Query: Treating Hyperuricemia
We see many people with gout. We are the best at treating an acute “attack”. Do you also treat their high uric acid or do you send them back to their PCP?
Jeffrey Klirsfeld, DPM, Levittown, NY
Query: Taxable or Non-Taxable?
I sell items in my office - pads, Formula 3, OTC orthotics, etc. and I am trying to figure out sales tax for these items I sell. I reviewed the Kansas guidelines and I am still puzzled.
Ali Davis, DPM, Overland Park, KS
Query: Practice EHR
I am interested in purchasing new software from Practice EHR. I would appreciate any feedback from current or past users.
Mitchell Zimmel, DPM, Little Silver, NJ
Query: Source for Refurbished Power Chairs
Does anyone know of a reputable source for refurbished power chairs?
Brian Kiel, DPM, Memphis, TN
Query: Source for Company That Buys Used Equipment
Does anyone have a recommendation of any company that would be interested in buying podiatry equipment?
Query: Becoming a Certified Surgical Foot and Ankle Coder
Where can I go to become a certified surgical foot and ankle coder?
Heidi Hirzy, CPC, Stevens Point, WI
Query: Tricare Chart Audit
I received a request for post-payment audit review of about 100 charts. I was told, ”The U.S. Government does not pay for medical records for post-payment audit review.” I am not aware of that and maybe I overlooked it in some of the signed paperwork. Is anyone else aware of this or has seen this in writing?
Query: DME Signage Requirements
I am moving my office to a different suite (but same address) in a multi-office medical building and want to be sure that the engraving on the front door of my office is correct with what is required for DME. I looked on CMS.gov under special payment rules for items furnished by DMPECOS suppliers and issuance of DMEPOS supplier billing privileges. It seems like all that is required on my front door is to post the hours the office is open. Is there a way to confirm this is all I need before it permanently goes on the door? Please advise.
MIchelle McCarroll, DPM, Allentown, PA
Query: Is Proper Billing Being Taught to Students
As a podiatrist involved in teaching of residents. I find correct billing a delinquency of the podiatry school education. I am wondering if anyone knows of a reason why? I have had a strawpoll taken from many students and residents who state that their school does not offer a coding and billing course. I believe this to be a necessity in the education of a student.
I would love feedback regarding this topic.
Adam Cirlincione, DPM, Garden City Park, NY
This patient is a 36 year old female. She has no medical history aside from claiming to smoke 5 cigarettes/day and appears healthy aside from recent onset lower extremity issues. She smelled heavily of smoke. She had COVID in November and still has a very involved cough upon initial presentation. The dorsal aspect of the right foot was stepped on by a stiletto heel on December 18th. Initially, the area was painful, swollen, and bruised. She describes a "blochy" appearance which lingered.
One month later, a wound opened up. She partially reduced activity and elevated the foot but the wound got worse, which included substantial swelling and pain. She was seen by a PCP. Cultures were negative. She has started 3 separate courses of...
Editor's note: This extended-length query can be read here.
Query: CPT Code for Arthroeresis Implant
There has been recent discussion regarding orthotics and arthroeresis on this forum. I find it absurd that podiatrists have implanted thousands of these devices yet we still don’t have a CPT specific code for this procedure and it is still not reimbursable by the majority of insurance companies. I have spoken to many colleagues around the country and have heard of all sorts of ways this procedure is being billed. Why must the profession play games to get paid for medically accepted procedures? Why don’t we have a specific code for this procedure? Shouldn’t we? What am I missing?
Jeffrey Kass, DPM, Forest Hills, NY
Query: Source for Proper Fitting CAM Walkers
Does anyone have a source for proper fitting cam walkers (both tall and short)? The distal straps (the two that go over the forefoot) are always too short regardless of the manufacturers I have tried, and they barely close over the foot when it doesn't even have a bandage (e.g., for a sprain). It is difficult at best to get them to fit over even the simplest type of bandage and the Velcro barely reaches for closure. Putting one on after a surgical procedure is almost impossible without having to add tape to keep them closed. They are simply way too short.
I would also appreciate a source for pediatric-sized CAM boots as well. I have asked PM Pediatrics where they get theirs, but they outsource all of them to a company that provides the boots as needed, and it is they who bill the insurance and get reimbursed. They would not sell to me.
