The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

April 17, 2009 #3,522 Publisher-Barry Block, DPM, JD

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Even Cosmetic Foot Surgery Has Limits: NY Podiatrist

At her office, or Institute Beauté, as she has dubbed it, Dr. Suzanne Levine has patented the foot facial ($225), a treatment that includes a foot mask, callus removal and a collagen-inducing copper cream; and a procedure called Pillows for Your Feet (starting at $500), recommended twice annually, involving Juvéderm and Sculptra injections that provide cushioning for foot soles, making it easier to wear sadistic heels. She also administers foot Botox to get rid of wrinkles and swelling—gotta avoid the dreaded cankle!—and does a bleaching treatment ($225) for yellowing toenails. And then there is the controversial toe-shortening procedure of pesky extra-long second toes—sometimes done to ease discomfort, other times for cosmetic reasons—in which middle bones of the toe are removed, making it easier to squeeze into a wider variety of designer shoes. It starts at $1,500.

Dr. Suzanne Levine (Photo Ryan Meehan)

Dr. Levine does have her limits. She marveled at some of the masochistic requests of some clients, who “come in and say, ‘My foot is too wide, can you make it narrow and chop the bones?’ Or, ‘I want my foot to be dainty, I want it to go from a size eight and a half to a six.’” And she refuses to do liposuction on the toes, which some patients have requested lately. Said Dr. Levine: “I tell them they have to see a psychiatrist.”

Source: Irina Aleksander, The New York Observer [4/14/09]
 

HIPAA Covered Entities Face a Variety of New Enforcement Risks

For years, privacy advocates savaged the HHS Office for Civil Rights (OCR) for failing to enforce the privacy rule — it has yet to level a single dollar in fines — a situation many believe has led to lax compliance. Things picked up a bit when CMS, assigned to enforce the security rule, hired a contractor to conduct audits of covered entities (CEs).

So some cheered when the American Recovery and Reinvestment Act of 2009 (ARRA) provided for a doubling of fines for violators, and for the first time, gave state attorneys general (AGs) the authority to bring civil actions under HIPAA in district court. The new law now requires CMS and OCR to conduct formal investigations of complaints where a preliminary inquiry of the incident shows that "willful neglect" is the cause.

"Privacy and security enforcement will get much more aggressive" under the Obama administration, says Washington, D.C. attorney, Robert Hudock, with Epstein, Becker & Green. He expects a shift from the voluntary compliance approach that has marked enforcement so far to more fines and penalties.

Source: Report on Patient Privacy [4/14/09]

Networking Knowledge

Remember these pointers as you build your professional network—and your reputation.

• Use “I” statements. Let others see who you are.
• Speak from experience. Avoid generalities.
• Avoid interrogation. Strive for a conversation, not a lecture.
• Don’t offer “fix its.” Refrain from offering advice. Avoid “You should …” statements.

Source: Adapted from One Phone Call Away: Secrets of a Master Networker, Jeffrey Meshel with Douglas Garr, Portfolio via Communication Briefings

Query: Resistant Verruca

I have been treating a 65 y/o woman for a 4th toe distal tip verruca that started after her chemotherapy/radiation treatment had been completed for uterine CA. PMH: Graves disease, Mal-absorption syndrome, breast and uterine CA, both in remission. I have tried excision twice. The  pathology report was verruca on both. I have tried pulse dye laser destruction. She has tried topicals including Aldara, Carac and various keratolytics and acids. The lesion seemed to be under the nail, so I  removed the nail, which grew back Penicillum species and mold. I am running out of ideas, short of a distal tip excision.

Eveline Tan, DPM, Wheaton, IL

Query: Charging Additional Fees

I accept assignment with Medicare. Is there a scenario that I can use to LEGALLY charge patients an additional fee?

For example:
1) Uncovered service/supply: CPT 99070?
2) Rental fee for equipment needed to perform a certain procedure?

Lya Findel, Glendale, CA

Response: If the service is statutorily non-covered, you can charge the patient directly for anything directly related to the non-covered item/service. You may want to fill out an advance beneficiary notice of non-coverage (ABN), although it is not required, just to be on the safe side.

The important point is to ensure that the items/services you are referring to are truly statutorily non-covered. If they can be covered, for instance, as a rental, or under the circumstances you are dispensing the supply for, and you ignore that benefit, charging the patient, you could have some problems down the road.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found at:
http://www.codingline.com/subscribe.htm

RE: Bone Tumor Diagnosis (Steven Melek, DPM)
From: Multiple Respondents

This looks like a possible osteochondroma to me, which is metaphyseal  in origin and can be post-traumatic and do have a low recurrence rate after excision. Location is typical. If and when you excise the growth, look for a white cartilagenous covering over the growth and do a deep saucerization to reduce the chance of regrowth.

