The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

December 10, 2008 #3,421 Editor-Barry Block, DPM, JD

A service of Podiatry Management http://www.podiatrym.com
E-mail us by hitting the reply key.
COPYRIGHT 2008- No part of PM News can be reproduced without the
express written permission of Kane Communications, Inc.

Feet Need Extra Care in Winter: NY Podiatrist

"Feet are, most of the time, neglected," said Marc Ginsburg, a podiatrist with Capital Region Foot Care in Albany. "Until something bothers them, and then all of the sudden, the foot becomes the most important part of the anatomy."

Dr. Marc Ginsburg

Most people think foot pain is normal and that it will go away, but waiting it out only exacerbates problems, Ginsburg said. "The normal foot is one that lets you ambulate through life without pain," he said. "When you are in pain every day, something is wrong."

Winter brings cold temperatures and greater risk of frostbite and chilblains, Ginsburg said. Be sure to wear warm, waterproof shoes, and avoid prolonged exposure to freezing temperatures. When you come indoors, take your shoes off immediately. To warm up feet faster, change into warm, dry socks.

Source: Molly Belmont, Albany Times-Union [12/09/08]

NYCPM Pi Delta Honor Society Launches 2008-9 Lecture Series

The NYCPM Pi Delta National Podiatry Honor Society, Gamma Chapter, opened its 2008-9 lecture series recently with a lecture on pedal melanoma by Bryan C. Markinson, DPM, Chief of Podiatric Medicine and Surgery at the Mount Sinai School of Medicine, and Adjunct Professor of Podiatric Medicine at NYCPM. Dr. Markinson’s lecture, which was co-sponsored by the American Society of Podiatric Dermatology, was the first in a planned six-lecture series, with Dr. David Armstrong scheduled to lecture via video teleconference later this year. Khurram H. Khan, DPM, Clinical Assistant Professor of Podiatric Medicine at NYCPM, is the faculty advisor for the Pi Delta chapter at the College.

Dr. Lawrence B. Harkless discusses the diabetic foot during his lecture at NYCPM.

Earlier speakers in the Pi Delta lecture series at NYCPM included Lawrence B. Harkless, DPM, Founding Dean of the College of Podiatric Medicine at Western University of Health Sciences, who shared some of his renowned expertise on the diabetic foot; Lawrence A. Lavery, DPM, MPH, Professor of Surgery at Texas A&M Health Science Center College of Medicine whose morning lecture, “Diabetic Foot Risk Prevention Program”, was followed by several workshops in the afternoon; and John S. Steinberg, DPM, Assistant Professor at Georgetown University School of Medicine in Washington, D.C., who spoke on “Advanced Technology in Diabetic Wound Healing.”

Query: Natural-looking Hallux Prosthesis

I have a 29 year old female who underwent amputation of her right hallux due to OM in October. She recently asked if there was something cosmetic that could be done to give her the appearance of a big toe. Any suggestions?

Sharon I. Monter, DPM, Point Pleasant Beach, NJ

Query: Billing for A5513 Versus A5512

I was recently informed the clinical record must include justification notes for the dispensing of A5513* inserts. I am curious what conditions would act as justification for CMS that would qualify the patient for custom-molded inserts?

Ronald Wright, Hermitage, PA

Response: The Therapeutic Shoe Program for Diabetes (TSPD) local coverage determination (LCD) has no current specifications outlining the specific symptoms or diagnoses required for coverage of any specific type of shoe, insert or modification other than what is already stated in the LCD and in the "Physician Certification of Diabetes."

This is no different than the LCD on AFOs which does not stipulate that the diagnoses or symptoms are required for a specific type of AFO, CAM-walker boot, etc. The net profit margin for suppliers for custom inserts A5513 is minimal compared to that of pre-fabricated, heat-molded inserts (A5512), probably minimizing the financial incentives for widespread fraud. However, the increased reimbursement costs to Medicare are substantial. It is for this latter reason that your documentation should be thorough.

Even though the LCD might not distinguish when to use a custom versus non-custom insert, your medical documentation must have some rationale for the type of insert or device you have chosen (e.g., patient's weight, activity level, deformities, previous failure of less expensive inserts to reduce symptoms, etc.), particularly if a less costly alternative is available. This rationale should meet the burden of community standards (medical necessity), and not simply be justified because it may or may not be easier to produce. In the case of inserts, upon audit, a lack of documentation would likely result in Medicare reducing your payment to that of the less expensive heat-molded insert (A5512).

It is possible that some future changes to the TSPD may require specific symptoms or local diagnosis to qualify patients for the more expensive device, but this likely not to occur prior to 2011. I will be presenting some further disussion on this and other DME issues at the Codingline-NYSPMA and SAM 2009 conferences this coming January.