Charles Morelli, DPM, Mamaroneck, NY
Query: Shopping for a Digital X-Ray Machine
I am thinking about getting a digital x-ray machine. There are many different companies for this and I've found prices that range from $15K to $32K. I've heard that a digital x-ray can be retrofitted into an old style x-ray tubehead, or you can buy a totally new machine. Does anyone have any recommendations for a quality machine that's low cost? I'm a one-doctor private practice and don't need a large device with all the best features. It would be nice if the digital x-ray would integrate with the EMR TrakNet I use.
Robert Dale, DPM, Clarksburg, WV
Query: DEA Renewal
My DEA license is up for renewal and I am considering not renewing it. The only controlled substance I write for is post-op permanent nail procedures. I am considering using Advil Dual Action for post-op pain. Has anyone not renewed their DEA license and what experience did you have?
Catherine Yack, DPM, Huntsville, AL
Query: Insulin Resistance and Tinea Unguium
That a patient with Type 2 diabetes mellitus has a proclivity to fungal infections is not news to the profession. The increased risk of the immunocompromised diabetic patient and the 'sugary' environment provided can be fertile ground for fungal infections. What impresses me about this ubiquitous condition is the apparent extraordinary resistance to treatment. Oral terbinafine, perhaps the definitive gold standard in treatment, claims a 70% mycologic cure rate. If true, I am impressed; my experience with patients causes me to wonder if this number isn't in fact much lower. Better, for sure, than topical ciclopirox 8% lacquer which boasts a meager 29%. Medical workers have noted that up to 60% of the population may have insulin resistance. This may affect not only the pre-diabetic and diabetic population, but also the non-diabetic patient.
Insulin resistance is linked in the literature to numerous cutaneous manifestations, e.g. early onset male pattern baldness, skin tags, acanthosis nigricans, hydranitis supperativa, acne, rosacea, eczema, and psoriasis. This made me wonder if there can be a connection also with tinea. If there is a connection between insulin resistance and fungal infection, might this explain why satisfactory treatment (clinical and mycological) for nail fungus can be difficult to achieve and maintain? I was unable to find any studies investigating such a connection. Perhaps one of our learned colleagues may know more.
Dieter J. Fellner, DPM, NY, NY
Query: Diphencyprone for Recalcitrant Warts
I just read an article in a dermatology journal regarding the use of diphencyprone for recalcitrant warts on hands and feet boasting a 88% cure rate. The protocol involves a sensitization application on the forearm followed by a direct application to the largest wart on the hand or foot 2 weeks after sensitization. Follow-up treatment at 2-week intervals typically took up to 6 visits for resolution.
Does anyone have experience with this procedure/protocol and success rate? Can it be used on children? How expensive is the medication? What concentration is most effective with the least side-effects. Where to purchase?
John Moglia, DPM, Berkeley Hts., NJ
Query: Source for Cantharone Plus
My staff informs me that all of our sources for purchasing Cantharone Plus have "dried up", including Dormer Labs. Does anyone have a reliable source for this wart treatment medication? Are the ingredients available to have it compounded by a pharmacy?
Jane Graebner, DPM, Delaware, OH
Query: Non-Healing DFU of the 1st MPJ
The patient is a 53 year old IDDM with a non-healing ulcer of the plantar left 1st MTPJ. He had his left great toe amputated in August 2021 due to infection. His ABI was 1.1. He did heal while off work by early December. I sent him back to work with an AFO, a patellar weight-bearing device to reduce loading on the plantar hallux. He has returned to work as of 12/22/21, but after 4 weeks at his reduced schedule, the wound re-opened.
The use of a kneeler bike has improved the situation in the last 2 weeks. Any thoughts on the long-term management of this individual? The AFO is off-loading, and he removes it once he gets home. He maintains that he keeps the pressure off of it.
Query: Difficulty for New Podiatrists to Get into Provider Networks
I am just starting out in practice. The most common private insurance in my area is Fidelis Care. I cannot get into their provider network, and most of the patients do not have the ability to go out-of-network. There are a few other insurance plans I cannot get into. This is going to put a big damper on my ability to make a living. How can this be legal? Any tips for getting into these networks? When I apply, I get the following message:
"On behalf of Fidelis Care, I would like to thank you for your interest in our provider network. After a careful review of our present provider network, we have concluded that at this time, we will not be expanding our network in your specialty area."
