The Voice of Podiatrists

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December 15, 2007 #3,118 Editor-Barry Block, DPM, JD

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Much Back and Knee Pain Related to Foot: PA Podiatrist

For some patients, a new style may be just what the doctor ordered. Podiatrist Kathya Zinszer says they have to fit the person who's going to wear them. "Every person is an individual, and every footprint and foot type is like your own basic fingerprint. So every shoe type is going to be different for different patients."

Dr. Kathya Zinszer

With this motion detection system, cameras on the outside of the runway send out infrared light. They reflect movement of sensors placed on patients' ankles, toes and legs. That provides a 3-D image of the patient in mid-stride. "A lot of patients who come in to see us, come in and are having a lot of lower back pain or knee pain, and it really starts from the foot," said Zinszer.

The Gait Study Center at Temple University is considered one of the most advanced labs of its kind in the world. Their technology can also be used to help you find the right running shoe.

Source: Leslie LoBue, WJRT ABC News [7/11/07]

IA Podiatrist is a Frequent Medical Volunteer to Mexico

A lot of people celebrate the New Year by making a resolution or taking a cruise. For Dr. Richard Lepird of Estherville, celebrating the New Year takes on a whole different meaning. The first weekend in January, Dr. Lepird will depart for Mexico where he will again provide medical care for people who can’t afford it. They’ll be getting the best of care, too, at least from Dr. Lepird, a podiatric surgeon who invented the procedure of metatarsis reductis, a procedure for straightening the foot in patients with club foot.

Dr. Richard Lepird

This is the third year Dr. Lepird has volunteered his services to Liga, or The Flying Doctors of Mercy. He took four trips to Mexico last year. Members pay $200 to help pay for fuel for one trip each month to Mexico to volunteer their services. It’s a grueling schedule. Dr. Lepird and a medical team of 90-100 people will leave on a Friday and work the rest of the day then Saturday and Sunday. Dr. Lepird will work in the Mexican state of Sinaloe at El Forte or San Blass.

Many of the illnesses that Dr. Lepird treats include congenital deformities. He said he has seen more problems with club foot than at any time during his practice in the United States. He also observes poor prenatal and postnatal care and general medical neglect.

Source: Michael Tidemann, Esterville Daily News [12/12/07]

House Democrats Delay Vote on Medicare Bill

The House on Wednesday decided to delay until next week a vote on a Medicare package that would delay the scheduled 10% reduction to Medicare physician fees, CongressDaily reports. According to CongressDaily, "Democrats are hoping to win support in the Senate for more than the 'bare-bones' fix being proposed by House Republicans, but it is unclear if that will be possible" (Johnson/Bourge, CongressDaily, 12/13). Aides from both parties said that the bare-bones package released on Wednesday could become law if Democrats fail to pass a broader bill before Congress adjourns.

The Republican package would halt the physician fee cut, but it does not include any fee increase. The proposal also would extend for one year several Medicare programs that are about to expire, including a program that gives higher reimbursement to rural health care providers, transitional Medicaid assistance and exemptions to caps on occupational therapy benefits.

Source: CongressDaily Via American Health Line [12/13/07]

Query: Bunionectomy for Patient With Severe Gout

I have a 30 year old male patient who had a long history of multiple gouty episodes, particularly in the left 1st MT joint until he finally was put on appropriate medication for his uric acid. When I started seeing him 2 months ago, an acute attack was just resolving. His x-rays show typical gouty (punched out) lesions in the first met. head. He also has signs of stage 1 hallux rigidus. He has never been able to move his joint more than 10 degrees due to pain and/or limitation. His pain is fairly severe even after a period of immobilization and NSAIDs. If I do surgery (for hallux rigidus) I predict the joint is going to be a mess due to chalky gouty tophus. Any suggestions (fusion? implant? Keller? other conservative tx?) would be appreciated.

Diane Phalen, DPM, San Marcos, TX

Query: NHIC Medicare Denial of Routine Foot Care

Our Medicare carrier is NHIC (California). I recently billed CPT 11720-59 (debridement of nails, 1-5) denied. The patient had a dystrophic, mycotic hallux nail which I debrided. The billing diagnoses were ICD-9 110.1 (onychomycosis) and ICD-9 357.2 (polyneuropathy in diabetes). Ulcer debridement was also billed that day, and we were reimbursed.

My billing service sent me an article written by Dr. Poggio stating nails needed another diagnosis, such as ICD-9 681.11 (paronychia) or ICD-9 729.5 (pain in limb). However, that article referred to symptomatic nails, not Medicare "covered" routine foot care in an at risk patient. The explanation of benefits did not make the patient responsible for this service. She had been covered previously for the foot care service in the past (approximately 85 days prior). Are we doing something wrong?