Paul Kesselman, DPM, Woodside, NY

Codingline subscription information can be found here

RE: Painful Heel Fissures (Pat Evoy, DPM)
From: Multiple Respondents

Dry skin is a lack of water in the skin, not a lack of oil. It is more important when a lotion is applied than what lotion is used. Apply Heel Balm, which is urea and petroleum jelly, immediately after the daily bath to trap the moisture in the skin. Also, have the patient gently rub a pumice stone on the heel during the bath. Use Plastizote inserts in the shoes to reduce trauma.

Dwight L. Bates, DPM, Dallas, TX, dlbates04@yahoo.com

I treat these like ulcers and debride the callused area down to bleeding tissue. I then use Steri strips across the site and allow the area to heal much like a surgical wound. Leave strips in place for 5 days - do not get foot wet. These usually heal readily.

Joel Morse, DPM, Washington, DC, Foxhallfoot@aol.com

Any atypical hyperkeratotic processes receive a biopsy and investigation for topical irritants. This has seemingly been linked to the wearing of certain shoes. For typical heel hyperkeratosis, I too use super glue and debridement. My treatment consists of controlling hyperhydrosis if it exists. I then use a 40% urea-based agent under occlusion at night with a topical anti-fungal qd for one month. I recommend Dr. Jill’s silicone-type lined heel sock for ease of use. Following this treatment, I prescribe a high potency steroid under occlusion at night for a one-week period with daily applications of 40% urea, and then bid urea after the week of steroid.

I dispense a foot-shaped pumice stone and give them specific instruction not to “sand” down the area, but to gently wipe away loose skin. Sanding the area creates friction and exacerbates the skin growth. Loose shoes and open shoes also lead to this condition. For continued care, I dispense Gordon Labs Calacylic cream for night time use and another daily moisturizer of our choice. Patients need to know that this will be a daily maintenance and ongoing issue. Gordon Labs Bromolotion is a great choice for continued treatment of hyperhydrosis since it is a moisturizer as well as drying agent in one and can be used chronically.

You may want to have this regimen pre-printed. Put this on the same page as the explanation of this condition and daily care instructions. The patient will be well-informed by the time you walk in the room so you don’t have to repeat yourself.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Latest Research on Subtalar Joint Axis Location
From: Kevin A. Kirby, DPM

There is some recent research that may greatly change the way we view the forces and moments that affect foot and lower extremity function. A multidisciplinary study will soon be published in the Journal of Biomechanics which involved researchers from the Penn State Biomechanics Lab, National Institutes of Health at Bethesda and the California School of Podiatric Medicine that used a new method to locate the three-dimensional location of the subtalar joint (STJ) axis.

In this study, MRI scans of feet (moved by a special apparatus that places a constant dorsi-flexion load on the forefoot to minimize ankle joint motion) showed that non-invasive measurement of calcaneal to tibial motion allowed very good approximation of STJ axis spatial location.

Our research on this new method for locating the three-dimensional location of the STJ axis has just been listed in the "Articles in Press" section of the Journal of Biomechanics website and is titled In Vivo Tests of an Improved Method for Functional Location of the Subtalar Joint Axis. This multidisciplinary research represents a significant step forward in our ability to non-invasively track the three-dimensional location of the STJ axis and builds on our previous research that established the viability of using this method of determining STJ spatial location in cadaver feet (Lewis GS, Kirby KA, Piazza SJ: Determination of subtalar joint axis location by restriction of talocrural joint motion. Gait and Posture. 25:63-69, 2007).

It is hoped that this research will eventually allow real-time analysis of the kinetics of the STJ in research and in the gait analysis lab setting to further illuminate how abnormalities in STJ kinetics affect the production of abnormal gait patterns and painful mechanically-induced pathologies within the human foot and lower extremity.

Kevin A. Kirby, DPM, Sacramento, CA, kevinakirby@comcast.net

RE: Persistent Pain and Numbness in Foot (Robert M. Przynosch, DPM)
From: Barry Mullen, DPM

There's a given history of prior S1 radicular pain affecting the left lower extremity w/ recently performed spine surgery at that level. There are suggestive, though not definitive, electrodiagnostic studies for S1 radiculopthy. The patient's current symptoms are neuritic in nature and along the S1 dermatome. Motor involvement occurs late in this nerve injury course, so the EMG could be expected to be normal at this point in time.

Additionally, radicular pain often spares proximal lower extremity involvement, but almost always affects terminal branches of that nerve root. The sural nerve is compromised of an S1 root component, so the current residual symptom is almost assuredly NOT localized to the sural nerve, even though this is where subjective symptoms currently manifest. Local treatment directed at the sural neve may or may not alleviate the pain, especially in the absence of distal entrapment signs. I agree with simply trying a local anesthetic nerve block of the sural nerve. If the patient's neuritic pain isn't completely alleviated by the block, then local treatment of the sural nerve is destined to fail regardless of treatment choice. In that scenario, treatment must be re-directed to the S1 nerve root.

