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10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Doran Edwards, MD
I appreciate Dr. Bass's post and his enthusiasm for the Arche LEAP Vitals exam for patients with diabetes. There is one point of clarification that needs to be provided. Dr. Bass wrote, “if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression, and this patient may need a prescription based upon the findings of the LEAP tests, the patient will then meet the requirements for an E/M service.”
The quick and efficient LEAP Vitals tests are all about skin integrity in this high risk population. We understand that “chronic illness” as well as “chronic illness with exacerbation” helps determine, in part, the level associated with the E/M service through medical decision-making (i.e. 99212 versus 99213). By no means does the patient need to exhibit exacerbation or progression of their diabetes to qualify for the LEAP Vitals tests, nor the ability to meet the medical necessity associated with an E/M billing. A prescription is also not required.
Any abnormal findings on the LEAP Vitals Exam, i.e dry and xerotic skin (L85.3) caused by sudomotor dysfunction, is a significant risk to a patient with diabetes. It therefore warrants a care plan, either an initial care plan or a change to a previous care plan that’s not working well. This change in medical condition alone provides the medical necessity for an evaluation and management service through the counseling of the patient on their risks associated with dry skin, and changing their treatment, even if only an over-the-counter skin care recommendation.
Doran Edwards, MD, Former DME MAC and PDAC Medical Director
Other messages in this thread:
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Alan Bass, DPM, CPC
As a certified professional coder and someone who has reviewed the Arche LEAP Vitals+ Program, I agree with Dr. Edwards’ assessment. The program provides the user with real-time physiologic findings. Following the guidelines for an E&M visit provided by the AMA, if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression and this patient may need a prescription based on the findings when performing the tests within the program, the patient will meet the requirements for an E&M.
Disclaimer: I have no financial relationship with Arche Healthcare.
Alan Bass, DPM, CPC, Manalapan, NJ
09/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: David Secord, DPM
My experience was somewhat the opposite, in that an anchor for one of the local television stations happened into my office for a nail procedure, worried that it would keep her from wearing stylish (I would go with inappropriate, but there you go) dress shoes as part of her work and that everyone she knew assured her that the experience would be akin to a slow trip through hell. She was amazed that she didn’t feel the injection stick (ethyl chloride) and didn’t feel the injection (1% lidocaine with epi, 0.5% Marcaine plain, 8.4% sodium bicarbonate to buffer the injectable back to physiologic pH) and didn’t have any pain after the procedure (no tourniquet needed due to the use of epi in the block). She recommended that the anchor at another station in Corpus Christi see me, as she had the same problem and staved off the procedure for the same reasons. She had the same positive experience.
The two of them began a discussion with me about my practice and I mentioned that...
Editor's note: Dr. Secord's extended-length letter can be read here.
08/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Steven E Tager, DPM
I too am a life member of APMA. I also did not get solicited for my opinion on the APMA definition of podiatry. I will withhold my contribution this year.
Recalling something about "taxation without representation" comes to mind and who knows more about "history can teach us a lot" than those who lived it?
Steven E Tager, DPM, (Retired), Scottsdale, AZ
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: APMA Member
I am a life member of APMA who was solicited for a $150 voluntary contribution. I did not get solicited for my opinion on the APMA definition of podiatry. I think I'll withhold my contribution this year just like the Life Member in the August 27, 2024 PM News. That's only two of us withholding and it won't make much difference in the APMA budget, but perhaps other Life Members who have not sent their contribution might follow suit and join us. What our action does do is alert the younger members of APMA what the future holds in store for them. Perhaps APMA could count 3 out of 5 Life Members in determining our input.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
08/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Richard Haas, DPM
I have been in practice 44 years and can’t understand why the APMA has not been able to make podiatrists physicians in the eye of the law. I have seen pharmacists giving injections and physical therapists giving wound care freaking our profession out.
Being recognized as a physician should have always been the most important goal of the APMA, not worrying if we are MDP or PMD, etc. Who cares about that if we are not recognized as physicians. Where does our dues money go? DOs and dentists seem to know what to do with their money in regards to political action for their members.
Richard Haas, DPM, Temecula, CA
07/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Greg Caringi, DPM
I have read this thread with interest. My OCPM classmate and Kern Hospital co-resident, Dr. Eric Lauf, took on this problem and published his research in 1982, "Manual dexterity: its importance in podiatry" (J Am Podiatry Assoc. 1982 Jun;72(6):291-8.). Since Eric passed much too soon (at the age of 47), I will recall this to the best of my ability. Eric had a friend at the Case Western Reserve Dental School. Even then, dental school admissions took spatial relationships and manual dexterity testing seriously. After observing their metrics, Eric tried to apply them to the students at OCPM.
