The Voice of Podiatrists

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December 31, 2008 #3,438 Editor-Barry Block, DPM, JD

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PA Podiatrist & Orthopedist Cite Need for Diabetes Awareness

The American Podiatric Medical Association says the national epidemic of diabetes is producing "alarming levels" of lower-limb amputations, which most often occur when the disease is poorly controlled, prompting heart and kidney disease, and circulation and eye problems. Poor circulation, especially in people lacking sensation in their legs and feet, can prompt unsuspected foot ulcers, wounds, fractures and deformities that require timely treatment to prevent gangrene and amputation.

Dr. Patrick Burns

"Nationally, we are trying to make people more aware," said Dr. Patrick Burns, a podiatrist with the University of Pittsburgh Medical Center's Department of Orthopaedics. "But, unfortunately, we don't seem to be making headway with amputations."

Because early detection is key, orthopedist Dr. Steven A. Connor said regions lacking podiatrists or physicians who routinely check the feet of those with diabetes can allow severe problems to arise. Podiatrists test pulses and sensation in feet and legs, check for skeletal or muscular problems that could prompt wounds and infections, and use angioplasty and stents to restore circulation to legs and feet. Doctors also can prescribe special shoes to reduce friction injuries.

Source: David Templeton, Pittsburgh Post-Gazette [12/29/08]

Query: Dry Needling With Steroid for Chronic Heel Pain

I have a 74 year old healthy male with chronic heel pain for over 15 years. He presented to my office after several rounds with various orthotics, steroid injections, night splints, NSAID's, physical therapy and extra corporeal shockwave therapy. The patient exhibited a plantar calcaneal spur as well as a hallux rigidus of the same foot. I decided to try another round of low-energy ESWT, which has improved the situation about 30-40% in about 8 weeks.

I have read about dry needling combined with a steroid injection under ultrasound-guided technique. Does anyone have any experience with this technique, and if so, what kind of outcomes have been attained from this procedure?

Robert Chelin, DPM, Toronto, Canada

Query: Refusal to Treat AIDS Patient

I was consulted at a nursing home facility by a doctor who belongs to a big medical group. When I went to see the patient, I felt that they were sticking me with that consult. The patient has late stage AIDS with gangrene of toes and positive venous duplex. My understanding is that this group has their own podiatrist whom they did not call for this patient. I looked at the chart and walked away. Is there any legal obligation for not seeing the patient?

Name Withheld

Editor’s comment: PM News does not provide legal advice. Based on the facts presented, this is likely both a legal and an ethical violation. Physicians cannot refuse to treat patients because they have AIDS.

Refusing to treat a patient because of AIDS is considered discrimination Under the APMA Code of Ethics

ME4.21 The podiatrist shall not discriminate against any patient because of race, religion, ethnicity, gender, sexual orientation, disability, socioeconomic status, or health status.

Query: Osteomyelitic Bone Biopsy/Debridement

When performing a deep debridement/drainage on an ankle for a deep tissue abscess, I came across a deep osteomyelitic bone pocket in the tibia that had not been evident on x-ray the day before.

Can a bone biopsy, superficial, CPT 20240, be added to the deep tissue debridement (CPT 11044)? If not...why not?

Barry A. Wertheimer, DPM, Redondo Beach, CA

Response: If you billed CPT 11044, any 'same site', then removal of bone for biopsy would be included in the debridement skin, subcutaneous tissue, muscle and bone code, and would not be separately reimbursed. So, to answer your question, yes, in this case, it would be bundled/included in the CPT 11044 allowance.

If you performed debridement of soft tissue, and attempted to treat the osteomyelitic bone (e.g., excision of bone, partial, for osteomyelitis [calcaneus or tibia or fibula]; or drainage of bone abscess), then you would bill CPT 11043 and CPT 2812x/CPT 2764x. You would not also bill the bone biopsy.

If you billed CPT 11043 because the only debridement you performed was infected, necrotic soft tissue, and your primary bone procedure was the biopsy, then you can bill for both CPT 11043 and the bone biopsy.

Other codes to consider for the soft tissue work: CPT 20000 - incision of soft tissue abscess (eg, secondary to osteomyelitis); superficial; or CPT 20005 - incision of soft tissue abscess (eg, secondary to osteomyelitis); deep or complicated.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found here

RE: 3-Layer Unna Boot (Jane Graebner, DPM)
From: Eric J. Lullove, DPM, Robert Wunderlich, DPM

There are many companies that provide multi-layer compression dressings. Medline (Dynaflex) and Smith & Nephew (Profore) are types of 3 or 4 multi-layer compression bandages. 3M (Coban 2 Layer) is another type of dressing.