Try the block...if she's still in pain, get her back to her spine surgeon for additional workup to determine if a proximal neurolysis about the S1 nerve root and its surrounding scar tissue created by the spine fusion can alleviate the entrapment. That seems like the most logical conclusion to this patient's pain relief.

Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

RE: HR 676 and HMOitis
From: Vito J. Rizzo, DPM

All the comments that have been posted on this subject express the frustration experienced by most doctors just trying to do what is best for their patients and continue to survive as businesses. There is an undertone that we are powerless when pitted against the insurance companies. One may conclude then that a fundamental change must be made in our industry; the insurance companies must be removed from the healthcare decision-making equation. This affords us an opportunity to affect change. Providers want change, patients want change, and even politicians want change. It is only the insurance companies that want to maintain the status quo. So, what can we do?

First, we must remember that in this country the people have the power. Next, an alternative to the status quo must be identified and promoted. Third, we must demand the change to occur. A perfect system will never be found. What is needed is an acceptable system. This is a system with fair rules and guidelines; ones that are consistent. There must also be a mechanism to influence changing the rules and guidelines that considers the input of those providing the services. Fees must be fair. Administration cost must be low. And the motive to profit by the managers must be eliminated. For this change to occur rapidly and seamlessly the provider panel must be in place and the policies and procedures should be recognizable and understood and must be immediately implementable.

This solution already exists. The program we are looking for is Medicare for All Americans. Eliminate all the for-profit insurance companies from the equation. I urge everyone to look at HR 676. This may not be the perfect solution, but it is fair and do-able, and it takes the power away from the insurance companies.

Vito J. Rizzo, DPM, Bay Shore, NY, vjrizzo@optonline.net

ASSOCIATE POSITION- BALTIMORE, MARYLAND

Busy practice in the Pikesville/Owings Mills area located in 1st class medical building seeks motivated individual to work PART-TIME. Must be surgically trained. Must have a great personality and a good sense of humor. State-of-the-art office with hospital-grade ASC. Good mix of general podiatry, sports medicine and surgery. Competitive salary. Benefits for malpractice and health insurance allowances are available and negotiable. Please forward your CV by fax to 410-602-9781 or by email at mwaiken@comcast.net

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

NEW YORK COLLEGE OF PODIATRIC MEDICINE REUNIONS

The Alumni Association of the New York College of Podiatric Medicine is interested in assisting any classes celebrating significant reunions next year, e.g. the Class of 1984 (25th reunion), the Class of 1989 (20th), the Class of 1994 (15th), and the Class of 1999 (10th) for all classes interested in a reunion, now is the time to act. For example, you may wish to have an event during the upcoming New York Clinical Conference, which is convenient and widely attended. Please contact Howard Rusk, Jr., Director of Alumni Relations, at hrusk@nycpm.edu He will gladly help plan and coordinate all your reunion activities.

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

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

PRACTICE FOR SALE – CONNECTICUT

Well-established. Grossing 200K; Norwalk/Westport CT. Dr. recently deceased. High Volume Medicare ; NO BROKERS; Please email: berist92@gmail.com

ASSOCIATE POSITION – ST. LOUIS, MISSOURI

Excellent opportunity for PSR 24-36 foot and ankle surgically-trained physician. Looking for hard-working, personable, highly-motivated individuals to join our group and build their own practice. Position leading to partnership. Great opportunity with excellent salary and benefits. Please e-mail CV and references to cavallinig@foothealers.com

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

NJ PODIATRY PRACTICE WANTED

Two eager podiatrists are looking to acquire another podiatric practice in New Jersey. Not interested in a partnership, just a complete buy out. The practice must be participating with Aetna. If interested, please call (917) 301-1919 or e-mail at NJFootDoc@hotmail.com

ASSOCIATE MONTANA

Great opportunity for a PSR-24 or 36 residency trained individual to join a dynamic two doctor group with physical therapy. Needs good FF surgical skills, RF a bonus. Beautiful office and great area of the country for outdoor recreation minded individuals. Opportunity for partnership after employment. Reply to: jclough@sofast.net

PM Classified Ads Reach over 11,500 DPM's and Students Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 11,500 DPM's. Write bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451 Ext 110.

• To Post a message, send it to:    bblock@podiatrym.com
• Notes should be original and may not be submitted to other publications or listservs without our express written permission.
• Notes must be in the following form:
  RE: (Topic)
  From: (your name, DPM)
  Body of letter. Be concise. Limit to 250 words or less). Use Spellchecker
  Your name, DPM City/State
• Subscribers are reminded that they have an ethical obligation to disclose any potential conflicts of interest when commenting on any product, procedure, or service.