The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

November 28, 2009 #3,713 Publisher-Barry Block, DPM, JD

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NJ Podiatrist Discusses Keys to Good Foot Health

"Oh, my aching feet!" is a common complaint, but your feet may be telling you that something is seriously wrong. Dr. Alan Rothstein, a podiatrist whose office is in the Willowbrook Center, sees a lot of foot problems in his practice, which are often exacerbated by people putting off getting help.

Dr. Alan Rothstein (Photo Barbara Sherman)

"Don't ignore symptoms and signs," he advised. "They frequently won't go away on their own. Problems should be addressed as soon as possible. As people get older, the ability to heal is impaired or delayed. He advises people, "Don't ignore minor infections. People come in with ulcerations. One woman had an ulceration due to shoes she bought on sale."

The key to good foot health is education, prevention, and follow-up care, according to Rothstein.

Source: Barbara Sherman, The Regal Courier, [11/25/09]

CT Podiatrist's Office Makes Patients Feel More Comfortable  

A visit to the doctor’s office can be a frightening experience. From the fear of the unknown, to fears of needles and pain, many Americans dread seeing a doctor for treatment. Norwalk podiatrist Dr. Harris Greenberger is familiar with these fears. “Some people have negative associations with doctors’ offices,” said Greenberger, founder of Sound Foot Care Center of Connecticut. “From anticipating a long wait to fearing what may result, patients are typically anxious about coming to their appointment.” 

Dr. Harris Greenberger

“Our goal is to minimize patient anxiety by providing a comfortable in-office experience that helps them to feel at-ease. Our goal is to make them feel like guests, rather than patients, which is why I have incorporated so many personal touches into my practice.” Among the personal touches Dr. Greenberger has incorporated into his practice are televisions installed in each exam room.

Source: Earthtimes [11/26/09]

TX Podiatrist Donates $100K to New Medical School 

Nuns tossed Marque Allen out of grade school for misbehavior, and high school teachers told him he wasn't "college material." But Glassboro State College (NJ) biology professor Richard Meagher saw something else: a future doctor. "He saw something in me at the time when I did not," said Allen, now the foot and ankle physician for the NBA's San Antonio Spurs. "His vision and the opportunities he presented to me changed my future."

Dr. Marque Allen and his wife Yvette (Photo: Ed Hille)

Today, Allen, 43, who grew up in Lindenwold, donated $100,000 to start a scholarship in Meagher's name at the new Cooper Medical School of Rowan University. He hopes the gift inspires others to contribute.

Allen attended the Temple University School of Podiatric Medicine, the University of Pennsylvania, Thomas Jefferson University Health, and the University of Texas Health Science Center. Now a podiatric surgeon, he works with five other doctors in a busy sports-medicine practice in San Antonio. He spends most of his time treating ankles sprained or broken on the football field.

Cynthia Henry, Philadelphia Inquirer [11/25/09]

Only 55% of Physicians Qualified for PQRI in 2008

More than 85,000 physicians and other health professionals shared more than $92 million worth of bonuses from the 2008 run of the Medicare Physician Quality Reporting Initiative. But another roughly 70,000 doctors who participated did not see a single dime from the effort.

The PQRI, operating for its first full year in 2008 after its six-month launch in 2007, gave physicians the chance to earn up to a 1.5% bonus on all their Medicare fees for the year by reporting quality information to the government. If the Centers for Medicare & Medicaid Services determined that a doctor had included enough quality measures on his or her claims forms for a sufficient percentage of patients to which the measures applied, that physician would qualify for a lump-sum payout.

Source: David Glendinning, AM News [11/23/09]
                                             

Query: Hospital Consults

With Medicare eliminating payment for all of the consult codes, I have a few senerios that I am wondering how I should bill.

Scenario 1: Doc gets a request for a hospital consult from another doctor. He has never seen or treated the patient before. I can't use the initial hospital codes, CPT 99221-99223 (initial hospital care, per day, for the E/M of a patient), because another doctor admitted the patient. So what code would I use?

Scenario 2: Doc gets a request for a hospital consult from another doctor for a patient that he had seen before. What would be the appropriate code for this scenerio?

Scenario 3: Doc gets a request for a hospital "re-consult" from a doctor for a patient that he has already performed a consultation during the same hospital admission. How is this coded?

