The Voice of Podiatrists

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December 03, 2008 #3,415 Editor-Barry Block, DPM, JD

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CO Podiatrist Uses Ilizarov Apparatus to Prevent Amputation

Things were looking bad for Stephen Ogonowski. Antibiotic-resistant bacteria had devoured his right ankle down to the bone, leaving an inches-wide hole full of raw and ravaged tissue. Amputation seemed certain, just as it was six months earlier when his left foot became infected and his leg had to be removed below the knee. This time, though, podiatrist Dr. Bryan Groth assembled a diverse team of doctors and a new orthopedic device to surgically save the decimated foot -- and most likely, Ogonowski's life.

Dr. Bryan Groth

Two months earlier, Groth surgically removed chunks of tissue infected with methicillin-resistant Staphylococcus aureus, or MRSA. The easy thing would have been to remove the foot. But Groth knew what that could mean: "The mortality rates are so daunting," he said; they soar for double-amputees in poor health. So he believed "limb salvage" was justified. He performs only about half a dozen such surgeries a year, usually on patients with fewer complications.

In surgery, the OR team don lead aprons, since he relies on x-ray images to chart the path for an inserted stent. Then, Groth takes over -- with a saw. Like a mechanic, he goes to work on the intricate framework around the foot and ankle, removing damaged parts and fastening together those that remain. Once the ankle is in place, he drills metal rods through the bones. When he's finished, a new device called a halo will be fastened to the leg with pins that go through it. The halo, officially called an Ilizarov apparatus, keeps the foot immobile, yet doesn't encase it like a cast -- a critical point for such a serious wound.

Source: Brian Newsome, The Gazette - McClatchy-Tribune Information Services via COMTEX, [11/30/08]

TX Podiatric Foundation Donates Shoes to Ike Victims

The Texas Podiatric Medical Foundation (TPMF) has donated 250 pairs of shoes to children affected by Hurricane Ike. After the hurricane, many children in the Seabrook area lost all of their belongings. The students of Seabrook Intermediate began a shoe drive to help the children in their surrounding area. “Many of the children found clothing and shoes within rubble and tried to clean them the best they could so they would at least have something to wear,” said Tammy Fuqua, coordinator of the project.

(From L-R) Seabrook Principal David Williams, Student Volunteer Morgan Ehmling, and TPMF Member Dr. Kirk Koepsel

TPMF performs medical missions to Mexico, and had received a large donation of shoes by a donor from Arizona for the rural and indigent patients treated at the central Mexico clinics. When the Foundation learned of these Texas children without shoes, they rallied to the cause and made their donation.

Query: Austin-Akin Coding

What is the best way to code for an Austin-Akin-type bunionectomy procedure. Is it best to use CPT 28296 (bunionectomy with osteotomy) and CPT 28298 (bunionectomy with osteotomy proximal hallux phalanx), or better to use CPT 28299 (bunionectomy with double osteotomy)?

I was once told that using the Austin (or Mitchell)-type bunionectomy code, CPT 28296, and Akin procedure code, CPT 28298, together was bundling, but I have also heard that is not true.

Gregory Still, DPM, Denver, CO

Response: The proper way to code an Austin-Akin-type bunionectomy is with the single code, CPT 28299. In the professional edition of the CPT book, there is an example illustration of a distal 1st metatarsal, proximal hallux phalanx set of osteotomies with bunionectomy.

It is very important to realization that IF you were to bill CPT 28296 and CPT 28298, you would be billing 2 separate bunionectomy procedures - which you are not when you are performing an Austin-Akin-type bunionectomy on one foot. Billing CPT 28296 and CPT 28298 when performing a single bunionectomy with two osteotomies is not "bundling," it is duplicate billing.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here

RE: Efficacy of Alternate Treatment for Heel Pain (Allen Mark Jacobs, DPM)
From: Elliot Udell, DPM, Steven Goldstein, DPM

I salute Dr. Jacobs for calling attention to the fact that many podiatric seminars feature speakers who have financial ties to companies and the speakers overtly or subtly promote a particular pharmaceutical. He also points out that many doctors with financial ties to companies also publish articles in non-peer-reviewed journals. The problem, however, is by no means limited to our profession and is definitely not limited to non-peer-reviewed journals. Some of the most prestigious medical journals in the world publish papers whose authors have financial ties to pharmaceutical companies. Of course, these papers will list these affiliations on the last page, but many readers just look at the abstracts and little more.

On November 28, 2008, the New York Times published an expose on part of the problem. The article illustrated how many physicians prescribe expensive anti-hypertensive medications (in light of published evidence that there are cheaper, but equally effective older medications available) because the doctors are influenced by corporate-sponsored lectures at conventions, as well as doctors trained and paid by the companies to talk up their product to their colleagues. The article in the Times didn't mention that companies use additional manipulative tactics to promote their products, such as lavish advertisements in medical journals and television ads aimed at patients. All of this boils down to a serious problem that not only has the potential to adversely affect the way we perform as doctors, but also the medical care we personally receive at the hands of our own physicians.