Unlike dentistry, there was a poor correlation in podiatry. His research became of practical use when Eric introduced the use of the Purdue Pegboard Test (a psychomotor test of manual dexterity and bimanual coordination) as part of the screening process in selecting residents at Kern Hospital. I later began using the Purdue Pegboard at Suburban General Hospital when we selected our surgical residents. It became an important part of our selection process. On a personal note, this reminds me how great a loss it was to our profession when we lost Dr. Eric Lauf in 2001.
Greg Caringi, DPM - North Wales, PA
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
12/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Bret Ribotsky, DPM
Steve, as you and the readers of this forum know, nobody’s as hard on the establishment than me. At least monthly, I log onto the APMA E advocacy site and send letters to all my congressional leaders on many of the topics that APMA suggests. I have never seen a result of these form letters, but I guess APMA does (or I hope they would not pay for this service). It would be nice to see a report of how many others do this.
Barry provides this incredible forum where each of us can share our opinions. But over the last few years, I believe there’s only 20 to 30 people who have regularly written on this forum. I often received 30 to 40 emails/text messages after I post something, and when I encourage each of these people to write directly, so that their opinion can be included in the discussion, they all refrain from wanting to get involved.
Fortunately, we have a few great leaders. Paul, Elliot, Allen, Steven, Keith, Robert, Bryan, Joel, Jim, Michael, Richard, Ivar, and I’m sure a few more who will join me and write what we’re all thinking. Let’s not forget, “Our lives begin to end the day we become silent about things that matter." - Martin Luther King Jr.
Bret Ribotsky, DPM, Ft. Lauderdale, FL
08/08/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lawrence Rubin, DPM
With reference to the post by Dr. Jacobs suggesting that "LEAP" be used in the future to "summarize the examination and treatment of the diabetic patient," it should be recognized that this may create confusion. "LEAP" is already in use in the government's HRSA amputation prevention program, as well as the Lower Extremity Amputation Prevention (LEAP) Alliance that was trademarked and registered as a 501(c)3 non-profit charity in 2009.
Lawrence Rubin, DPM, Las Vegas, NV
08/04/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Paul Kesselman, DPM
Dr. Jacobs, as usual, makes many important statements during his recent letter to the editor regarding the need for podiatrists and other healthcare providers to be afforded the opportunity to provide an annual comprehensive diabetic foot examination.
Unfortunately, the current system does not agree as it is not only not affordable but inaccessible to most. Let me explain. Screening examinations with rare exceptions are unfortunately non-covered services. In the case of diabetic foot screening, the only two screening examinations are coded under Loss of Protective Sensation, better known as LOPS (Initial G0245) or Subsequent (G0246).
These are widely under-utilized because...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/25/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lloyd Smith, DPM
George is correct, but this problem has existed for at least 4 decades. Virtual education is the new reality and saves podiatrists thousands of dollars. I loved the meetings, the interaction, and the renewal of friendships of in-person meetings.
I understand the plight of the vendors. At APMA, we regularly discussed the annual meetings, the costs, the profits, and the need for corporate sponsorship. The companies always wanted greater access to the attendees. We always made every effort to increase exhibit hall attendance.
The new era of virtual meetings creates a new set of challenges. I’m sure the meetings’ leadership will do whatever it can to engage in discussions.
Lloyd Smith, DPM, Newton, MA
07/13/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: James Koon, DPM
I’ve billed 11730 maybe 5 times in a 25 year career. If it’s infected and clinically appropriate, 11750. If it’s just the corner, bang it out under ethyl chloride anesthesia. If it’s a recurrent problem, 11750. It’s moral, ethical, and almost always definitive.
Wouldn’t you want one and done if it were you?
James Koon, DPM, Winter Haven, FL
07/05/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Kathleen Neuhoff, DPM, DVM
I read Dr. Rosenblatt’ letter with interest and a bit of confusion. I transitioned my practice to a self-pay 3 years ago. Unfortunately, I did it two months before Covid and this combination made it financially very challenging. However, we persisted and are now doing well. We managed the Medicare issue by having the patients pay us (we do not accept assignment) and filing for them. We file only for appropriate covered charges and Medicare reimburses the patient. We do not file any appeals or deal with Medicare at all, other than filing the initial claim. We do provide fee sheets with ICD and CPT codes if a patient wishes to file themselves with their insurance.
I perform approximately 5 “major” surgeries per month (tarsal tunnel, bunionectomies, exostectomies, hammertoe repairs, etc.). Patients pay for these. There are a few who prefer to go to a practice which files their insurance for surgeries, and I happily refer them to one of my colleagues.
I took my staff with me to the IPMA and Midwest meetings. After attending them, my staff is incredibly grateful that they do not need to deal with the insurances…so am I! I think it would be very difficult to do a self-pay if you were a cardiac surgeon or a neurosurgeon, but it is very doable for podiatry. Perhaps I find it easier because I am also a veterinarian, and clients routinely pay bills that are more than a bunionectomy! If a podiatrist wants to have a contract with his/her patients rather than their insurance company, it can be done.
