The Voice of Podiatrists

Serving Over 13,500 Podiatrists Daily

December 22, 2011 #4,338 Publisher-Barry Block, DPM, JD

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Laser for Onychomycosis is Best Option for Most Patients: NJ Podiatrist

One of the latest innovations introduced in podiatry is the new laser treatment for toenail fungus, a treatment which heats up the cells to obliterate the fungus without damaging one's nails, Dr. Jonathan Margolin explained. Other medications like pills, he said, can have undesirable side-effects. 

Dr. Jonathan Margolin (Photo: Joe Camporeale)

"Lasers are better," he said. "They're new to the market and have proven to be effective. Treatments only last 15-20 minutes and anesthesia is not necessary." Margolin added that laser procedures may not be the best option for diabetics, or those with nerve or circulatory problems.

Source: Joseph Ritacco, Northjersey.com [12/15/11]

CA Podiatrist Worries About Potential of Injuries From Running Barefoot

Harvard researchers reported in the scientific journal Nature that bare feet take less of a pounding during a run than their shoe-cushioned counterparts. This news exploded through the running world, prompting new runners to flock to the sport. Many podiatrists, however, disputed the findings. If constraining feet in running shoes is bad, they argued, why do custom-made orthotics help so many people?

Dr. Alvie Hurray

Dr. Alvie Hurray, a Santa Cruz podiatrist, thinks some runners can get away with running barefoot or in minimal shoes. After all, he said, "There are people who can jump out of a tree and not break a leg." But he worries about the potential for injuries.

Source: Meghan D. Rosen, Santa Cruz Sentinel [12/17/11]

House Rejects Senate Tax Measure; Doc Pay Cut Looms

The threat of a 27.4% cut to Medicare physician payments Jan. 1 became more real Tuesday after the House of Representatives voted 229-193 on a motion to disagree with a Senate-amended version of a House payroll tax cut bill that would have placed a two-month freeze on payments to the nation's doctors.

In that same vote, the lower chamber requested a conference, which would allow the House and Senate to resolve their differences in the two bills. On Saturday, the Senate approved an amended version of a House payroll tax cut bill that the House passed Dec. 13. Both pieces of legislation would avert the scheduled reduction in Medicare physician payments and extend certain healthcare provisions that are set to expire by year’s end. But while the House version calls for a two-year fix to the sustainable growth-rate formula and provides a 1% update for doctors in 2012 and 2013, the Senate’s amended legislation would place a two-month freeze on physician payments until Feb. 29.

Source: Jessica Zigmond, Modern Healthcare [12/20/11]

Alleged Failure to Diagnose a Post-op Infection (NY)

Facts: On Jan. 30, 2007, plaintiff Barbara Weiss, 61, a homemaker, underwent surgery performed by defendant podiatrist A, in which multiple procedures were performed to repair a bunion and hammertoes in her right foot. Multiple bones were cut and/or removed during the surgery, and pins were inserted through her skin and into her toe.

On Feb. 9, 2007, Weiss presented to Defendant B a podiatrist employed at the time by Defendant A and currently his partner, for a post-operative visit and complained of severe pain. The foot was noted to be swollen and red with a serous discharge present, and Weiss was prescribed an antibiotic, Zithromax, without performing a culture.

Weiss returned to Defendant B on Feb. 16, with a...

Editor's Note: The complete jury verdict reporter can be read here.

Result: Verdict-Mixed, Award Total: $500,000 The jury found defendant B liable, for departing from accepted standards of care, and further found Defendant A not liable. Weiss was awarded $500,000 for past pain and suffering.

Plaintiff's expert: Jeffrey Adler, DPM, New York, NY
Defendant's expert: Michael Trepal, DPM, New York, NY

Ponder Ideas Optimistically

Embrace ideas and optimism from others by following the 24x3 listening plan. When someone presents you with a new concept, pause for 24 seconds to ponder positive thoughts before thinking and saying anything negative.

