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11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Jon Purdy, DPM
I had a similar frustrating experience when I sent myself for my first routine colonoscopy. I was told an exam was necessary and received one from their PA. A little palpation here and there and an order for stool examination. To my protest, I was told the doctor will not do the procedure without it. I complied and received my first bill for a CPT 99204. I questioned the validity of that exam level with the office manager to no avail.
On the day of the procedure, the doctor asked if I was ready and said they would be taking me back. I said what about my results? He looked confused. I told him I was told he would not do the procedure without the stool path and he said “that is not true.” So I underwent my procedure irritated about the entire process thus far. In recover the doctor said, “everything looks great, but there was one spot of inflammation I needed to biopsy.” It was a “Where’s Waldo” game to discern anything in the photo, but I know that extra $350 comes in handy.
So they made some good money on me while I was stuck with unnecessary bills, frustration, and inconvenience. This just verified to me of what is out there, and what I do not do to my patients.
Jon Purdy, DPM, New Iberia, LA
Other messages in this thread:
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Adam M Budny, DPM
I read this post earlier today and quite honestly I was perplexed, as I am one of the "insurance podiatrists" who I believe represent the majority of the profession, as opposed to a boutique/direct pay" podiatrist (which seems to be Dr. Roth's implied practice model?). I see nothing wrong with billing a new patient visit or x-ray as a diagnostic study. How else would a practice run if you did not bill new/established visits of one sort or another?
Specifically, in my experience and clinical practice, stretching exercises are actually the mainstay of management for plantar fasciitis, and all of my patients are given literature and a home exercise program (HEP) for performing this at their initial visit. Regarding shockwave therapy, this is also a well accepted treatment option per the American College of Foot and Ankle Surgeons Clinical Consensus...
Editor's note: Dr. Budny's extended-length letter can be read here.
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Charles Morelli, DPM
I'd like to echo Dr. Roth's sentiment and experience when it comes to the fact that "the medical billing rip-off is rampant in medicine and podiatry." Yes, every profession has their bad actors, but sometimes you come across with a story that makes you shake your head. I'll try to be brief.
A patient was seeing the same podiatrist every 6 weeks, for over 22 years. He was treating her for a chronically ingrown nail, was cutting the corner of her nail, charging her the $25.00 co-pay and I imagine also billing her insurance carrier. She called one day for an appointment and asked to be seen as she was in pain, and felt it was an emergency. According to the patient, no matter how hard she pleaded, she could not be seen and...
Editor's note: Dr. Morelli's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Paul Kesselman, DPM
I stand by my partner Alan Bass, DPM, whose opinion is absolutely correct. Each patient encounter should have at a minimum an appropriate history and physical with components of lower extremity systems including but not limited to dermatology and must also include neurovascular and a MSK examination. Any changes in patient history or PE should be well documented and incorporated into the note.
But the change in history is not what will get you paid for a separate E/M nor is documenting a change in the physical examination. It is that last part, the management, what exactly did you do? If all you did was document a change in history, nope. If all you did was document a change in the PE, again, no dice. You must document all 3 issues, ...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Lawrence Rubin, DPM
A recent post in PM News pertaining to insurance reimbursement compliance said, "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." To prevent confusion of business names, this is not a stated opinion of the 501(c)3 not-for-profit LEAP Alliance.
Lawrence Rubin, DPM, Las Vegas, NV
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Ron Werter, DPM
What I don’t understand (and maybe the lawyers among us could explain) is how does the insurance company have the legal right to charge the doctor for writing a prescription. The doctor has no financial stake in the prescription; the patient and the pharmacy are the ones who have financial benefit. Is there something in an insurance company contract that says they can do that?
Ron Werter, DPM, NY, NY
09/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Back to the Future
From: Steven Finer, DPM
Upon reading the new issue of Podiatry Management, I counted ten ads for various creams and lotions pertaining to skin, nails, and pain relief. There were other ads for orthotics and podiatry-related machines. I have a 1962 Journal of the American Podiatry Association. It contains three ads for prescription internal medications. Also there were various ads for skin, nails, and orthotics. I know the various surgical magazines feature countless ads for surgical instruments and devices.
Must we now read internal medicine journals and use the Internet to review the latest medical news. I know everything is segregated in medicine, but this 62 year old journal was ahead of its time.