Diana Jackson-Adams, Shelbyville, KY

Response: Scenario #1: Yes, under the CMS rules that go into effect for Medicare1/1/10, you would use the CPT 99221-99223 codes for Medicare patients when the patient is inpatient status (this is "original" Medicare and RR Medicare only. It does not apply to Medicare Advantage or to other government programs such as Medicaid, Tricare, etc -- unless of course, those payers decide to change their policies, as well).

Scenario #2: To the best of our knowledge at this time (CMS has not yet released instructions to the Medicare contractors), new vs. established would not make a difference for an inpatient consult. You'd use the CPT 99221-99223 codes as indicated in Scenario #1. The Medicare Physician Final rule directs you to use the CPT 99201-99215 codes for consultation services provided to observation status patients. In that case, new vs. established would apply.

Scenario #3: Currently, those "re-consults" during the same hospital admission are coded with the subsequent hospital visit codes, CPT 99231-99233. Those rules will not be changing.

Joan Gilhooly, CPC, CHCC, Cornelius, NC

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RE: Congenital Hypertrophy of Intrinsic Muscles (S. Jeffrey Siegel, DPM)
From: Gerald Mauriello, Jr., DPM, MA

What is the chief complaint? I would be careful in the case of a deformity without pain. Even in the presence of "a full feeling", this is a child. Due to the obvious risks associated with "debulking muscle," I would be reluctant to rush the patient to the OR.

Gerald Mauriello, Jr., DPM, MA, Philadelphia, PA, drmauriello@gmail.com
 

RE: Osteomyelitis (Richard Frost, DPM)
From: Multiple Respondents

Dr. Richard Frost has a 64 year old patient with diabetic neuropathy of the 3rd and 4th proximal phalangeal bases and likely also their associated metatarsal heads. This was caused by extruding nail from footgear. There is no way to be able to "promise" a neuropathic diabetic patient any result from any form of treatment or non-treatment.

This case cries out for multiple consultation, and the consideration of an extended period of non-weight-bearing and IV antibiotics, with close monitoring for extension of the infection, prior to surgery. This patient will have to accept the "unlucky" aspects of his disease and not shunt them over to his physicians. This is a situation where a "heart to heart" talk with the patient and his family are not only recommended, but absolutely necessary. This condition is not the "fault" of his doctors, and the patient's attitude sounds like the ground-zero building of a lawsuit.

Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

Dr. Frost may treat osteo with six weeks of antibiotics as opposed to surgery. He may want to open and culture but most likely will get a negative culture. I think an MRI as being diagnostic for osteo is way overrated. I have seen many false positives treated with unnecessary operations, and even amputations on people with Charcot joint, RA, and chronic gout. In my opinion, if there is no direct positive cause (like an ulcer to the bone), you should perform T99 and indium (or a similar) bone scans to diagnose osteo. Remember, if the indium scan is not more intense than the T99 scan, it is not diagnostic for osteo. The only 100% diagnosis is made by excision and culture.
 
Gary S Smith, DPM, Bradford, PA, penndoc@verizon.net

I can't tell what type of patient this is or what type of doctor-patient relationship you have with this gentleman. I don't think there is enough information to give a great answer as to the best procedure. If, however, this is a patient who does not show an understanding or respect for the position you are both in as a patient and surgeon, then the best procedure may not be one at all.  This is a patient to whom I would state, in writing and orally, that in all likelihood, there will be another surgery in the future.

Jonathan B. Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Adolescent Verruca Treatment (Chris Seuferling, DPM)
From: Multiple Respondents

Clearly, there are multiple ways to treat veruca. For this type of patient, we would try a prescription for Drysol to apply topically once daily. In many of these patients, the skin is too moist. In our practice, we write a prescription for physical therapy for ultrasound application to the verruca. There is no guarantee with any treatment for verruca. Vitamin A adjunct treatment is often instituted: approx 7500 IU /day for 3 weeks.

George Pattis, DPM, George Pattis, DPM georgepattis@aol.com

If there has been longstanding and failing treatment with cantharadine, I'd consider using bleomycin injections.

Zenon M. Duda, DPM, Cape Girardeau, MO,  zenonduda@gmail.com

For the last two years, I have used a topical amalgam of salicylic acid and 5-FU. I practice in the Chicago suburbs, and so order this product at a compounding pharmacy called NuCara pharmacy located in Elmhurst, IL (630-834-9768). The product costs about $65 and it’s about $5 to ship. It is applied nightly to the lesions and is occluded by tape that comes with the product. This product has virtually obviated the need for fulguration-type procedures. It has been predictably effective for isolated lesions as well as mosaic presentations. My patients are seen in six week intervals, undergo typical debridement, and the lesions have usually resolved by the 12th week of treatment.