In future situations, move to the next level by waiting 24 minutes before responding in a critical way. Take that time to think about ways the idea or part of the idea might work to improve current conditions. Work toward the ability to wait 24 hours before thinking about and articulating the cons.

Benefit: By optimistically pondering ideas and thoughts, you will discover new possibilities that others prematurely rejected.

Source: Adapted from “Learning Optimism With the 24x3 Rule,” Anthony Tjan, HBR Blog Network via Communications Briefings

Query: Holiday Staff Bonuses

I am a newly in practice (about a year) with an office manager and two staff members (one part-time). I'm looking for guidance on how much of a holiday bonus I should give each of them.   

Name Withheld

Query: TENS Unit Billing
 
Does anyone bill Medicare DMERC for portable TENS used for neuropathy? The codes I was given are E0720, E0731 and A4595. Medicare says these are M51 (missing/incomplete/invalid procedure codes).

Sherie Akerley, Coder, Fort Myers, FL

Response: The codes you gave:
E0720 - Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0731 - Form fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
A4595 - Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)

are not procedure codes. The carrier may be looking for a corresponding musculoskeletal procedure code. Before you bill this to DMERC, you should check your Part B and DME carriers' policy specific for allowed codes accepted with TENS.

By the way, you may find that not many carriers cover TENS for neuropathy (as opposed to some limited parameters for use in musculoskeletal pain management).

Tony Poggio, DPM , Alameda, CA

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RE: Orthotic Therapy For Hallux Rigidus (John Scholl, DPM)
From: Keith Gurnick, DPM, Robert S. Schwartz, CPed

The diagnosis of hallux rigidus, by itself, does not necessarily mean that a foot orthotic is indicated. Gait analysis findings and biomechanical measurements would provide additional information to help answer your question. However non-surgical suggestions would include:
1) Suggesting a very stiff-soled shoe with a roomy toe-box.
2) Intra-articular steroid injection to help reduce any joint pain.
3) A full sole carboplast inlay to stiffen up any shoe flexibility.
4) Work or activity modification to reduce propulsive forces across the involved joint.
5) Maybe orthotics.

Keith Gurnick, DPM, Los Angeles, CA,  keithgrnk@aol.com

Try a ready-made rocker sole shoe with at least 20 degrees of dorsiflexion at the 1st MTPJ. MBT, Finnamic, PW Minor, and Alden are some of the brands that come to mind. Of course, a rigid rocker can be added to any shoe. If he is wearing a shoe with enough depth to accommodate an orthotic with a Morton’s extension, that is a viable option.

Robert S. Schwartz, CPed, NY, NY, rss@eneslow.com

RE: Chronic Diabetic Ulcer (Kel Sherkin, DPM)
From: Timothy P. Shea,  DPM

Diabetic foot ulcers of longer than three months need to be considered senescent and in a state of non-healing. This indicates a high index of suspicion for adjunctive vascular disease and deep bone/joint infection, even if x-rays are negative.
 
My recommendation for this wound is: MRI if possible to determine bone involvement. Vascular evaluation (preferably by vascular surgeon to determine nature and extent of vascularity available for healing). If needed, do the vascular procedure first. Revisit medical management. Once stable, plan deep surgical extensive debridement of the wound (probably to include the bone and joint. This may require distal amputation). Take deep cultures of the wound for appropriate infection management. Do close monitoring of medical status (commonly out of control blood sugar) .

Post-op plan: leave the wound open unless it can be closed primarily, with all infected tissue removed. Negative pressure wound therapy, off- load foot with cast, weekly debridements, and if possible advanced tissue therapy 2-4 weeks after surgery. Use markers of decrease in square volume (length by width cm.) of the wound by 50% at 4 weeks, 80% at 8 weeks,100% 12-14 weeks.

Be aggressive in wound and medical management. Advise the patient that he is at high risk for loss of limb and life from this type of problem. Follow-up therapy when the wound heals with appropriate footgear and evaluation every month. These are the types of wounds that easily go on to ray resections, transmetatarsal amputations, and then BKAs. Patient compliance will be a major factor in managing this wound.