Steven Finer, DPM, Philadelphia, PA
09/03/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jerry Peterson, DPM
No, you are not missing something. He should be able to assist ANY physician on ANY surgery. In Oregon, a podiatric physician can assist in general surgical procedures, Ortho, Neuro procedures, etc. They are not required to have the privileges to be able to assist. Good luck moving forward.
Jerry Peterson, DPM, West Lynn, OR
08/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Steven J Berlin, DPM, Carl Solomon, DPM
I read that several retired podiatrists have felt slighted by not being able or being denied the opportunity to voice their opinions on current events affecting the profession. That certainly needs to change. I suggest a column of current situations affecting this great profession. We need a special column in the newsletter drafted by senior editors and/or Journal to encourage the opinions of us older podiatrists
Steven J Berlin, DPM
I acknowledge, but don't agree with the philosophy that life members are ineligible to vote because "... members eligible to vote in a referendum are those who are most likely to be affected by the outcomes of a referendum."
That makes about as much sense as not allowing voting rights to members who are employed by a hospital or other institution, because they may not be affected by certain issues that would have a greater impact on private practice docs. Some issues affect everybody and some issues do not affect everybody. We cannot permit our membership to be fragmented like that.
Carl Solomon, DPM, Life Member, APMA
Editor's note: This topic is now closed.
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Eric J. Lullove, DPM
There are numerous multilayer compression systems on the market for management and treatment of venous leg ulcers. They are not “replacements” of an Unna boot. They are specific for a different diagnosis code set. Multilayer compression systems should be billed with the I87.xxx series ICD-10s. The CPT code for those systems is 29581. The code is not a substitute for making a multi-layer compression from your supplies — this code was designed specifically for the compression system kits that are manufactured by 3M, Urgo, Milliken, Hartmann, et al.
You must document the need for edema control, CEAP or VCSS clinical documentation for a VLU or venous hypertension (or hyper congestion) as well as the failure of conservative therapy of elevation and stockings. You also should as a caveat have a recent ABI dated from the initial onset of the venous event or ulcer and any other additional vascular studies (venography, for example). As always, it’s about documentation, documentation, documentation, especially with wound care services.
Eric J. Lullove, DPM, Coconut Creek, FL
01/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Gian Steinhauser, DPM
I’ve used Stryker Smart Toe implants for over a decade and had no issue with them with MRI in the past. Stryker Smart Toe implants are made of memometal nitinol, an alloy made approximately of 50% nickel and 50% titanium. Nitinol, a nickel-titanium alloy, is generally considered safe for magnetic resonance imaging (MRI). Nitinol is non-ferromagnetic, meaning it doesn't dislodge during an MRI and only heats slightly. It's considered safe for MRI. The metal typically will show a bit of image flare around the implant site on MRI imaging, so as long as you’re not interested in seeing tissue directly adjacent to the implant, it should be fine.
Gian Steinhauser, DPM, Houston, TX
01/12/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Steven Kravitz, DPM
Dr. Jacobs’ post to pay tribute to Dr. James Ganley is an absolute pleasure to read. Thank you Dr. Jacobs for taking the time to articulate this and to Dr. Block for publishing and helping it gain some traction and attention, so that many have the ability to read it. There are a lot of lessons in it, and Dr. Jacobs' beautifully touches the surface describing attributes, nuances, and the ability to get to feel who Dr. Ganley was, and why he is recognized as an icon. Humble with humility, brilliant, without exception compassionate for others, a sense of balance in life, and ability to enjoy other aspects outside of his profession... sailing being just one of them.
One important point that comes out as you read the tribute is how much Dr. Ganley appreciated and enjoyed being a podiatrist. There's too much negativity today about our profession and...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
11/22/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Howard Bonenberger, DPM
I worked with Mike Crosby for evaluation, pricing, and negotiation of the terms of the sale of my solo practice in 2017. I found him to be a great resource. At a minimum, a 5-year look back at financials should be performed. I would avoid the low-priced consultants. You could leave a lot of money on the table.
There is much more to it than you can imagine. Find a highly regarded medical practice business attorney (not malpractice). Your CPA should also be involved if they are qualified in this arena and may be able to recommend an attorney to interview.
Howard Bonenberger, DPM (retired), Hollis, NH
11/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Richard M. Cowin, DPM
For a practice valuation, I highly recommend Mr. David Price at Podiatry Broker. He offers three (3) levels of service for three (3) different prices: $395.00 for a ballpark evaluation, $995 for an off-site evaluation, and $3,995 for an on-site evaluation.
