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09/08/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Ivar E. Roth, DPM, MPH
I would like to inform those not taking routine care patients that they are missing the boat. I give a full examination when routine care patients enter my office. I consider this a service to them and advise them of all the areas of concern that I observe, and inform them of their conditions that need attention. The majority of these routine care patients need some other services. I only inform; no pressure or sales tactics are used. I let the patient tell me if they desire further care.
Since most of these patients never had any professional take the time to inform and explain to them what they need or did not know, many opt to have the services that I explain are available. For instance, I just had a C and C patient come in and decide they want their fungus nails treated and get a pair of orthotics. That patient who came in for a $125 service left paying $3,525.
As a direct care doctor that extra effort I spent on them both helped them with their medical issues that they had no idea that they had, and it reimbursed me very nicely for their care.
Ivar E. Roth, DPM, MPH, Newport Beach, CA.
Other messages in this thread:
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Kudos to Dr. Ribotsky for suggesting that there be some way of tracking podiatrists diagnosed with some form of cancer. As a cancer patient in remission, this issue is very close to me.
The medical community is grappling with another issue. Patients with breast and colon cancer are now presenting at very young ages. One patient of mine had his first colonoscopy at age forty and discovered that he had stage four colon cancer. Another young woman in her thirties is undergoing treatment for breast cancer. Are these caused by unidentified carcinogens or are people discovering these conditions earlier in life because of testing and awareness?
Elliot Udell, DPM, Hicksville, NY
05/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Kornfeld, DPM
Since this thread is still going, I would like to bring up a really important point that Dr. Meisler glossed over. Patients coming from these concierge practices were willing to pay directly when they came and were "surprised that they did not have to pay at the time of their visit." That should tell you something about the value they are experiencing in a direct-pay practice. That's number one.
Number 2, I agree with Dr. Meisler that eliminating poor payors will always make room for more value in the practice. However, it is important to note that as long as you continue to accept insurance, you will always be fighting an uphill battle. You will need to see a high volume of patients which means a large office, large staff, and high expenses. You will still have to navigate the slippery slope of...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
02/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Dominic Bianco
Public knowledge and educating the public is really part of the answer. The other part is the patient has to feel confident and comfortable with their choice when seeking medical attention.
Retailers are now selling custom-made orthotics utilizing shippable impression kits. These start at $200. Originally, they were only available through podiatrists who were selling to their patients custom orthotics for $200 back in the 1980s. Now it seems these products are widespread, not just in custom orthotics but for all kinds of podiatry products.
Podiatrists, on average, are seeing 10-20 patients per day. Overseeing their practice and growing it takes a lot of...
Editor's note: Dominic Bianco's extended-length letter can be read here.
09/15/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Richard M. Maleski, DPM, RPh
I'm somewhat confused by the responses to this topic. I retired a few years ago, but I believe my information is current. In Pennsylvania, podiatrists are prohibited from using ancillary personnel to cut nails or calluses. Podiatrists must perform those services themselves, otherwise they are committing insurance fraud (if sent in to insurance.) Admittedly, this took place years ago, but in 2008, I spoke with the PPMA about training my certified podiatric assistant to cut nails and calluses, and was told that this was fraudulent if sent in to a third party payer, (billing for services that I wasn't providing) and allowing a person to perform services that I was not legally entitled or licensed to supervise.
I was seeing 40-50 patients daily 4 days per week at that time, and typically on any given day about 1/2 to 2/3 were "routine care." I was giving up new patients because...
Editor's note: Dr. Maleski's extended-length letter can be read here.
08/15/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Khurram Khan, DPM
To piggy back on Dr. Pressman’s post: When listening for Doppler sounds, pay attention to the difference in quality of the sounds from all 3 vessels. In this article we recently published, we employed a modified lower-extremity Allen test to demonstrate an irregularity in vascular perfusion in the foot after a difference in pitch between the dorsalis pedis artery and the posterior tibial artery was heard using a hand-held Doppler.
Khurram Khan, DPM, Clinical Associate Prof, TUSPM
07/19/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Lawrence Rubin, DPM
Dr. Zicherman's response to my post regarding Medicare's past revision of utilization guidelines for CPT coded nail avulsion procedures questioned the authority of the Office of the Inspector General (OIG) to require Medicare to curb "abusive" billing by podiatrists. The following link to the OIG website explains this ability.
It is also important to know that since 2002, podiatrists have been at high risk of audits and punitive actions for what the OIG considers abusive billing for debridement of onychomycosis. Read more about this here.
The reality of all this is that Medicare claims from podiatrists...
Editor's note: Dr. Rubin's extended-length letter can be read here.
01/30/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Rem Jackson
I read Dr. Kornfield’s response to Dr. Roth’s post, re: DPMs not calling themselves podiatrists and his suggestion that better PR is the answer, and Iwholeheartedly agree. If the APMA, for example, created a PR campaign that could be distributed through all the channels available today that was designed as Dr. Kornfield suggests to make the word "podiatrist" synonymous in the minds of the public with “medical and surgical management of the foot and ankle”, it could have a decidedly positive effect in the public’s mind.
A national campaign like this would be prohibitively expensive for any group to initiate (GEICO spends millions so that we know “15 minutes can save you 15% or more on your car insurance”). If provided to all members who could use it on their websites, in their emails, in their social media, and in all their marketing efforts, it could have a significant national reach and make great strides toward bringing the profession and the word podiatrist into public awareness. I couldn’t agree with Dr. Kornfield more.
Rem Jackson, CEO, Top Practices
12/01/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Mark Hinkes, DPM
I read the comment from Judd Davis, DPM about feeling trapped in the fee-for-service business model and not interested in changing to a "direct care "model. There is a third option for podiatrists. That option is the value care based business model which is being rapidly adopted by many integrated healthcare companies. The difference is dramatic. The focus of the fee for service business model is quantity of care (how many things can you bill for?) with no focus on prevention. The focus of value based care is 180 degrees away from that with the focus being on the quality of the care and promoting prevention.
