January 02, 2010 #3,743 Publisher-Barry Block, DPM, JD
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We would like to thank the following PM News readers for their frequent contributions during 2009: Eugene Batelli, DPM, Robert Bijak, DPM, Richard Boone, Mike Boxer, DPM, Esq., Peter Bregman, DPM, Chris Browning, DPM, Juliet Burk, DPM, Neil Burrell, DPM, Paul Busman, DPM, Robert Chelin, DPM, Nat Chotechuang, DPM, G Dock Dockery, DPM, Michael Forman, DPM, Neal Frankel, DPM, Harry Goldsmith, DPM, Steven Goldstein, DPM, Richard Gosnay, DPM, Thomas A. Graziano, DPM, MD, Keith Gurnick, DPM, David E. Gurvis, DPM, Lynn Homisak, PRT, Allen Jacobs, Alan Kalker, DPM, Brian Kashan, DPM, Jeffrey Kass, DPM, Marc Katz, DPM, Paul Kesselman, DPM, Kevin Kirby, DPM, Robert Kornfeld, DPM, Joel Lang, DPM, Frank Lattarulo, DPM, Neil Levin, DPM,Bryan Markinson, DPM, Gerald Mauriello, Jr., DPM, Ken Meisler, DPM, Barry Mullen, DPM, Al Musella, DPM, Hal Ornstein, DPM, Narmo L. Ortiz, Jr., DPM, Jonathan Purdy, DPM, Anthony Poggi, DPM, Bret Ribotsky, DPM, Doug Richie, DPM, Jeffrey Root, Michael Rosenblatt, DPM, Ivar Roth, DPM, Roody Samimi, DPM, Robert Schwartz, C. Ped, Dennis Shavelson, DPM, Richard A. Simmons, DPM, Robert Steinberg, DPM, Tip Sullivan, R.D.Teitelbaum, DPM, Michael Turlik, Wm. Barry Turner, RN, DPM, DPM, Elliot Udell, DPM, Lowell Weil, Sr., DPM, Simon Young, DPM, and David Zuckerman, DPM.
We also thank everyone else who sent in queries, responses, or news items.
PODIATRISTS IN THE NEWS
TX Podiatrist Discusses Pregnancy and Foot Health
"Oh my aching feet” is a phrase you hear often from pregnant women. But, are sore feet a symptom that they just must deal with during pregnancy? According to the American College of Foot and Ankle Surgeons (ACFAS), the answer is “no.” There are many remedies available to help alleviate foot pain.
Dr. Marybeth Crane
According to Marybeth Crane, DPM, a Dallas-area foot and ankle surgeon, women often experience foot pain during pregnancy because of increased weight, foot instability, and swelling. “In the last five years, I’ve seen an increase in pregnant women with foot pain because more women than ever before are active, even running marathons, during their pregnancies,” Dr. Crane says.
It is also not uncommon for women to experience a change in their foot size during pregnancy. “A permanent growth in a women’s foot, up to half a size, can occur from the release of the same hormone, relaxin, that allows the pelvis to open to deliver the baby. It makes the ligaments in your feet more flexible, causing feet to spread wider and longer,” Dr. Crane adds.
PODIATRISTS IN THE COMMUNITY
TX Podiatrist Uses Facebook and Twitter to Stay in Touch with Patients
So where do you draw the line between patient and personal? One afternoon, Leah Flannigan was searching through Facebook and stumbled across her podiatrist's page. "I just typed in his name and I found him," Flannigan says. "And he's the kind of doctor that I felt would probably accept me as a friend, even though I was his patient."
Dr. Andrew Schneider
Dr. Andrew Schneider did accept her request. "It gives us a little bit of a bond that's outside the whole doctor-patient relationship," Flannigan says. "I've had patients contact me where they're out of town, and they hop on Twitter and they shoot me a quick question," Dr. Schneider says.
Source: Cindy Hsu, WCBS-TV [12/30/09]
'Meaningful Use' Criteria Released
HHS issued two sets of much-anticipated federal regulations that significantly further the government's healthcare information technology adoption agenda. The first set of regulations lists the “meaningful use” criteria that healthcare providers must meet to qualify for federal IT subsidies based on how they use their electronic health records. The second set of regulations lays out the standards and certification criteria that those EHRs must meet for their users to collect the money.
Under the proposed meaningful use regulations, eligible healthcare providers must use their EHRs to: improve the quality, safety and efficiency of healthcare services; reduce healthcare disparities; engage patients and their families; improve the coordination of care; improve population and public health; and ensure the privacy and security of personal medical information.
