Query: Is This a Stark Law Violation?
My office has been approached by EBM Medical to offer compound prescriptions that are not covered by Medicare. Physicians are paid “directly by patients”.
Considering the recent article on the Stark Law, is EBM Medical’s business model to reimburse physicians for compounds ordered directly to patients legal?
Scott T Grodman, DPM, Taylor, MI
Query: New CPME CME Rule
I am a podiatrist in Ohio. It is my understanding the State Medical Board now has a new rule where only the amount spent on a CME is the credit given. For instance, if a physician watches a video for CME, but the video is only 57 minutes long and not one hour, a full credit will not be awarded and only a credit equaling the 57 minutes is given. How will this affect the Podiatry Management CME credits?
Rosella Gabriele, DPM, Cleveland, OH
Editor’s Response: This new CPME rule, which took effect on July 1, 2025 does not affect Podiatry Management’s instructional media CPME-Approved CME program. It only affects programs that use a lecturer, either live or online. PM’s CMEs are each 1.5 credit hours as certified by a psychometrician.
06/25/2025
QUERIES (DEA)
Query: Mate Training
My DEA license renews July 31. I need to complete the 8 hours of opioid education requirement.
I have contacted our state board (KY) who didn't have any information. I sent an email to the DEA asking for guidance without response. Is there a specific MATE training for podiatry? Does any online MATE training suffice?
Steven Block, DPM, Owensboro, KY
06/20/2025
QUERIES (CLINICAL)
Query: Management of Fryberg’s Infraction
My patient is a 13-year-old diabetic female who is a very active soccer player. She recently went through a nutritional issue as she was bulimic for about six months. This has been managed and she’s doing well. She showed up to my office with pain into the third and fourth metatarsal heads and we have an MRI that’s consistent with acute Fryberg’s infraction. I would be very interested to hear how people have managed this.
06/12/2025
QUERIES (CLINICAL)
Query: Hyluronidase for Scar Tissue
I have a patient who is suffering from chronic pain from what I think is scar tissue at the first branch of the lateral plantar nerve. It is affecting the quality of their life. They had surgery for removal of an accessory soleus that was causing pain but it left them with scar tissue causing nerve entanglement. This has been confirmed by post-operative MRI. Local blocks, multiple shots of cortisone, desiccated alcohol, and most recently D5W perineurial injections have all failed in fact some have exacerbated the problem.
She came to see me to discuss hyluronidase injections into the scar tissue to see if that would help. She is vehemently opposed to any other surgery which I don’t blame her. She is a good patient and has reasonable expectations. Does anyone have experience with the use of hyluronidase to reduce scar tissue and what protocols and dosages are being administered?
06/10/2025
QUERIES (EMR)
Query: Recommendations of Podiatry-Specific EMR
I am looking for a podiatry-specific EMR. Any recommendations?
Daniel Kormylo, DPM, Rocky Point, NY
06/09/2025
QUERIES (NON-CLINICAL)
Query: Medicare Verification Websites
Any recommendations for a Medicare verification website? Which are the least expensive ones?
Stan Luksenburg, DPM, Cleveland, OH
06/06/2025
QUERIES (CLINICAL)
Query: Taking Blood Pressure Prior to Minor Procedures
I’d like to ask a question about an incident that occurred the other day. I was excising a painful hyperkeratotic lesion from the 5th toe lateral proximal nail fold with lidocaine plain. During the excision of this 3 mm lesion, bleeding did not stop for more than 30 minutes. I decided to take her blood pressure which was 206/104. I assumed her BP was causing this bleeding issue since she was not on any anticoagulants, no hematologic pathologies as per her PCP.
I’d like to ask if we should take BPs on patients we are doing any procedure on as minor as this is. P.S. the bleeding finally stopped, but I did send her to the ED which confirmed hypertension as well. The lesion was sent for pathology.
Name Withheld
06/05/2025
QUERIES (LICENSING ISSUES)
Query: Preparation Materials for PM Lexus Exam
I'm a retired podiatrist wanting to re-establish my license in CA, so I need to take the PM Lexus Exam. The problem is I can't find any specific preparation materials for that test. Do you know of any such preparation materials? Are there any other study materials in particular that can prepare you for that test?
Name Withheld
06/05/2025
QUERIES (DEALING WITH PATIENTS)
Query: Patients Who Want to be Seen Immediately
We are noticing a trend in our community, and I'd like to know how others are addressing this issue. The problem is that we are getting calls from more and more patients who want to be seen "today", and if we are booked or closed for that day, they go elsewhere. These are not patients with true emergencies who absolutely must be seen immediately. It could be a patient with a mycotic nail or some other foot condition that has persisted for a while and they decided that they finally want to see a podiatrist and don't want to wait for an appointment.
If this is indeed a trend, how are others addressing this situation without having to keep your offices open 24/7.
Elliot Udell, DPM, Hicksville, NY
06/03/2025
QUERIES (CLINICAL)
Query: Short Proximal Phalanx
Over the 36 years of surgery, I have done many osteoclasis procedures on metatarsals—but never on a proximal phalanx alone. A gradual lengthening is preferred over a single stage lengthening due to vascular concerns.