Steven Ginex, DPM, Palm Desert, CA

Response: There are two NHIC (California) Medicare local carrier determinations (LCDs) that discuss palliative nail services. One is for routine foot care (for the non-symptomatic "at risk" patient) and the other is for nails that are "symptomatic." The qualifiers are wholly different. You correctly coded for an "at-risk" patient,
CPT 11720-59 (debridement of nails, 1-5)

[NOTE: The "-59" modifier was used because an ulcer debridement was also performed; and the CCIs require a modifier on the nail debridement code to correctly unbundle the two procedures] with ICD-9 357.2 (polyneuropathy in diabetes) and ICD-9 110.1 (onychomycosis)

You also, per ICD-9 coding guidelines, should have included ICD-9 250.6 - the underlying disease - above ICD-9 357.2 in Section 21 (diagnosis) of the 1500 claim form. This may or may not have been the reason for the denial. Because ICD-9 357.2 has a asterisk (*) by it, you would also need to have included the diabetes-treating physician's name, NPI, and the date the patient was last seen by their MD/DO for diabetes treatment/follow-up. If this was not included, you would have had CPT 11720 denied. In either of these first two cases, correct the mistakes, and submit the corrected claim for redetermination.

Lastly, if you included all the above - i.e., did everything correct -and were still denied reimbursement with the explanation of benefits error message not making sense, you may be a victim of a system glitch. You or your billing service should contact NHIC, and asked why the claim was denied reimbursement.

Tony Poggio, DPM, Alameda, CA

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RE: Patient Who Returns After Being Discharged (Name Withheld)
From: David Secord, DPM, Elliot Udell, DPM

I had a diabetic patient who wore completely inappropriate shoes, causing his 2nd digit hammertoe to ulcerate at the proximal interphalangeal joint. After controlling the infection and then doing an arthroplasty, I saw the patient 3 days later. He was without crutches, without post-op shoe, without a dressing on the foot and wearing the exact same damn shoes on the post-operative foot as caused the infection in the first place. He was indignant with his claim that “I didn’t think I needed them anymore”—despite oral and written instructions, signed by the patient, indicating the post-op period of non-weightbearing and compliance with keeping the dressing Clean, dry and intact.

His weight-bearing on the foot in the inappropriate shoe tore the incision open, pulling the sutures through the skin. He had the audacity to ask me why I “didn’t put the stitch across both sides of the incision.” When I finally got this guy to heal, I discharged him with a certified letter. He ended up having scar tissue at the torn open incision and came back to the office 4 months later saying that if I agreed to redo the surgery for free he would agree not to sue me.

I was actually more than happy to explain his complication, his malignant non-compliance, and his discharge and handed him a copy of his charting, pointing out the careful documentation and pictures of the course of his surgery, stupidity and complication and showed him the door. If you have documented behavior of this type in a patient and discharged them, don’t shy away from that decision. Toxic behavior shouldn’t be tolerated and no apologies should be offered for removing it from your practice.

David Secord, DPM, Corpus Christie, TX, David5603@pol.net

Editor’s Note: An Extended-length note by Dr. Udell appears at: http://www.podiatrym.com/letters2.cfm?id=17050&start=1

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. 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 -- www.homephysicians.com

ASSOCIATE PART-TIME POSITION MARYLAND

Part-time, Leading to a full time position. A well-established, successful podiatry group in Washington Suburban area of Maryland , Ownership opportunity. Surgery Center on-site. Great office staff. Flexible schedule. Great opportunity. Biomechanics and or Surgical residency experience preferred. Fax Curriculum to 240 465 0332. Email pmrypmry@yahoo.com. Call 240 604 4564.

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

FULL OR PART-TIME POSITION WANTED – LOS ANGELES COUNTY

Well-trained podiatrist looking for a full or part-time position in Los Angeles County area. Professional, motivated, courteous and interacts well with patients and staff. Recently completed Kaiser 3-year surgical training program. CV and letters of recommendation available upon request. samiam_dpm@yahoo.com or 818-693-4790.

A well-established, ethical solo podiatry practice wishes to expand its current surgical services by hiring a full time associate with PSR-24/36 training which includes strong surgical rear-foot and ankle reconstruction, diabetic limb salvage (AZ is a no amputation state) and ER trauma. ABPS qualified/certification required. Applicant must be personable and caring to patients. Practice in an office base within a state-of-the-art orthopedic surgical hospital environment and plenty of future expansion capabilities for a bright, eager, reliable associate. Email complete CV with current references and photo to footdoc352@cox.net

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