Timothy P. Shea, DPM, Walnur Creek, CA, tsheapodiatry@yahoo.com

RE: Study Guides for ABPS Recertification Exam (Bob Kuvent, DPM)
From: Ann Miller, RN, MHA

Dr. Kuvent may want to consider Podiatry Board Preparation Software (podiatryprep.com). I own this product and found it very helpful; however, the last time I called for support, I was told this product did not run under Windows 7. I hope this has changed, but you may need to find an older system to use for your studying.
 
David Hettinger, DPM, Wheaton, IL, davidhett@msn.com

Editor's note: According to the publisher, this program will run on Windows 7 with an Adobe reader (which is free).

RE: Starting a Practice (Michael Rosenblatt, Peter Harvey, DPM)
From: Jeffrey Kass, DPM, Peter Smith, DPM

I echo the comments of Drs. Rosenblatt and Harvey. I was laughing when reading Dr. Harvey's post - his greatest tip came from Bob Levoy. I learned that tip back in first grade. It was actually G-d who needs to be credited, as we are taught HE rested on Saturday.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

I am intrigued by Dr. Harvey’s comment about not working on Saturdays.  What is the rationale behind that?  Currently, I work a short day on Saturday (8:00 – 11:00AM).  If you can give me a compelling reason, I would gladly give it up!
 
Peter Smith, DPM, Stony Brook, NY, ps84@bc.edu

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ASSOCIATE POSITION - TEXAS

Practice in Houston is looking for PSR 24/36, BE/BC trained doctor. We are situated in an affluent area with a large medical community with EMR, diagnostic ultrasound, digital x-ray, multi use laser and our own surgery center. We seek a highly skilled surgeon, well-trained in trauma, wound care and rear foot reconstructive procedures willing to learn and incorporate into our “system.” Must be outgoing, goal-oriented, motivated and positive. Partnership available after successfully attaining the first year’s goals. Compensation includes excellent salary, health benefits, paid vacation and CMEs. Please send CV, references and letter of interest to faajobs@gmail.com

ASSOCIATE POSITION - DAYTON, OH

Join a well-established modern practice in Dayton, Ohio. Excellent reputation and referral base. Base salary $120,000, benefits and bonus structure. EMR, diagnostic ultrasound, Padnet vascular studies, CO2 lasers, all aspects of DME. We seek a surgeon that is well-trained and personable to join our group of 4 podiatric surgeons. Would like to have this individual buy in to the practice eventually. Please send CV and to Ohiodoctors@aol.com

ASSOCIATE POSITION - NEW JERSEY

Associate/Partnership available to energetic doctor(s) or willing to merge into larger group/multi-specialty practice. 25% Medicare, 75% Privates/HMOs, No Medicaid. 8,500 visits per year. Diversified hospital/office wound care, hospital/ASC surgery, and general podiatry. 27 years of excellent local reputation. 2,700 sq ft office opposite hospital in desirable Monmouth County. capstops@aol.com

ASSOCIATE POSITION - EAST TENNESSEE

30 year old practice with 5 offices in greater Knoxville area seeking ethical, personable, hardworking, team player. $160,000 base salary with bonus incentives and benefits. Post-residency experience a plus. Please send resume to ddavidphawk@yahoo.com

ASSOCIATE POSITION - SOUTHWEST FLORIDA

Immediate position for associate to partnership for a surgeon that is BQ/BC by ABPS. Must be a PSR-24 or PM&S-36 trained. Excellent start salary with bonus. Must be ethical, self-starter, hard worker, team player. Willingness to learn/work as part of a team. Great ancillaries & surgery facility. Must be proficient in rearfoot/ankle surgery. Email CV with letter of intent to: susmitad86@yahoo.com

ASSOCIATE POSITION - TEXAS

Well established, expanding podiatric medical and surgical practice with multiple locations Northeast of Dallas, Texas. Modern offices with EHR, digital radiography, Padnet vascular studies and laser. We offer a competitive salary and benefits package for a motivated, ethical, personable and well trained PSR/36 or board equivalent. This individual will also assist managing the residency program. Send resume (CV)to northtexaspodiatry@yahoo.com along with a letter of intent.