Kathleen Neuhoff, DPM, DVM, South Bend, IN
06/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Kim Antol
The X-Cel x-ray machine, (specifically designed for podiatry for use with film and chemistry) has been the podiatry standard and workhorse for DPMs for many, many years with numerous machines manufactured in the '80s still in use today.
Amazingly, these machines can be modified with today’s technology, (DR-ready) by replacing the 8-in. high Orthoposer base with a low 3½ in. one, ADA handicap-accessible base (unlike the AD2D system’s very high 8-in. base).
Old or new, together with today’s wide range of hospital-grade DR imaging plates and modest pricing makes the X-Cel still the podiatry standard.
Kim Antol, Sigma Digital X-Ray
05/23/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Jeffrey Carnett, DPM, Grad Dip Ed, MFA, Dip Ac
In regard to ABPM certification of non-USA trained podiatrists, I appreciate PM News for publishing our concerns as we have little opportunity to let the American podiatric community know of the true picture of practicing overseas. I have been in full time practice overseas since 1995, working in Asia and Australasia. In that time, I have worked with a consortium of DPMs who, like me, struggle with harassment and discrimination from non-U.S. trained podiatrists.
I have shared Dr. Garoufalis' explanation with this group and all see the actions to certify non-DPMs (U.S. trained) as providing an American credential to those with inadequate education and experience. We feel it is discriminatory and will only harm us further. It was an ill-conceived idea seemingly based on limited first-hand experience of the true situation DPMs face overseas. We are in the trenches and ABPM is selling the other side bullets to shoot at us.
This ABPM International program should not be supported by the American profession of podiatric medicine and surgery. I think the other APMA-approved Board should also be concerned about this as it too would affect credibility of any American certifying activity. This will be used by bachelor degree podiatrists to claim they are certified in surgery to their local authorities and unwitting public.
Jeffrey Carnett, DPM, Grad Dip Ed, MFA, Dip Ac
05/22/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Multiple Respondents
A very heartfelt congratulations to you on the occasion of publishing the 7,500 issue of PM News. It is a very special milestone to celebrate. Thank you for all you have given to our profession!
Seth Rubenstein, DPM
Congratulations, Barry! What an impressive milestone! We are a better profession because of PM News! A huge amount of gratitude to you and your team for all that you do.
Gene Mirkin, DPM
When we were students, we could not have imagined the ability to have real-time conversations about a wide variety of both medical and business-related topics with our peers and other experts in our profession on a daily basis. Thank you for pioneering this most valuable resource. I personally appreciate your dedication and hard work.
Greg Caringi, DPM
I would like to add my heartfelt congratulations and express my sincere gratitude for the invaluable news and communications services that Barry Block, DPM, JD has provided to the podiatry profession for nearly 3 decades. 7,500 issues! So many of us have gotten so used to receiving PM News all these years, that we take for granted the connection that it gives us to what is going on in the profession, both the ability to speak to and hear from this wonderful community, this brother/sisterhood. Thank you, Barry, for what you do!
Alan Sherman, DPM
05/19/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lloyd Smith, DPM
The comments from Dr. Carnett are disturbing. Can someone with credible knowledge of this situation provide comments?
Years ago, as APMA President, I moderated a meeting of an international group of podiatrists. Concerns were presented that all podiatrists are influenced by what is happening in other countries. In particular U.S. podiatry was of greatest concern.
It would be incredibly disturbing if recognized organizations are adversely affecting fellow podiatrists in countries outside the USA.
Lloyd Smith, DPM, Newton, MA
03/24/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Jay Callarman, DPM
I wholeheartedly agree with Walter Perez, DPM regarding his comment today about board certification. It should not matter how long after residency a DPM can sit for a board exam. The CPME needs to get rid of this requirement. I would like to sit for ABPM but since I am over 8 years out of residency, I cannot. I will be sitting for the ABMSP exam this April but would rather be certified by ABPM.
Jay Callarman, DPM, Yakima, WA
01/27/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Howard Zlotoff, DPM
I am responding to discussions about granting privileges to podiatrists in a hospital or surgical center setting. The notion that the medical director and chairman of the department that oversee podiatric services independent of outside board certification is both dangerous and flawed.
The process cannot be objective if competing practitioners, i.e. podiatrists, orthopedists, and surgeons are the primary gatekeepers of surgical privileges to be granted. The obvious conflict of interest will be challenged if the applicant is denied privileges requested. Recognized surgical board qualification/certification must be the determining factor as the primary tool used to grant use of the operating room. This protects the department, the hospital, and most importantly the safety of the patient. Yes, the department chairman should have input to review the procedures that the applicant has performed in the past and those procedures they are requesting. New technologies, e.g. laser, arthroscopic, fixation systems evolve and, through continuing education and workshops, new and existing department members must demonstrate competency of these advances also.