You should keep in mind that the type of patient that you are compressing determines your compression bandage. If you have a very active ambulating patient, you are better off with a short-stretch bandage, such as the 3M Coban 2 Layer (which happens to be the only short stretch bandage on the market). The 3M Coban 2 Layer will continuously compress the leg, which is perfect for your primary or secondary lymphedema patients or venous leg wounds that qualify for compression in an ambulating patient. For your nursing home or more non-ambulating patients, the Unna boot and similar compresson wraps (Dynaflex, Profore) are considered long stretch and do not compress once the leg has reached its optimal compression from the bandage.

THe bandages usually run from $12-30 and can be ordered through any of the major medical suppliers.

Eric J. Lullove, DPM, Boca Raton, FL, ericsops@yahoo.com

Perhaps the best-known multi-layer compressive dressing is a product called Profore, which is manufactured by Smith+Nephew. It utilizes 4 layers, and a non-adherent primary dressing is also included in each kit. It offers improved retention of a therapeutic level of compression (7 days vs. 1-3 days for an Unna boot), and improved patient comfort. The main disadvantage is cost; it is several times more expensive than an Unna boot dressing. In my experience, it is a much better product than an Unna boot, but unfortunately cost and inadequate reimbursement prevent me from using it for many of my patients (cost is about $28, Medicare reimbursement is about $11). Profore is available from most medical supply distributors (Gill Podiatry, for example).

Robert Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com

RE: VA Podiatrist Offers Medically Supervised Pedicures
From: Brian Kashan, DPM

Ironically, we were recently speaking of setting up the exact same medically supervised pedicure as Dr. Waskin has done. Is there a need? Absolutely! And patients ask for it all of the time. We haven't instituted it as yet, but are working on it. I believe it will fill a niche and provide a safe, clean, and cosmetic service to our high-risk patients.

Brian Kashan, DPM, Baltimore, MD, drbkas@worldnet.att.net

RE: Developing a Relationship with Nursing Homes (Chad Schwarz)
From: Jon Purdy, DPM

I worked the nursing home circuit when I started my practice cold. What I found were more barriers than facilitators in getting in to treat these poor folks in need. Under legal advisement, I put in place a consent to treat form that the patient or family member would sign prior to my initial and continued treatment. I also had them sign on to a HIPAA agreement at the same time. In the case of a registered facility, no individual agreement needed to be signed, as you would be under their global umbrella.

To work my way into these facilities, I did two things. I contracted with an agency that did all this for me for a percentage. I also approached facilities on my own. I usually found that any current treating podiatrists were more passive in their involvement and I was a welcomed addition. I also found many times that the current podiatrist “only did nails.” Consider giving periodic talks for residents as a way of introducing yourself.

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

ASSOCIATE POSITION 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

ASSOCIATE POSITION WANTED - GEORGIA,TENNEESSEE OR ALABAMA

I am looking for an opportunity to be a full-time associate with a well-established podiatric facility; I have worked in a private office setting for four years with surgical privileges at Wellstar Kennestone Hospital and Windy Hill Hospital and Banks Jackson Commerce Hospital. Rick Thornton, DPM, 312-752-7713 E-mail, rico_t16@yahoo.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 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 -SOUTHERN NEW JERSEY

I’m looking for podiatrist who wants additional practice hours. Perfect for combining your own practice with an additional income. Must be on Aetna Insurance, Horizon Blue Shield, Medicare, and most commercial carriers. I am looking for someone who has a desire to learn how a very successful practice is run, so that I will be able to have time away from my practice. The payscale is based on straight Commission. Could lead to partnership or sale. E-mail contact information, CV, and why you would be perfect for this opportunity. Contact foot.care@verizon.net

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

ASSOCIATE POSITION WANTED – MA, CENTRAL FL, or SEATTLE, WA

Graduating resident in June 2009 with superior people skill & work ethic and diverse PM&S-36 surgical training. Seeking for an employment as an associate. Preference to Massachusetts state, central Florida or Seattle. Khanhmei Wong, DPM. 617-640-1107 or pager 774-299-1943.

ASSOCIATE POSITION – CINCINNATI, OHIO

This is your once-in-a-lifetime opportunity to join one of the most successful practices in the United States. No seniority system. If you are motivated and have completed a PSR24-36 residency, your income is limited only by your enthusiasm and desire to achieve. Fax resume, including photo, to: 513-577-7261 or E-mail resume to Kroesch4poh@aol.com

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