Under the interim final EHR regulations, EHRs must be able to securely exchange information among providers and between providers and patients using standardized data elements and technologies. The regulations outline standardized formats for such things as clinical summaries; medical descriptions of clinical conditions and test results; and how that information is exchanged over the Internet.
Source: David Burda, Modern Healthcare [12/30/09]
Query: Medicare as Secondary Payer for Shoes
We have a patient who received diabetic shoes. Anthem Blue Shield, the patient's primary insurance company, paid $0.00. We then submitted the claim to the patient's secondary payer which happens to be Medicare (DME). They denied reimbursement because the primary paid zero. Any suggestion as to how we can submit?
Michael Fein, DPM, Bethel, CT
Response: To my knowledge, Medicare does not coordinate benefits when it comes to covered services. Medicare covers what they cover. I don't think I've ever seen where Medicare denied payment of a covered service, even as a secondary where there has been a true primary denial (other than a claims error).
You may want to go back and review the denials again, and determine the EXACT reason why both claims were denied. Without denial codes and explicit written reasons for non-payment, it's makes it more difficult to assist to find out the cause.
RE: Bunion in 14 Year Old (Chris Browning, DPM) From: Lowell Scott Weil, Sr., DPM, Richard Gosnay, DPM
The correction of hallux valgus deformity in young teens can be very challenging because of several factors. The great majority of these patients that Barouk refers to as "congenital hallux valgus", present with an increased PASA (proximal articular set angle), or its synonym, DMAA (distal metatarsal articular angle). This structural deformity combined with a high intermetatarsal angle and phalangeal, DASA (distal articular set angle) and open growth plate (noted on the x-ray provided) makes this an All American Bunion deformity.
Each year, our group performs surgery on about 20 congenital bunion patients (under 20 years old). A recent pilot study of a five-year or longer term follow-up by one of our fellows, Shine John, DPM showed complete satisfaction in nine of ten patients, with the tenth having some recurrence.
We use the Scarf bunionectomy with PASA correction, and in this case, I would add an Akin osteotomy. The so-called hypermobility can be neutralized through soft tissue correction. Based on the x-ray presented, there is already a short first metatarsal (which will be further compromised with a Lapidus procedure), and probable arrest of the remaining linear growth of the first metatarsal. This is a difficult case and should only be performed by an experienced foot & ankle surgeon.
I completely agree with Dr. Browning's decision to perform a Lapidus in this case. This boy has transverse plain deformity in spades, but even in cases where the transverse plain deformity is not so extensive, hypermobility = Lapidus. The growth plates at the lesser metatarsal heads appear to be almost closed. So, I am assuming that the plate at the base of the first metatarsal is also done. If not, it may be prudent to put the procedure off for a year or so. The first metatarsal appears short with respect to the second. And the Lapidus will shorten the first ray further. So I suggest that Dr. Browning might perform a variant of the Reverdin that I described earlier. In this case, I would cut a distal "L" osteotomy like a Reverdin Green. But, instead of shortening the medial cortex, I lengthen the lateral cortex with a 2-3 mm chip of bone graft. I fashion the graft from the exostosis I take off the bunion. The graft takes 12 weeks to incorporate, but the plantar wing of the osteotomy heals long before that. So, the patient may walk as soon as the Lapidus is healed. Please e-mail me directly if you would like a photo of the radiographs.
Incidentally, I was taught that it is impossible to evaluate first ray elevatus from lateral radiographs because small variations in the position of the x-ray head or of the foot drastically alter the appearance. Even if that variation could be eliminated, the first metatarsal is twice as thick as the second, and it sits on a couple of sesamoid bones. I believe that elevatus is evaluated by examining the foot with the lesser metatarsals loaded.
The photo, and indeed Dr. Browning's description of the x-ray lead me to believe that we are dealing with an osteo-cartilaginous growth or simple exostosis. Cartilage lesions need to be carefully evaluated, and since the lesion is painful, surgery will be required. I would recommend doing this in hospital, alerting the pathology department that you are going to be doing a frozen section, before you excise the lesion in its entirety.
If you discuss the case with them beforehand, you may be able to plan the complete resection with planned margins if indeed the lesion shows atypical or frank malignant disease on frozen section. Unfortunately, even if totally benign, you may have to be surgically aggressive just to avoid recurrence. Please keep us posted with the results!
It was difficult to ascertain on the photograph supplied, but is it possible that the end of the toe with the suspected glomus tumor was also much longer than its neighbors?