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

I have no financial ties to any company that makes any product. I am not a paid consultant, nor do I own stock in any company making a product. With over 120 podiatric surgeons using cryosurgery for recalcitrant heel pain and over 7,000 procedures performed, collectively the overall one-treatment success rate is between 85 to 96%. Should a patient require a second procedure, the success rate averages 98%. The first major study was published by Javier Cavasos in Texas on a 5-year study of 2,500 patients in the International Journal of Foot Surgery, which is peer-reviewed. Even if that article were not published, Dr. Fallat has published articles on heel pain with the use of cryosurgery in the Journal of Foot and Ankle Surgery as well.

I have no problem treating the toughest heel pain cases, as they always seem to have medical calcaneal nerve involvement, which makes cryosurgery an excellent modality for these patients.

Steven H. Goldstein, DPM, Royal Palm Beach, FL, stevefootdr1@cs.com

RE: Meritorious Service Award – Janet Simon, DPM
From: Kathy Satterfield, DPM

Kudos to the APMA for recognizing the often unsung heroes of our profession who are out there doing the heavy lifting on a daily basis, asking for no rewards for themselves. In the case of my friend, Janet Simon - a strong, valuable, proud member of AAWP - she may not ask for personal recognition but she won't be shy about asking you to pitch in and help on a project to make it a success! We can all take a lesson from her success and dedication to this profession.

Kathy Satterfield, DPM, San Antonio, TX, vksatterfielddpm@aol.com

RE: E-Prescribing Software (Adnan Shariff, DPM)
From: Theresa Hughes, DPM

I currently use a free online service for e-prescribing. It's called Allscripts. They are wonderful about keeping physicians updated. I've even already received all the G codes needed for Medicare to submit for the incentive program. It's an easy-to-work-with program. The website is allscripts.com

Theresa Hughes, DPM, Galesburg, IL, tmhughes@galesburgclinic.com

RE: Practice in England (William M. Miller, DPM)
From: Jay Wenig, DPM

I lived in Great Britain from March of 1991 through March 1993 when I was stationed at RAF Lakenheath in the US Air Force. I taught surgery to the British podiatrists. The practice of podiatry in the UK is very different than what we have here. In the UK, as opposed to the rest of the common market, they are allowed to use local anesthesia. Chiropodists (podiatrists), let’s say in France or Holland ,cannot use local anesthesia.

Podiatrists in the UK cannot prescribe. This includes antibiotics. If your patients need antibiotics, they have to be obtained from the primary care doctor. Tylenol #2 (Paracetamol) is available without a prescription in the UK. In the UK, podiatrists can do surgery since they can inject local, but getting sedation would be a problem. A British podiatrist may surgically remove a neuroma, but not inject it with steroids or absolute alcohol, etc.

Otherwise, everyone is friendly and the patients seem to be appreciative of your efforts. I do remember one time a Scottish podiatrist spoke to the English patient who did not understand him. All I did was repeat what he had said, but in my American accent.

Jay Wenig, DPM, Dayton, OH, jaywenig@aol.com

RE: Inheriting Employees (Name Withheld)
From: Eric Hart, DPM

I agree strongly with name withheld, who noted his frustrations as an employee. What one must remember is that each physician holds a degree and each physician is ultimately responsible for his/her own actions and patients. Let’s face it, many of the experienced podiatrists in any community have something to learn from podiatrists just out of residency. No one would argue that the young practitioner has far more to learn regarding practice management and some of the pitfalls of different treatment plans, but this is best done in a positive manner as one colleague to another.

If you want to make all of the medical decisions for every patient to come through the door, then you should have become an MD/DO and hired a physician's assistant. Associates are not your PA’s and if you treat them that way, you are undermining their degree and in turn yours. I applaud all of the employers who use employee meetings to discuss treatments, billing, etc in a group setting and are willing to hear why or why not one approach is better than another. For the employers that force their employees to do things their way—and often this includes questionable billing practices, I hope you can see that there is a better way.

Eric Hart, DPM, Salt Lake City, UT, ericandalix@yahoo.com

ASSOCIATE - METRO NEW YORK--LONG ISLAND & NEW YORK CITY

Excellent Opportunity for immediate partnership with established practice. Excellent Salary arrangement, serious inquiries only. Send CV along with response. E-mail: rrranch7@yahoo.com

ASSOCIATE POSITION – MASSACHUSETTS

Excellent opportunity for a highly-motivated, entrepreneurial individual to join a very successful, rapidly growing multi-office practice, North of Boston. Seeking a PSR-24/36 trained podiatrist to join our group. We offer a competitive salary/benefit package with the opportunity of partnership after one year, for the right individual. Send CV and letter of interest to drfleishman@nefootankle.com

PODIATRIST NEEDED—SEATTLE, WA

Established podiatric practice in Seattle, WA is looking for licensed podiatrist for part-time leading to full-time position. Need help with Adult Family Homes and Nursing Homes as well as in the office. Flexible schedule and attractive compensation. For all details please call 206-661-9644.

ASSOCIATE POSITION –GEORGIA

A well-established practice in South Georgia seeks a full time PSR-24/36 trained podiatrist. Excellent benefit package. Please send CV to agriffin@southernpodiatry.com. For more information, visit our website

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 part-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

ASSOCIATE POSITION AVAILABLE-MIDTOWN MANHATTAN

Looking for Full-time associate to work in well established practices in midtown Manhattan and Forest Hills. Immediate opening for PSR 24-36 surgically trained Podiatrist. Great opportunity with competitive salary along with malpractice benefits. Please send CV to slurie@papapc.net

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PODIATRISTS NEEDED - CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. 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 Visit our website

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