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Short Proximal Phalanx |
I am planning to place the proximal pins in the metatarsal and the distal pins in the distal aspect of the proximal phalanx. I am open to comments and suggestions.
05/16/2025
QUERIES (CLINICAL)
RE: Unusual Surgical Suture
Gary Smith, DPM
I saw a patient this week who showed me their hernia repair incision 3 weeks post-op. The incision had been closed with 10 external horizontal mattress sutures with what appears to be 2-0 Vicryl. The incision seems fine but the patient is still having inflammation and drainage around the sutures in the knot areas above the incision. The patient has been getting it wet in the shower since Day 2 as allowed by their surgeon. I have never heard of absorbable sutures being used like this. It seems to me they are providing a portal for moisture and bacteria to enter the skin. The knots are yellow and look like bacteria farms. Is this something new? Has anybody ever heard of this?
Gary Smith, DPM, Bradford, PA
04/23/2025
QUERIES (CLINICAL)
Query: Concentration of Dextrose Solution for Prolotherapy?
Does anyone have any experience in prolotherapy for lower extremity conditions. What concentration of the dextrose solution do you find to be the most effective?
Brent Rubin, DPM, Lakewood Ranch, FL
04/21/2025
QUERIES (NON-CLINICAL)
Query: PICO Ultrasound Machine Won’t Download Images
My old PICO will no longer download images onto my flash drive. Does anyone know of a viable workaround or a way to fix this?
A James Fisher, DPM, Eureka, CA
04/14/2025
QUERIES (CODING AND BILLING)
Query: Orthotics Denial
A male patient was seen for bilateral plantar fasciitis. The decision was made to proceed with custom orthotics, and Bio-foam impression casting was done and documented. The patient was dispensed the devices about 3 weeks later, and the claim was submitted to Wellmark Blue Cross Blue Shield of Iowa using L3000 LT,GA and L3000 RT, GA. We received a pre-payment medical record request from Optum, and after review of the records submitted, the claim was denied with the reason: "Documentation does not support services billed" with additional Remarks: “Not supported. The submitted medical records do not contain sufficient details of custom fabrication of the orthotic to support the billed charges. A custom fabricated item is one that is individually made for a specific patient. Of note, classification of custom fabricated requires a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, and/or other images of the body part."
We submitted additional records, including the progress note from the visit at which the impressions were done, as well as the orthotic lab invoice with the patient's name, but it was again denied with the same reasoning.
Any suggestions on how to satisfy this documentation requirement when the fabrication and customization is done at an outside lab? It appears in this case that our billing service was able to appeal and get the claim paid, but it was a total of 9 months from the date of service.
Michael Orosz, DPM Cedar Rapids, IA
04/09/2025
QUERIES (CODING & BILLING)
Query: Injection For Sesamoiditis
While reviewing coding descriptions, the question of an injection for sesamoiditis was stated as extraarticular, defined as a procedure where medication is injected into the tissues surrounding a joint, rather than directly into the joint. There is no indication the injection was into a tendon, ligament, or aponeurosis as described in CPT 20550 or 20551. Would then CPT 96372 for subcutaneous or intramuscular be more appropriate?
Valerie Roberts, CPC, Minot, ND
04/07/2025
QUERIES (MEDICAL-LEGAL)
Query: Fraudulent Misrepresentation in Sale of a Practice
We bought a practice. Then, once we took over, discovered they had billed inappropriately and documented what they did. It’s in the notes what they did, but they billed fraudulently. Example: Office visit for nail and callus care every 4-6 weeks. We bought the practice based on collections, but we would not have known until we actually saw the patient that the treatments were all billed wrong; so, the cost of practice was inflated and the practice was worth much less. What can we do? Re-negotiate? File a lawsuit? Institute a qui tam action?
Name Withheld
04/07/2025
QUERIES (CLINICAL)
Query: Invisible Metallic Fragments (Morgellons Disease?)
A middle-aged female patient presented with a complaint of an embedded metallic shard in one of her feet after walking barefoot on a garage floor, even though she felt no puncture or injury at that time. She had attempted self removal of the foreign object with a scalpel several times prior to the initial visit. On exam, there was a single tiny 1 mm reddish macule. X-rays did not show any metal or other visible foreign body. She was convinced of its presence and stated the fragment must be too small to be seen on the x-rays.
I performed an exploratory I&D of the macule and nothing was found. She returned a month later stating that the problem was still there, causing pain; and now she had it in the other foot as well. She stated she had removed a couple of tiny black filaments herself and could not understand why I couldn't see them. An exam again showed a couple of tiny red macules. Less aggressive trimming/enucleation of the macules yielded nothing. I researched this and came across Morgellons disease, a psychiatric disorder, which seems to fit. Has anyone else encountered this? Any suggestions for treatment?
Name Withheld
04/03/2025
QUERIES (DISABILITY INSURANCE)
From: Name Withheld 1 (NY)
To the ‘name withheld’ who had a disability issue, I too had the exact same experience with UNUM. You will have little choice but to file suit.