Godfrey Viegas, DPM,  Crystal Lake, IL, gviegas1234@sbcglobal.net)

My wife, who is in the medical field, recently went to a lecture on immunization with Gardasil. It is a vaccine that prevents several HPV infections. A PCP pointed out a patient, very similar to yours, who came in to his office. Everything was done by both him and a dermatologist, with no success. This patient, was given this vaccine, and within 2 months, all warts went away. You may want to talk to her parents about this. She could kill two birds with one stone, because there is a lot of overlap with plantar warts being that they also are a HPV virus.

You may want to do some further research on it. It recently got approved for males to get the vaccine, since they are the carriers, and there are no tests that show they have it. It will be interesting to see over the next several years as kids get this vaccine, if the number of patients with warts starts to decrease.

Doug Mason, DPM, Freeport, IL, drdiver@yahoo.com

RE: Metanx and EBM
From: Michael Turlik, DPM

After an abbreviated MEDLINE search, it is not clear to me what benefits patients will derive from this treatment. I would appreciate reference to any level-I studies which would demonstrate the effectiveness or efficacy of using Metanx to reduce the symptoms associated with small fiber disease in diabetes. 

Michael Turlik, DPM, Cleveland, OH, mmturlik@aol.com
 

RE: Custom vs. Pre-Fab Orthotics (Andrew Cassidy, DPM, MS)
From: Robert Bijak, DPM, Mr. Jeffrey Root

Editor’s Note: Although this topic has been closed, these letters can be viewed at: http://www.podiatrym.com/letters2.cfm?id=30780&start=1

PRACTICE FOR SALE - CENTRAL SOUTH CAROLINA

Practice grossing $400,000 annually based on one full-time doctor with two offices. Surgery is currently about 10-15% but can easily be increased. Medicare makes up 52% of revenues. May be able to take over practice with no money down. Interested parties email to footdocsc@gmail.com

ASSOCIATE POSITION - MINEOLA, NEW YORK

Full-time associate position with future partnership potential available with busy multi-office practices on Long Island. Must be proficient in all phases of podiatry with emphasis on surgery, biomechanics and RFC. Minimum standards include either a three-year PSR, or board qualified/certified status with ABPS. Existing hospital privileges with a NY based facility helpful. Interested doctors are encouraged to e-mail their CV to mets724@gmail.com

ASSOCIATE POSITION FULL-TIME - SUBURBS OF CHICAGO

PSR 36 - month-trained podiatrist needed for busy suburban Chicago practice. Office and diagnostic equipment state-of-the-art. Full benefit package included. If interested, please fax your curriculum vitae to 847.352.0270 or email to foot1st@yahoo.com

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes. Top hospitals. Fax CV with references to 703-491-9994

ASSOCIATE POSITION - PHOENIX, ARIZONA

Part Time/Full Time, ethical and hard working graduate of a PSR 24+/36 Residency to join our growing multi-location practice. Good mix of Surgery/Pediatric/Trauma. Very modern offices with EMR, U/S, Digital X-Ray, ESWT, ABI Testing. Excellent referral base, and a well-trained staff. Base salary, bonus structure, benefits. Current AZ License a Must. Please e-mail CV and references to azpodiatrists@hotmail.com

ASSOCIATE POSITIONS - INDIANA/OHIO

PrimeSource Healthcare is a leading provider of mobile, on-site healthcare services at long-term and skilled nursing facilities. Our exceptional growth has created an immediate need for traveling, independent contractors of podiatry services in Indiana/Ohio. Earn between $175k and $225k per year. E-mail CV to kwright@pshcs.com. Visit us at pshcs.com.

ASSOCIATE POSITION - FREDERICK, MD

Well-established and growing 2 office state-of-the-art practice located in medical/professional buildings. EMR, Digital X-ray, Ultrasound, DME provider, etc. Competitive Base Salary plus bonus, malpractice, health insurance, etc. PSR 24 minimum/Board Qualified or Certified with ability and desire to take ER call. If interested, forward CV to DOCSBNB@aol.com

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to fmassuda@footexperts.com

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

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