Richard M. Cowin, DPM, Orlando. FL
10/11/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: John Cozzarelli, DPM
Dr. Jacobs' comments on Krystexxa's FDA indication are not accurate. He references that it is indicated for the treatment of hyperuricemia.
Direct from the Patient Package Insert "INDICATIONS AND USAGE KRYSTEXXA® (pegloticase) is indicated, for the treatment of chronic gout in adult patients refractory to conventional therapy. Gout refractory to conventional therapy occurs in patients who have failed to normalize serum uric acid and whose signs and symptoms are inadequately controlled with xanthine oxidase inhibitors at the maximum medically appropriate dose or for whom these drugs are contraindicated.
Limitations of Use: KRYSTEXXA is not recommended for the treatment of asymptomatic hyperuricemia."
John Cozzarelli, DPM, Belleville, NJ
09/18/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Brian Kiel, DPM
I have two simple remarks in regard to recent issues in our profession. Firstly, CPME and AMPA may well be “separate” entities, but if you believe that, then I have a bridge to sell you over the Mississippi River. Secondly, there is letter after letter bemoaning the fact that we have given up routine foot care, but you have to have a 3-year surgical residency to practice. Does that not seem convoluted to you? Just a thought.
Brian Kiel, DPM, Memphis, TN
09/14/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Ivar E. Roth DPM, MPH
I have been offering routine foot care since I began practicing 38 years ago after completing a 3 year surgical residency program. Lately, and I am not sure why, there has been a huge increase in new patient calls for routine care. I am averaging 4 new patients a day who just want their nails and calluses trimmed. Today again, I had one of those patients request that I make her orthotics after I explained why they would help her. Believe me, routine care is bringing in lots of pathology to my office. Two others wanted to have treatments for their fungus nails. While it has taken years to develop this following, I think that the other podiatrists in town have abandoned this care, and I am now thankfully the recipient.
Lastly, I call my extended care nail techs “podiacurists” as they all are former pedicurists converted to medical nail techs/podiacurists who I have trained to do nails and callus care. I sincerely hope that any podiatrist who want to get busier get the word out that you do routine care; you will not regret that decision.
Ivar E. Roth DPM, MPH, Newport Beach, CA
09/06/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Elliot Udell, DPM
Dr. Rubin is dead on target when he questions whether podiatrists trained in foot surgery are no longer addressing non-surgical foot problems. This discussion is linked to the ongoing discussion on nurses who are starting foot care clinics. As a profession, we are like ostriches with our heads buried in the sand; we don't want to see that other non-doctoral level professions can and will encroach on all facets of foot care. Those who feel that their professions are secure because they only do surgery have their heads buried deeper in the sand.
In my local hospital, PAs working in the operating room have told me that the general surgeons often allow them to do procedures "skin to skin." It is a matter of training and we could see future clinics run by physician assistants, trained by orthopedists and podiatrists, delivering high levels of foot care without the need of a podiatrist. It's only a matter of time until this happens. We have had many discussions over the years about non-podiatrists casting for and dispensing orthotics. It hit home when I witnessed my own physical therapist taking impressions for and ordering orthotics for his patient and the order was placed at a lab that promotes itself to our profession. What is the solution? Until there are legal statutes put into place, we simply have to love and be good at taking care of feet, and happy patients will refer others to podiatrists for foot and ankle care.
Elliot Udell, DPM, Hicksville, NY
09/06/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Allen Jacobs, DPM
Dr. Rubin notes that podiatrists, in deference to alternative healthcare providers, maintain the ability to provide "optimal preventive and therapeutic foot-care". Optimal care is more than selling diabetic shoes and toenail reduction. It is evaluation and treatment of or referral for treatment of neuropathy, vascular disease, dermatological disorders, gait abnormalities, and off-loading of areas predisposed to ulceration. It is active treatment of onychomycosis. The question you must ask yourself is whether or not you do indeed provide “optimal care" .
Allen Jacobs, DPM, St. Louis, MO
07/12/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Substance Abuse Is Climbing Among Seniors
From: Robert G. Smith DPM. MSc, RPh
I read with great interest: “Substance Abuse is Climbing Among Seniors” written by Paula Span of the New York Times on July 9, 2023 and reported by national news outlets the morning of July 10, 2023. Data is presented from experts in the fields of gerontology, sociology, psychology, and addiction medicine.