My suggestion is to contact the law firm of Schwartz, Conroy & Hack,PC in Garden City and Manhattan. They are disability lawsuit specialists.
Name Withheld 1 (NY)
04/02/2025
QUERIES (DISABILITY INSURANCE)
Query: OOC Disability Policy
I took out something called an own occupation (OOC) policy. I was told that if I became disabled from performing surgery, I’m able to perform office visits and orthotics, etc. and still be classified as 100% disabled as a podiatric surgeon. Now that I filed a claim, I’m being told something different from my disability company, UNUM.
They are also stating that if a certain percentage of income is lost and I’m unable to perform surgery, but make up the difference in orthotics etc., that I’m not “disabled” anymore. Can anyone please recommend someone I can speak with regarding this issue.
Name Withheld (NY)
Editor’s comment: PM News does not provide legal advice: The answer is usually found in the fine print of the disability policy. Guardian, for example, says “True Own-Occupation: If you can’t work in your regular occupation but are willing and able to work in some other capacity, this definition means you can get your full benefit payment even while holding another kind of job. For those in a medical specialty, it is crucial to have insurance that accurately reflects the specialized nature of their careers. If the surgeon in the above scenario had disability insurance for physicians with this definition, he or she could take a teaching or consulting job and still receive replacement income for the entire benefit period.”
03/07/2025
QUERIES (CODING & BILLING)
Query: Insurance Reimbursement
Charges were submitted to a patient's insurance for care they received in mid-February 2024 and the insurance paid us shortly afterwards. We recently received a request from the insurance company to reimburse the amount paid a year ago. They state we were paid by mistake as the patient's benefits had terminated prior to the date of services.
Reimbursement amounts to a few hundred dollars. Are we obligated to reimburse the insurance for their mistake as it would be difficult to bill this patient for services a year later?
PM News Subscriber
02/28/2025
QUERIES (CODING & BILLING)
Query: ANTHEM Blue Cross Payments for Orthotic Casting
I would like to find out from my colleagues around the country if they are seeing the following:
In the October, November, and December issues of the California Podiatric News Magazine (CPMA) , there was a section on page 21 about Anthem Blue Cross Best Billing Practices for orthotics. In the second paragraph, it discusses using the code S0395 for the casting code. According to CPMA and their legal section, Anthem signed off agreeing to this.
However, we have been doing that for a number of months and while Anthem initially does pay the code, they then come back a few weeks later demanding a refund stating it is inclusive in L3000. They then, if not reimbursed immediately, begin offsetting other payments and deducting the amount they paid from future payments until they have been fully reimbursed. We have forwarded examples of the payments and then the recoupment requests but have not heard anything. Has anyone else been having these issues?
Vince Marino, DPM, Novato, CA
02/28/2025
QUERIES (CLINICAL)
Query: Plaque-Like Calluses on Weight-Bearing Surfaces
A 19 year-old Hispanic female patient presented with plaque-like calluses on the weight-bearing surfaces (balls and heels) of BOTH feet which started a month after starting a new job at a memory care facility. Her new job consists of helping folks with bedtime routines, (wears/changes gloves routinely), and wiping/cleaning residents and repositioning them as needed. Shortly after the skin changes on her feet occurred, her fingernails started to become discolored, pitted, dystrophic and thickened with dark longitudinal streaking, starting with the right thumb nail. Her toenails look fairly normal with no obvious signs of fungal infection.
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Plaque-Like Calluses on Weight-Bearing Surfaces |
This seems to be auto-immune driven, however, given the sudden onset with the new job and heavy use of gloves, I have some concern for infection, either fungal or bacterial. We have started her on antifungals to see if this helps. A dermatologist has suggested hereditary palmoplantar keratoderma, recommending symptomatic treatment with inserts and urea cream. A biopsy is being considered, but first utilizing supportive inserts to reduce stress/weight on the weight-bearing surfaces. Additionally, she will start applying urea cream to one foot, triamcinolone to the other, and see what results we get. Of interest, the patient also has a history of loop bowel in addition to scoliosis and eczema. No skin changes to the knees, back, neck, etc., although she has a very dry scaly scalp. Psoriasis is a consideration. Input and suggestions are appreciated.
02/26/2025
QUERIES (CODING AND BILLING)
Query: Denial of CPT 28300 by BCBS
We are receiving denials on CPT 28300 billed in conjunction with a CPT 28730. The denial reason states, "The benefit for this service is included in the payment/allowance for another service/procedure which has already been adjudicated. Refer to the 835 healthcare policy identification segment (loop 2110 service payment information ref)."
A calcaneal osteotomy is clearly a separately identifiable service from a multiple midfoot fusion. Any thoughts?
PM News Subscriber
01/31/2025
QUERIES (MEDICAL-LEGAL)
So does that mean that we have to find this list and check every employee that we plan to hire? If yes, where do we find this list?
Farshid Nejad DPM, Beverly Hills, CA
Editor's comment: PM News does not provide legal advice. You can check to see if a potential exployee is on the HHS-OIG list by clicking here.
