procedure), utilizing corticocancellous allograft, combined with either a plate or an external fixator. This might be the safest procedure to consider, if she were to ambulate earlier than you would like. It may not give you the amount of correction you desire.

Otherwise for stability and weight bearing, you can put on a frame (e.g., Orthofix Sheffield Ring Fixator), and put on a second plantar U-ring to take place of the weight bearing surface. This will be very expensive, technically difficult if you are not familiar with frames and you will be married to this patient for quite some time. A lot to do for a bunion! To maintain non-weight bearing, I have been using a roll-a-bout (www.roll-a-bout.com) and have had success. It's not for everyone, but should be considered. Unless she has United Healthcare and you are "out of network", this just might be the case that makes you wish you had made a different decision.

Charles Morelli DPM, Mamaroneck, NY, charles@themorellifamily.net

I have received over 50 well thought-out and considered responses to my post about my Downs syndrome patient and Bunion surgery. That's way too many to thank each respondent personally. So I am sending a general public thanks to each who responded. Anyone who says camaraderie is dead in our profession need only to look at the number of responses I have gotten.

David E. Gurvis, DPM

RE: Bariatric Surgery Referrals For Obese Patients
From: David Secord, DPM

One thing to consider is the morbidity/mortality of bariatric surgery when contemplating referral. A recently released study in "Endocrinology Today" lists mortality as high as 30% for bariatric gastroplasty patients (5%-30%). It did not break down mortality as far as technique (Roux-en-Y gastric bypass, gastric banding, vertical banded gastroplasty or bilopancreatic diversion), just gave the figures for benefit (weight loss, control of diabetes and glucose levels, hormone, incretin and adipocytokine level effects) and the list of complications (wound infection, anastomotic leakage, stomal stenosis, marginal ulceration, pouch dilation, staple failure, band migration or erosion, access port complications, thromboembolism, PE, dumping syndrome, GERD and nutrient deficiency).

With the figures on mortality after bariatric surgery reaching as high as 30%, I would be careful in making referral for the procedure. If a dead occurred and your name was included on the list of defendants, it might be a bad day in the courtroom.

David Secord, DPM, Corpus Christi, TX, Secord@medscape.com

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