Podiatrists often see distal IP joint hammering, traumatic nail disorders, etc. on elongated toes. If this condition occurs in a child, you may not wish to perform a shortening arthroplasty (as you might on an adult). Footgear is important in this circumstance, but I have seen distal phalangeal pathology on long toes, even with "adequate" length footgear. I'm sure many reading this have also.
It's worth notifying the parents of this problem, and giving them good advice on how to fit footgear to a child with this problem. But even if you do a distal surgery, there is no guarantee that the damage an elongated toe produces won't bring back the same or similar problem in the future. That too should be disclosed to parents.
Based on the appearance of the digit in the photograph, the nail appears normal. The tuft of the toe itself appears to be bulbous, with the nail adapting around the tuft. I would recommend checking closely on x-ray to rule out an osteochondroma. Frequently, they appear in this manner.
RE: Importance of Doppler Studies (Ivar E. Roth, DPM, MPH) From: Jeffrey Kass, DPM
Sniff test to do a procedure? I don't think whether or not a patient would pay for a procedure if they are a cash- paying patient is a logical way to decide whether or not to perform a test. The physician's clinical judgment is. There are known risk factors for PAD and there are known clinical signs and symptoms for PAD. Medicare even has specific local determination policy for when they are appropriate. Gosh, if I let the patient decide if they were going to pay for something if they didn't have insurance, a good portion of my diabetics with neuropathy wouldn't have feet; not because of performing a Doppler, they wouldn't even want an ulcer debrided. They don't feel pain - so "nothing is wrong."
There are a host of other scenarios I could give where, if left to the patient to decide, they would not have the service if they had to pay out-of-pocket. In fact, if patients would be willing to pay for services out-of-pocket, I think the majority of practitioners would not accept insurance.
As I have noted in previous postings, my biller is simple and efficient. She charges the national standard (to my understanding) at 6% of collections. She handles everything from renting of her software to balance billing, with her stationery and stamps. Using fax and the Internet, she can bill for anybody in the country. She may be reached at: firstname.lastname@example.org.
Richard Gosnay, DPM, Danbury, CT, email@example.com
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ASOOCIATE POSITION - MICHIGAN
Seeking high quality, RPR, PSR1, PSR2, or PSR3-trained associate for a fast-paced, established group practice in Southeast Michigan. This is a secure, long-term position. Emphasis on diabetic foot and wound care. Our outstanding staff allows you to concentrate on optimal patient care without the responsibilities of practice management. MUST have a Michigan license. Partnership possibility for the right individual. If you are highly motivated, ethical, and have good communication and clinical skills, please email your C.V. to firstname.lastname@example.org
ASSOCIATE POSITION - CHICAGO AREA
Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume email@example.com
PRACTICE FOR SALE - MAINE
20+ year, full scope, turn-key practice. Retiring seller will assist in transition. Excellent expansion potential, superb place to raise a firstname.lastname@example.org
DREAM PRACTICE OPPORTUNITY - OKLAHOMA
Use forefoot, rearfoot, wound skills in ideal small city with nearby lake. No buy-in costs. No limit on income. EMR. Act fast. OK State License deadline is 1-30-10 and test is comprehensive. Personality preferred over ego. Emailjulietburk@gmail.comor call 918-931-1425 for details.
ASSOCIATE POSITION - FREDERICK, MD
Well-established and growing 2 office state-of-the-art practice located in medical/professional buildings. EMR, Digital X-ray, Ultrasound, DME provider, etc. Competitive Base Salary plus bonus, malpractice, health insurance, etc. PSR 24 minimum/Board Qualified or Certified with ability and desire to take ER call. If interested, forward CV toDOCSBNB@aol.com
ASSOCIATE POSITION – CINCINNATI, OHIO
This is your once in a lifetime opportunity to join one of the most successful practices in the United States. We do not have a seniority system. If you are motivated and have completed a PSR 24-36 residency, your income is limited only by your enthusiasm and desire to achieve. Email resume to email@example.com
PRACTICE FOR SALE - TENNESSEE
Well established practice for sale. Full scope medical and surgical practice including DME. Exceptional practice with a high volume of new patients. Excellent hospital and surgical center privileges with investment opportunity. Great area for a family and the outdoorsman. 731-446-7285/E-mail firstname.lastname@example.org
PRACTICE FOR SALE - CENTRAL FL
Practice and medical building for sale, in beautiful, high quality of life, growing area, Central Fl.; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion & investment; good insurance climate. 352-223-2713 / E-mail: email@example.com
PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH
Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.
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