Query: Softening Solution for Calluses and Nails
For many years, patients being seen in my office for routine care were given whirlpools to soften thickened toenails, corns, and calluses. I have discontinued whirlpools over the past two years and instead use 3-WEA solution diluted in water and applied to the foot using polygauze non-woven 4 ply 4x4s. Although 3-WEA has been the long time industry standard for this foot prep, I find it isn't always providing enough softening of the skin and nails. The directions call for one gallon of water to 1/4 bottle of 3-WEA. Any mixture more concentrated leaves the foot slippery and difficult to handle.
For those of you still doing routine care on your patients, I would be interested to hear of other skin and nail softening products you are using for this treatment. Also describe how you are applying this solution to your patients' feet. Any input would be appreciated.
Jack Ressler, DPM, Delray Beach, FL
Query: Treatment of Osteomyelitis in a Distal Phalanx
I performed an arthroplasty on a patient’s 2nd toe to address a chronic diabetic wound. The patient developed cellulitis, and was given immediate IV antibiotics, but ultimately ended up with osteomyelitis at the end of the proximal phalangeal shaft and the base of middle phalanx. The patient is adamant about wanting to keep the toe. Has anybody had success resecting bone, inserting a single vancomycin-impregnated bone cement pellet on a K-wire, and leaving it for spacing?
Query: Anesthetizing an Infected Toe
For over 30 years, I have seen patients for ingrown nail surgery who presented with a localized infection and associated glomus tumors. While we were taught in school that an infection could “wall off” the effect of the local anesthetic, I’ve never had a problem with a hallux block at its base with the use of 2% Xylocaine plain in order to perform a partial nail border removal and matricectomy in the presence of infection. In the odd case over the years, I would also have to inject a few drops of Xylocaine proximal to the “corner” of the matrix and that usually did the trick. Perhaps it is the acidosis of the infected or inflamed tissue that lessens the effect of Xylocaine.
Today, for the first time in my practice, I was unable to anesthetize a 17-year-old’s toe in the presence of a medial and lateral ingrown nail infection —despite twice having added a few more drops of Xylocaine to the nail base area. Has anyone else had this problem? Do you use mepivicaine instead to better overcome the acidity? Or have I been mistaken all along in not having the patient wait a week with antibiotics before doing a partial nail border removal and matricectomy?
QUERIES (SPORTS MEDICINE)
Query: Achilles Tendon Injuries from Pickle Ball
As pickle ball becomes extremely popular, I am seeing more patients with injuries relating to the sport. Besides the typical ankle sprains, I have recently seen three patients with Achilles tendon injuries. MRIs revealed partial longitudinal tears in the tendon on all three patients. While waiting to get their MRIs, I have been dispensing 1/2" heel lifts bilaterally for them to use until I get the diagnostic results. If I have a patient with an Achilles tear, I refer them out to other podiatrists or orthopedic surgeons for continued care. Being semi-retired, I cannot do the proper follow-up needed for treatment of this condition.
Normal conservative treatment would be a CAM walker with heel lifts that are gradually reduced in a timely manner. I would appreciate some advice with a treatment plan that my colleagues are using to treat their patients with this type of injury. Please include treatment plans, time intervals especially with follow-up MRIs, and criteria followed if surgical intervention is needed.
Jack Ressler, DPM, Delray Beach, FL
Query: PRP and Compounded Medications
Has anyone successfully billed insurance for PRP treatments of chronic wounds? My compounding pharmacy will only provide compounded medications to patients (but not the clinic) to be used on patients. Does anyone have recommendations on where to obtain compounded medications to be used in the clinic?
Jengyu Lai, DPM, Rochester, MN
RE: Coping with Inflation
From: Richard A. Simmons, DPM
We are facing an inflation the likes of which our country has not seen in forty years. As physicians, we will feel the pinch now more than forty years ago because of the restrictions by Medicare and insurance panels. 40 years ago, physicians could charge Medicare patients their fee, regardless of the approved amount. We have no means of simply raising our fees 10% or so to adjust, yet everything we consume in our practices costs more. I do not have an answer, but I do have a simple question: what are we supposed to do?
Richard A. Simmons, DPM, Rockledge, FL