Keith Gurnick, DPM, LA, CA, keithgrnk@aol.com

My guess is a giant old epithelial cyst. The bone changes are secondary to cyst pressure. The treatment is to excise it. 

Ed Wiebe, DPM, Flagstaff, AZ, elw520@hotmail.com

It may a Nora's lesion (bizarre parosteal osteochondromatous proliferation). This lesion grows rapidly and has aggressive features on imaging studies, as well as confusion findings on histopathology, leading to many errors in diagnosis and potentially inappropriate treatments. The lesion is thought to be related to myositis ossificans, reactive periostitis, and subungual exostosis. It was described in 1983 by Dr. Nora, and is sometimes called Nora's disease or Nora's lesion.
 
Craig H. Thomajan,  DPM, Austin, TX, thomajan@austinfootandankle.com
 

RE: Aldara  and EBM (Allen Mark Jacobs, DPM)
From: Michael Turlik, DPM, Bob Kornfeld, DPM

The medical literature should never be used in isolation to make decisions regarding therapeutic interventions. Clinical studies should always be incorporated into the clinician’s expertise and the patient’s expectations. Not every therapeutic intervention need be validated by rigorous clinical trials or should one expect Level-1 evidence to be available for all needed therapeutic options.
 
Sometimes, lower levels of evidence may be all that is available. Anyone who has been in practice for any length of time develops their own treatment plans for common conditions. For me, prior to altering my treatment plan for common conditions (especially if I think my plan works), I would like to have some information that I would feel comfortable with. The more invasive and expensive treatment option is, the more likely I will only be satisfied with level-1 evidence.

Absence of evidence does not mean absence of effectiveness. Imiquimod may be an extremely effective treatment for pedal verruca. Since pedal verruca is a self-limited disease, it is difficult to tell with lesser levels of evidence if the improvement is due to imiquimod or just background improvement due to the natural course of the disease.

Anecdotal information regarding treatment efficacy is extremely common and a powerful source of information for the profession. “I know it works because I've seen it in my own practice!” However, anecdotal information is not valued by proponents of EBM because it is not transparent and reproducible. One of the problems with anecdotal information is that the clinician’s recall of past events may not always be accurate.

Michael Turlik, DPM, Cleveland, OH, mmturlik@aol.com

Editor’s Note: An extended-length note by Dr. Kornfeld appears at: http://www.podiatrym.com/letters2.cfm?id=25817&start=1

This topic is now closed.

RE: Unruly Children (Anas Khoury, DPM)
From: Keith Gurnick, DPM

Anyone who treats a lot of children is aware that unruly children disrupt and destroy the waiting rooms, annoy other patients and take more time and effort from the doctor and office staff to treat and can be challenging. There is no one trick that works all the time; however, you might try these.
    1) Your nursing staff, not you, should speak first with the parent to try to control the child, and also to the child.  (This is usually a waste of time)
    2) Try to minimize the waiting time for these patients, i.e., get them right in and get them right out.  Of course, if you try to schedule around these patients, they often cancel at the last minute or show up late, which causes other scheduling problems.
    3) Try to avoid scheduling more than one unruly child from the same unruly family at the same time.
    4) Schedule the difficult child as the first or last patient of the day.
   
Keith Gurnick, DPM, LA, CA, keithgrnk@aol.com
 

RE: Vascular Testing Systems (Frank Lattarulo, DPM)
From: Multiple Respondents

I echo Dr. Lattarulo's response. I, too have Biomedix and am happy with it. For completeness sake, I would like to add one point. The system calculates ankle and toe brachial indices. It also gives you pulse volume recordings at the level of the knee, calf, ankle, and great toe. It does not take pressures at the knee, and calf, so it does not measure pressures at all levels. I find this to be a drawback for an expensive piece of equipment.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

The first company that I think of, is PADnet+. The PADnet+ is an in-office vascular testing program for early identification of PAD and CVI. It was developed and is sold by BioMedix Vascular Solutions, Inc. It is easy-to-use, has in-office training for your staff, and it provides fair financial return for the appropriate patients. It also includes a complete marketing launch kit to roll out the program in your office. I would recommend that you read the article by Jonathon Moore, Podiatry Management, August 2008 that outlines the appropriate and optimum use of the PADnet+ in your practice.

Disclosure: BioMedix is a supporter of the American Academy of Podiatric Practice Management of which I serve as Chairman. I am not a paid speaker and not a paid consultant for BioMedix.

