The Voice of Podiatrists

Serving Over 10,000 Podiatrists Daily

November 08, 2007 #3,087 Editor-Barry Block, DPM, JD

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Walking in Shoes is Not a Milestone to be Rushed: IL Podiatrist

Who could blame parents for going a little gaga over all the fun footwear available to babes nowadays? Even so, Mom and Dad shouldn't rush to shoe their beginning biped. If they go to reputable retailers, "barefoot is best" will become a familiar refrain.

Dr. Marlene Reid

That's because the foot and its muscles develop through the pre-teen years. They do it best without restrictions, says podiatrist Marlene Reid, a spokeswoman for the American Podiatric Medical Association. Toes and soles also need a free range of motion for a baby to learn how to grip and balance.

"I'll sometimes see 2-year-olds in sandals that don't bend, and they have to lift their whole leg up to get the foot off the ground," Reid says. "If their foot can't bend, they're going to be prone to injury. I sometimes actually stop moms in the park and tell them." Many parents believe a child should be walking by 12 months and think the right shoes might help. But the average is between 12 and 15 months. And as a mother of two, Reid adds that it's not a milestone to hurry.

Source: Wendy Donahue, Chicago Tribune [11/ 6/ 07]

NC Father and Daughter Podiatrists Form “Dream Team”

Dr. Ainsley Roberson Rusevlyan has joined the practice of Dr. James H. Roberson, her father and a Washington podiatrist. . She earned her a bachelor of arts degree in biology at East Carolina University and graduated from podiatry school from her father's alma mater, Temple University School of Podiatric Medicine, and was awarded The Clinic Award for excellence in clinical skills. She completed a two-year surgical residency at the Veteran's Affairs Medical Center in Philadelphia, where she was chief resident.

Drs. Ainsley Roberson Rusevlyan and James H. Roberson

"We are delighted to have Ainsley join the practice as a provider," said Roberson, who has been in practice since 1968. "She has worked in the office since she was a little girl, doing everything from walking patients to their rooms to assisting in surgery. ... The beauty of this situation is that we can teach each other. It is a dream come true for both of us."

Like her father, Rusevlyan performs surgery and treats diseases and injuries of the foot and ankle. Her surgical residency at the Veteran's Affairs Medical Center allowed her to hone her skills as a surgeon. She said she chose the residency program because of the opportunity for autonomy of her practice. "The VA residency was such a great experience," she said. "Unlike many other residency programs, I was able to treat my patients from start to finish. This experience has helped prepare me for private practice. ... It is so nice to be home. Everyone in the community has welcomed me back with open arms."

Source: The Daily Reflector [11/5/07]

Zagat, WellPoint to Allow Customers to Rank Doctors

The Chicago Tribune on Sunday examined a partnership between Zagat Survey and WellPoint that will allow consumers to rate physicians (Deardorff, Chicago Tribune, 11/4). WellPoint in the next several months will release an online physician ranking guide based on patient input to more than one million members. The guide will rank physicians based on trust, communication, availability and office environment on a 30-point scale. The guide also will include patient comments. At least 10 responses about a physician will be required before any information is posted about them.

The ratings guide will not include information on medical expertise and will not be based on claims data, health plan-generated data or other factors, such as medical malpractice settlements. WellPoint plans to roll out the survey tool to all of its 35 million members. Physician ranking sites provide transparency and are part of consumer-driven health, according to some consumer health advocates.

Source: Chicago Tribune via American Health Line [11/6/07]

Query: Employee Theft

I just discovered quite accidentally that my office manager of 18 years secretly opened a bank account under my practice name, and has been siphoning off insurance checks into it. This was undetectable to me because she marked the patient files as paid. I don’t even know how much money she has embezzled. Any advice on how to handle this predicament would be appreciated.

Name Withheld

Editor’s comment: PM News does not provide legal advice. We suggest that you contact the district attorney’s office and have them investigate this matter. They can subpoena the bank records of this phony account and determine exactly how much your employee has deposited.

We suggest that you hire a bookkeeper or accountant to prevent this unfortunate event from happening again. You need a system which reconciles checks received with money deposited.

RE: Level of Amputation (David Gurvis, DPM)
From: Multiple Respondents

Based on the information provided it would be difficult for any of us to recommend the appropriate level of amputation. Although the vascular surgeon opines that a TMA will fail, and in the event that it does, the patient will ultimately be left with a BKA anyway. Although in the event that the TMA does not fail, the patient will have a more functional extremity. From a medical-legal standpoint, if the TMA is attempted and does fail would the vascular surgeons pre-op opinion carry weight over the opinion of the infectious disease specialist?

My suggestion is to first consider referring the patient to an intervention cardiologist or intervention vascular surgeon to determine whether or not the patient is a candidate for an atherectomy utilizing the Silver Hawk procedure. If the patient is a candidate, blood flow can be restored prior to performing the amputation (at either level), which would then provide the patient with the best possible chance to heal. If you are unaware of a referral source for the Silver Hawk procedure, I would be happy to put you in touch with my EV3 rep who could provide you with a referral source.