A number of salient points are offered by this narrative that include: "Despite alcohol playing a major role in elderly substance use disorder most substance use disorders among older people involve prescribed medications, not illegal drugs, 8.6 percent of substance use disorders involved opioids, mostly prescription pain relievers; 4.3 percent involved marijuana; and 2 percent involved...
Editor's note: Dr. Smith's extended-length letter can be read here.
03/30/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Lloyd Smith, DPM
Jon Hultman’s experience and wisdom is apparent in his comments. Podiatry has faced similar issues now facing the board certification process. At this point, a big tent approach is needed. All representative groups must be included and a skilled facilitator is needed. All relevant issues need discussion.
Without presenting an opinion, the solutions should come from this group. Having chaired a similar process, the interactive group needs to commit time, resources, and a deep desire to find compromises. The task is not easy. The need is apparent.
Lloyd Smith, DPM, Newton, MA
03/29/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jon A. Hultman, DPM, MBA
I think many of the postings concerning board certification on PM News miss an important point about our specialty. All of today’s residency programs are standardized, three-year, comprehensive programs, which include both medicine and surgery. With a few exceptions, the vast majority of those practicing in our specialty provide both surgical and non-surgical care. It seems illogical to me that a DPM today would need to choose between being board-certified in medicine or board-certified in surgery when they are trained to do both, and in practice, they do both.
Yes, some residency programs and fellowships provide more advanced types of surgical procedures, but every medical and surgical specialty has those same exceptions. It seems to me that after completing a three-year comprehensive medical/surgical residency program, there would be one certifying board that certifies DPMs as podiatric physician and surgeons.
Jon A. Hultman, DPM, MBA, Sacramento, CA
01/27/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: CMS Audits for Routine Foot Care
From: Sharon I. Monter, DPM
Audits for at-risk foot care are nothing new and they are simply part of doing business. While these CPT codes are certainly “on the radar screen” of CMS, they represent only a portion of what our profession contributes to the prevention of devastating and costly lower extremity complications.
Many podiatrists are now recognizing that they have a much greater responsibility than just performing at-risk foot care for our patients with diabetes. The precursors for complications are often evident if we simply use tools to comprehensively explore sudomotor conditions such as the skin moisture index, temperature variations, etc., and accurately stratify the risks of our patients with diabetes. Patient-engaging care plans can then be formulated around the findings. This, along with performing at-risk foot care, makes us a true specialist that differentiates ourselves from other specialties, while also making the encounter much more profitable for the practice.
Sharon I. Monter, DPM, Point Pleasant Beach, NJ
12/06/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Charging for Missed Appointments
From: Joel Lang, DPM
There has been a lot of chatter about charging for missed appointments. Though now retired, I did practice for 35 years. Over that time, I came to some realizations. An important one was that I was not the center of the universe in the patient’s life. I was only one event in their week among many events.
Patients miss appointments for too many reasons to list, but some are weather, car trouble, forgetfulness, family emergencies, illness, and let’s not forget those who do not fully control their own lives, like mothers, those with mental illness, and those who depend on others for transportation. Charging for a broken appointment may be adding insult to injury in their life experiences; that is certainly not...
Editor's note: Dr. Lang's extended-length letter can be read here.
11/25/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Jeffrey Kass, DPM
I agree with Dr. Herbert’s opinion. If things aren’t changing, it would behoove someone to change strategy or legal representation. One would think that new legal counsel would be hungry to show their worth. Most other professions are advancing their legal scopes and our profession remains pretty stagnant in comparison. I notice most of the doctors in my state who increase their scope are the ones that leave the state. But, yet the state societies keep the same lobbyists and attorneys. Makes one wonder.
Jeffrey Kass, DPM, Forest Hills, NY
11/10/2022
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Martin M Pressman, DPM
I have also been summarily rejected from these surveys because of my age (75) and years of practice (47). These “surveys” are not gathering information for academic purposes. They are underwritten by pharma or industry and aimed at practitioners to identify practice patterns for the purpose of selling them on the industry’s own product. They know we seasoned practitioners generally don’t fall for those games. I take that as a compliment.
Martin M Pressman, DPM, Summerville, SC
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