Hal Ornstein, DPM, Howell, NJ, toetoe@optonline.net

I would first recommend you review your Medicare and non-Medicare payers LCD which will stipulate the requirements for those performing the testing. Most Medicare LCD’s require that the physician him/herself perform the test. Alternatively a paraprofessional who has received accreditation in vascular technology may perform this exam. In many jurisdictions, the Medicare LCDs preclude your office staff, unless properly credentialed, from performing this exam. Certainly, office assistances can be trained to “set up” the patient for the testing and/or assist you with performing the exam. The LCD will also provide you with diagnostic information and other critical reimbursement information. Inquire with your colleagues who currently use in-office vascular testing and/or your state CAC rep for more reimbursement policy information.

Secondly, you should research which companies can provide you with an easy to use unit which provides software and electronic health record-type integration at an affordable cost. Review the advertisements in the popular podiatric publications and look at some units at some trade shows. In addition to cost, ask about support and maintenance fees.

I currently use one of Koven Technology's units and they have several affordable options for the podiatrist. I currently use a Koven unit which performs bi-directional Doppler, pulse cuff recording and photo plethysmography, and is integrated with their proprietary software. There are no annual maintenance costs and software upgrades are free.

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net
 

ASSOCIATE POSITION - CENTRAL VIRGINIA

Join a solo surgeon in a two office private practice, modern facilities with EMR and digital x-ray, reconstructive and trauma surgery.  Excellent starting salary and benefits. Position leads to partnership. Submit letter of introduction and CV to jdisabato@vfasa.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.

ASSOCIATE POSITION - ILLINOIS
 
Podiatrist needed to provide care for elderly population in Long-Term Care and Assisted Living Facilities. Must be ethical, hard-working, interested in geriatric care and willing to travel. e-mail resume to poddoc2328@hotmail.com

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 to f-massuda@footexperts.com

ASSOCIATE WANTED - FLORIDA

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Partnership opportunity for the right candidate. Preference given to a PSR 24+ resident completing their education this spring/summer, and must have a Florida license. Well-established practice, high tech with EMR and digital x-rays, with specialties in sports medicine, surgery and wound care. No nursing homes or HMO's. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family that is second to none. E-mail: kimvelez@tampabay.rr.com

PART-TIME NON-SURGICAL PRACTICE FOR SALE - NORTH JERSEY    
 
23 yo practice recently relocated to a spectacular newly-constructed and equipped storefront next to a busy supermarket with ample parking and senior citizens in vibrant downtown. Accepting Medicare and Blues only with great potential. Perfect for expanding to full-time, a second office or new practitioner with means and office experience.  Priced to sell. Financing possible. E-mail interest with contact to Mikedup1215@yahoo.com 

ASSOCIATE POSITION AVAILABLE-MIDTOWN MANHATTAN

Looking for Full-time associate to work in well established practices in midtown Manhattan and Forest Hills. Immediate opening for PSR 24-36 surgically trained Podiatrist. Great opportunity with competitive salary along with malpractice benefits. Please send CV to slurie@papapc.net

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com 

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

SEEKING ASSOCIATE POSITION - NEW JERSEY

I am a hard-working, compassionate, highly-trained and motivated podiatrist interested in a full-time or part-time position. Graduated from a PM&S-36 residency program. Extensive training focused on wound care, limb salvage, reconstruction, trauma and elective procedures.  Currently hold an active NJ license. Email: ft.n.ankle.dr@gmail.com

TWO YEAR FELLOWSHIP IN RECONSTRUCTIVE FOOT SURGERY AND RESEARCH

2-year fellowship at Beth Israel Deaconess Medical Center, a primary teaching hospital for Harvard Medical School. Fellows have clinic, perform complex reconstructive procedures (external fixation, flaps, Charcot reconstruction), and conduct clinical research (20%). Fellows train residents and receive appointment at Harvard Medical School faculty. Excellent salary/benefits. Program begins SEPTEMBER, 2009. Must have completed PSR-36 or similar. Submit applications to: Adam Landsman, DPM, PhD alandsma@bidmc.harvard.edu Include CV, letter describing goals and any research interests. Deadline: May 1, 2009.  Beth Israel Deaconess Medical Center and Harvard Medical School are Equal Opportunity Employers. Women and minorities are particularly encouraged to apply.

PODIATRIST NEEDED FOR MIAMI-DADE COUNTY

Multi office practice needs doctor of podiatry for full time and/or part time for private office, clinics, and nursing homes. Great opportunity to grow with and unlimited income potential. Offices in Miami, Hialeah, Westchester, and Cutler Ridge. Email to feetdoctor@aol.com

PM Classified Ads Reach over 11,500 DPM's and Students

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