My experiences creating and chairing several hospital podiatric departments taught me how critical this process is, and it must include objective gatekeeping blended with individual procedure granting for every member of the department. Again, the ultimate safety of the patient, who assumes their doctor is competent, must be the goal. It is a huge responsibility not to be taken lightly. Our national organizations who create these Boards must understand how important their mission relates to public safety and professional competency.
Howard Zlotoff, DPM, Camp Hill, PA
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
09/30/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Marc Jones, DPM
Much has been said of board certification primarily being a "protection of the public". Does that mean that those not board certified by ABFAS are not safe to do surgery and a danger to the public? If this is the case, take the residency class of 2014 which have had 8 years to get board certification (the max is 7 years). Per the ABFAS website, 118 have passed RRA case review and 259 passed foot case review.
There were 525 in this residency class. If all those doctors also passed the CBPS exam (unlikely), then 22% of the residency class are deemed safe to do rearfoot surgery and only 49% are deemed safe to do any surgery. Thus, either more than half of our 3-year surgically trained podiatrists are not doing surgery or are doing it in a dangerous manner, possibly harming the public. If either one of these is true, then the residency model needs to have a complete overhaul. More likely, the board certification process is not a good measure of surgical competency of a podiatrist, and it needs an overhaul.
Marc Jones, DPM, Spokane, WA
09/09/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Paul Kesselman, DPM
I for one, would like to thank Dr. Stewart for bringing this matter to PM News. He is a trusted colleague and valuable member of the APMA DME Workgroup.
Why do some find it so surprising that the power of the media is so convincible that so many otherwise sane people pay insane prices for unproven products/treatments? Why do these same consumers make the Home Shopping Network and other channels selling consumer goods 24x7 have so many people addicted to purchasing items they don't really need? It’s no accident that media outlets hire psychologists and marketing personnel who know...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
09/07/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Jeff Root
Unfortunately, Dr. Ressler, I have spoken to many people and patients who have gone to retail establishments who have paid over $1,000 for shoe inserts or "orthotics". Personally, I thought Dr. Stewart's video was spot on. People are often reluctant to schedule an appointment to see a podiatrist for foot pain but are comfortable walking into a retail establishment and seeking advice from a sales person with far less experience and credentials than a podiatrist. These customers are often sold several pairs of devices, costing well in excess of what a podiatrist would charge for a pair of well made, custom orthoses.
While there is a place for pre-fabricated, OTC devices, they are often highly overpriced when sold at some retail establishments. These same establishments typically run frequent commercials on television, thereby convincing consumers to come in for a free evaluation and a test fit where these individuals pay a hefty price for shoe inserts. Television commercials aren't cheap. It is not uncommon for consumers to pay $600 to $1,500 or more for one or more pairs of OTC devices that should only cost a few hundred dollars at best if they were purchased elsewhere or from a podiatrist. If you doubt this, I suggest you go to one of these retail establishments and pose as a patient with plantar fasciitis and see what the store has to offer. You may be surprised at the cost of their products and with their salesmanship.
Jeff Root, KevinRoot Medical
08/18/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
With all of this arguing about which board should certify podiatric surgery, we are ignoring an elephant in the room and it’s a big one. At a dinner this past week, a gastroenterologist was complaining to me that at his university-based hospital, PAs and nurse practitioners are fighting for the right to do endoscopies and colonoscopies and will probably win. Why? Because the hospitals make more money that way. At my local hospital, some of the PAs working in the OR told me that many of the surgeons will allow them to do belly surgery, skin-to-skin, with or without their physical supervision. When my mom fractured her pelvis, a PA or nurse practitioner took care of her from the moment we entered the ER to the moment we left, and we saw no medical doctor.
As Dylan wrote, "The times they are a changin." and only time will tell if it will be better or worse for patients.
Elliot Udell, DPM, Hicksville, NY
07/27/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Dr. Chaskin questions whether treating diabetes with insulin would be within our scope if the aim of our therapy would be to treat diabetic neuropathy caused by diabetes. The problem with allowing podiatrists to treat diabetes is that the training involved to properly manage diabetes is vast, and in many cases requires the training of an endocrinologist who specializes in diabetes. It’s not just insulin but many other drugs that are on the market.
Could a podiatrist be trained to manage diabetes? For sure. I truly believe that with proper training, my colleagues could be trained to do brain surgery and would be good at it. At present, however, we as a profession are not trained to properly manage the entire spectrum of diabetes nor are we trained or legally allowed to do non-podiatric surgical procedures.
Elliot Udell, DPM, Hicksville, NY
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