In value-based care, providers are incented to keep patients healthy and they get paid from a pool of cash that is dedicated for the care of each patient. Podiatry does have a presence in the integrated healthcare world and will become more important in the future. This will happen due to the ability of podiatry to provide proactive preventive care for people with chronic diseases like diabetes, to prevent diabetic foot ulcers that will prevent costly hospitalizations and amputations.
For those practitioners who can see the future clearly, changing from a fee-for-service to value care business model will entail affiliating with an integrated healthcare company and that will be disruptive to an existing practice but it can be done. If I were a new practitioner, I would pass on the private practice fee for service business model and seriously consider affiliating with an integrated healthcare company that uses the value care business model.
Mark Hinkes, DPM, Nashville, TN
12/01/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: The DPM/MD Controversy
From: Rod Tomczak, DPM, MD, EdD
The controversy concerning a degree change has been simmering for years and Podiatry Management has done an excellent job documenting both sides of the debate. While the arguments continue to simmer, podiatric educators have not input much lately. And now that the podiatry colleges have, for the most part, joined universities that grant MD or DO degrees, would these institutions condone a degree change or tolerate a podiatry college becoming a dual degree granting institution?
Some years ago, when I was a professor at the Des Moines school and Leonard Levy was the dean, we instituted a five-year program to grant a DPM/DO dual degree. During the second semester of the first year, the Commission on Osteopathic College Accreditation put an end to our experiment. We were told that...
Editor's comment: Dr. Tomczak's extended-length letter can be read here.
11/25/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Allen Jacobs, DPM
When corporations suggest that one utilize particular codes for reimbursement of goods or services from which they profit, research the appropriateness of such CPT or ICD-10 codes before utilizing them. Remember, the goal of industry is to increase product utilization and profit. The suggestion that topical application of 8% capsaicin qualifies as “destruction of a peripheral nerve” is dubious. We have all too much of code interpretation and manipulation in practice. Slant back nail removal without anesthesia billed as CPT 11730. Arthroereisis billed as “open reduction and internal fixation of a peritalar dislocation,” or “modified subtalar joint arthrodesis”. Radiofrequency coblation billed as “partial plantar fasciotomy”. Lapidus procedures with screw fixation extending into a cuneiform (s) billed as “intertarsal fusion”.
Recently, one particular company manufacturing hardware for performance of the Lapidus procedure has suggested that with the utilization of their device, a modifier may be added indicating that the procedure should be paid at a higher level due to complexity. Our residents in St. Louis have been given sample operative reports (from a particular company) to dictate so as to justify appending the complexity modifier to the Lapidus procedure. You will be the ones paying back the money on audit, not the corporate entities or the so called thought leaders who are receiving hundreds of thousands of dollars (or more) to encourage you to utilize coding of questionable accuracy. As an example, I would refer PM News readers to the recently published Culper Research Report, November 15, 2022 regarding Treace Medical Concepts.
Allen Jacobs, DPM, St. Louis, MO
10/03/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Martin M Pressman, DPM
I have been involved at all levels of training in podiatry. Starting with full-time teaching at TUSPM, residency training for 47 years, committee work for ABFAS on all examination levels. I was part of the team that developed CBPS, and remain on the Case Review Committee for my final year. I was also chairman of my state board in Connecticut for 40 years. I am part of the residency training program at Yale and was Section chief of podiatry in the department of orthopedics, at Yale School of Medicine 1997-2017 until we became a department at Yale New Haven Hospital with a full time department chair. I say all this to allow you to understand my perspective on this critical issue in podiatry.
I have read Drs. Oloff, Jacobs (both friends) and Dr. Ford (well respected) on this issue and all make salient points. I would like to add to the discussion with some other critical observations. #1. It is the licensing examination that sets the “minimal competency level...
Editor's note: Dr. Pressman's extended-length letter can be read here.
09/27/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Ivar Roth, DPM, MPH
Dr. Braham is right on. Advertising podiatry should be included in the credits on the show. The doctors who participate should recommend/demand that this be included with every show. GREAT idea.
Ivar Roth, DPM, MPH, Newport Beach, CA
05/25/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Richard A Simmons, DPM
My answer is driven by my patient base. My average patient is 87 years old, homebound, and typically she is registered with a hospice agency. I am an aggressive debrider and make every attempt at the first visit to expose the medial and lateral nailbed margins. I send these nail specimens to a dermatopathology laboratory from which I order PAS and PCR tests, including a terbinafine profile. Upon the patient's return, I will review the laboratory results with him/her. If the terbinafine profile infers that terbinafine could be effective, I circle it and write on the lab form: “Oral Lamisil may be effective.” I then explain that I will not prescribe the oral medication, but that the patient can have that talk with the primary caregiver.
At this point, I make my recommendations: either ketoconazole cream as a prescription or terbinafine cream OTC; and provide a detailed instruction sheet explaining how to use the product twice daily. I also recommend that they purchase OTC urea 40% cream to mix with the antifungal product. Thick, dystrophic nails that appear to have involvement in the matrix region never seem to resolve, though the nails will lighten up and there will be much less subungual debris. The moderate nails have mixed results, pretty much patient dependent: 1) patients who can diligently follow the twice daily instructions have shown marked improvement; 2) patients who haphazardly apply the medications get haphazard results.
From my standpoint, if the patient follows directions, the subsequent debridements are less painful and less traumatic. The main reason I prescribe ketoconazole cream is 1) it is economical and 2) it very rarely requires prior authorization.
Richard A Simmons, DPM, Rockledge, FL
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