Brian Homer, DPM, Clawson, MI drbhomer@gmail.com

It seems that Dr. Gurvis has done what he can and the vascular surgeon has given an expert opinion. You can't save them all. Remember, you will be doing this patient a favor by using the evidence you have and referring them for the BKA. You would be doing your patient a great disservice by advising, let alone performing, surgery that you know will fail. As for expert opinions, consider the source. Infectious disease specialists are not surgeons. They see the infected part, while you see the big picture. Listen to the vascular surgeon or get a second opinion from another one.

This is a good case that demonstrates the importance of DPMs forming alliances with other specialists in town to manage difficult cases. A vascular surgeon and ID internist are two people you should have on speed dial.

"Selling" a diagnosis or treatment plan to a patient can be difficult in situations like Dr. Gurvis'. I know that when I was in school and residency that it was not something we were taught and I have always thought it was an injustice that it was that way. We need to learn as young students and physicians how to talk to our patients about the difficult topics.

Marc Greenberg, DPM, Dayton, OH, tripperdpm@yahoo.com

With vascular analysis demonstrating poor perfusion below any particular level, an amputation within the under-perfused area is bound to fail. Sadly, it does not help the patient to do a lesser amputation that would delay the inevitable. The key word is ‘inevitable.’ I think the opinion is shared by many that it is better for the patient to get out of the hospital with a closed wound and begin the process of learning how to live life with or without a prosthesis.

Of course I am mindful of the morbidity associated with a BKA or AKA in terms of shortened life-expectancy and loss of independence. This is balanced by the morbidity, risks and cost of lengthy care for non-healing amputation sites. The procedure of choice should best be left to the vascular surgeon’s advice. If he/she can improve the circulation, then a transmetatarsal amputation may heal.

Parenthetically, blood stem-cell therapy is being done off-shore. Preliminary observations demonstrate incredible revascularization of coronary as well as peripheral arteries.. How long the reperfusions will last remains to be seen. I’ve seen evidence of 6-month revascularization of the leg in individuals with complete occlusion below the knee.

Philip Jay Organ, DPM, Naples, FL, philorgan@comcast.net

RE: Big Fish to Fry
From: Bryan C. Markinson, DPM

The November 5th PM News reported that a Georgia DPM was sentenced for narcotic distribution. It went on to state that the DPM “ordered approximately 202,500 doses of Hydrocodone, nearly four times as much as any other podiatrist registered with the DEA in the country.” This statement, unless misunderstood is also shocking. It is stating that the DEA knows of at least one DPM who is prescribing approximately 50,000 doses of the drug annually.

Let’s say that the typical pod works 50 weeks a year, which is reasonable. That comes to 1,000 doses per week. Assuming the typical patient doses themselves six times a day, for 42 doses per week (which would be expected of cancer patients, not bunionectomy and hammertoe patients) that means that some DPMs are prescribing hydrocodone 24 times a week. I find that unbelievable and even more unbelievable that four times that amount is what catches the eye of law enforcement.

Recently, two DPMs in NY were investigated for several million dollars worth (collected) over a five year period from one of the poorest payers. The outcome does not matter, but it would infuriate almost anyone with a conscience. The message to me is that enforcement is a joke, unless you are caught short on documentation leading to a determination that CPT 99213 should have been CPT 99212. Then, as so many warn in this forum, they GOTCHA!

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

Editor's response: We believe that the DEA is or has investigated the podiatrist who wrote for 50,000 doses of hydrocodone. The feds expend approximately the same effort going after big abusers than small abusers. This applies not only to controlled substances, but to E/M coding as well.

RE: Cerner Wisdom Software (Carl Ganio, DPM)
From: Multiple Respondents

We had been with Wisdom/InfoCure for many years and had found their response to updates very poor and customer support nearly non-existent. They nickel and dime you for every modification and add on. We finally made the leap to change and switched to advancedMD. They are phenomenal. The training was excellent. The transition was not nearly as painful as we feared. It is a web-based program so you need a fast internet connection (we have cable) and you will notice some delays at times. If your Internet is out, you are out of luck but that is rare. I believe you could dial-up if needed temporarily. The upside is that all your data is stored off site at their secure facility and constantly backed up. So no need to have backup systems in your office or worry that your staff is not backing up. Updates are automatic and transparent to you.

You pay a reasonable monthly subscription fee (and a very modest set up fee to start). No long-term contract needed either in case you ever change. You do not need any special hardware and do not even need a network. You can access your info from any computer with Internet access and a web browser. We do statements electronically through them and all insurances claims electronically from their clearing house. Payments come directly into the system also and my billing person merely needs to verify payments are being applied correctly (which they usually are). A 10-page Medicare EOB can take less than 15 min to complete. The scheduling software that comes with it is very good. They have a note system also but we have not used that (we have an alternate electronic note system) so I can’t tell you if that is a good idea or not.

Greg Rouw, DPM, Fergus Falls, MN, grouw@charter.net

I have been with Cerner since its inception (Don Rogers of DR Software) in 1991 and through WizDumb upgrades. I have seen this product go steadily downhill in support, to the point that it is spiraling down. Their ClearingHouse support is awful. It is not limited to NPI problems, it is systemwide.

Last month I switched to an outside billing system. I’m thrilled with the initial results. Cut your losses and get out NOW!

Pat Caputo, DPM, Holmdel, NJ, pat_caputo@alumni.rutgers.edu

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