ASSOCIATE POSITION - CENTRAL VALLEY/SOUTHERN CA

Seeking associate with partnership availability. Must be highly motivated and have good patient skills and personality. Salary excellent with all paid benefits/incentives including malpractice/401k and profit sharing. Compassionate and well-trained for immediate position. Surgery Center and hospital-based with no HMOs/no rest homes. Bilingual in English and Spanish preferred. Offering a permanent position/partnership in a multi-million dollar hi-tech practice with Partnership also in Surgery center. Please e-mail CV and short bio to: Tonya@wetreatyourfeet.com

ASSOCIATE POSITION - ALBANY/CAPITAL DISTRICT AREA

Immediate position available with generous salary, fringe benefits and percentage. All phases of Podiatry. For more information please contact Dawn at (518) 828-6516 or fax your resume to(518) 828-9510.

ASSOCIATE NEEDED - NORTHERN CINCINNATI, OHIO (FAIRFIELD)

Lead to partnership &/or buy practice. Well-established, reputable & successful (700K collection annual) 25+ year practice. Newer 2k sq.ft office condo & w/5 tx rooms, Aver.80 new patients monthly, full hospital privileges, DME, Padnet, digital x-rays. Inquires to email: gsherwood1@cinci.rr.com

ASSOCIATE POSITION - NAPLES, FLORIDA

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills to join multi-office practice. Hospital privileges available at 648 bed hospital system, 200 bed hospital system and multiple surgical centers. Candidate should have the skills and desire to perform rearfoot/ankle surgery. Florida has a great scope of practice law and we rotate for ER call. Candidate needs to be ethical and motivated. Established practitioner or new practitioner. In a cover letter tell me why you should be selected for the team. Email cover letter and CV with subject line "I am your new team member." to Drgordon@gulfcoastfootcare.com

ASSOCIATE POSITION - SOUTH CAROLINA

Upstate practice seeking PSR-24/36 trained associate. Full-time position with partnership opportunity. Must be ethical, highly-motivated with strong surgical and medical skills. Please send CV to palpodiatry@att.net

SPACE AVAILABLE - NYC & LI

Office to sublet and share - East 60th Manhattan, and Plainview, Long Island. access to an MRI, Joint Commission certified operating rooms, digital x-ray, diagnostic ultrasound, and access to a multi-specialty ambulatory surgical center. Also availability E 22nd between 2nd and 3rd and E 70th off 3rd. Turn-key operation - no investment needed 516 476-1815 PODO2345@AOL.COM

PRACTICE FOR SALE – NANAIMO, BRITISH COLUMBIA, CANADA

Have you ever dreamed of owning a practice where...you can see 0-50 patients daily * average 100 new patients monthly * have zero accounts receivable * gross $480K per year * live in a beautiful community with skiing, hiking, fishing, and boating on your doorstep. This could be yours! If interested contact pistone@telus.net or call 250-754-4192.

EQUIPMENT FOR SALE - SUPERPULSE 45 WATT PEAK POWER LASER (LUMIX2)

Superpulse 45 watt peak power Laser (lumix2) used once or twice. This is a real superpulse 910nw up to 100,000 HZ. Great Laser Used in the super bowl by the Green Bay Packer Why am I selling? I have too many lasers in my office now ( six) This is a great laser for plantar fasciitis. Achilles tendonitis. Lightweight portable. easy to use, fully programmable Sold to first person under $$12,000 You will NEVER get a laser like this at this price. Enjoy. it I just have too many lasers. David Zuckerman DPM footcare@comcast.net

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