The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

July 08, 2009 #3,591 Publisher-Barry Block, DPM, JD

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Flip-Flops Better Than Barefoot on the Beach: FL Podiatrist

Dr. Hal Bozof, a Fort Myers board-certified podiatrist, isn't a fan of flip-flops. "They just offer no support for the foot and for the arch," he said. "If you're on your feet for a long period of time, it can cause strain in the arch region of the foot." The arch starts collapsing and pain starts developing and other deformities can occur, he said.

Dr. Hal Bozof

But Bozof is not entirely anti-flip-flop. He encourages wearing them to the beach because he has treated patients for stepping on everything from glass to stingrays. "I'd rather they wear them than go barefoot," he said. "But I would rather see them wear some closed shoes like a sneaker or walking shoe with more protection and some arch support."

Source: Francesca Donlan, News-Press [7/7/09]

New Studies Suggest That Blues Plans Have 'Near-Monopolies'

Two recent studies conclude that many states — most of them ones in which a Blues plan is the market leader — lack competition in the health insurance market, thereby allowing health plans to raise premiums as they see fit. However, two multistate Blues plan operators contend that premium increases are driven primarily by medical costs. And at least one state insurance commissioner asserts that one reason the Blues plan in her state is the leader is that it's the only plan that has a real statewide network.

The studies conducted by Health Care For America NOW! (HCAN) and the American Hospital Association (AHA) were sent to Assistant Attorney General Christine Varney, who heads up the Antitrust Division of the Department of Justice (DOJ). The study sponsors request that she review industry mergers and consolidation for anticompetitive and antitrust actions that are fraudulent in nature.

HCAN's study uses enrollment data collected by the American Medical Association (AMA) to show that, in many states, one or two health plans have a dominant market share in terms of enrollment. The study contends that, in such states, insurers can set premium rates as they please, and it takes particular aim at the growth of profits among for-profit insurers between 2000 and 2007.

Source: Chris Meehan, AIS Report on Blue Cross and Blue Shield Plans [7/7/09]

Part 3-  Steps in the Medicare Underpayment/Overpayment Appeal Process by David Mullens, DPM, JD

The time requirements to stop the repayment of overpayment collections by Medicare are different than the usual time requirements to “appeal” underpayments. You should NEVER respond to an overpayment demand by writing a check.

First, let’s look at the time and money requirements for each step in the Medicare underpayment/overpayment appeals process.

Time and Money Requirements for Medicare Appeal Process

Query: Skin Lesion Associated With Heel Pain

I have a 47 yo male patient with a previous history of heel spur syndrome/plantar fasciitis. He presented to the office about a month ago for a set of OTC inserts as the pain started to re-occur. About two weeks ago, he noted exquisite pain and tenderness, more so than previously, and when looking at the foot, noted this dermatologic feature. 

Skin Lesion Associated With Heel Pain

The geographic margins are perfect, no longer then 1.5 cm on each leg.  It actually appears as though he stepped on something shaped as shown, which created underlying trauma. Yet, he denies any injury, etc. The lesion is located on the plantar medial aspect of the heel. Inside the margins/borders, the skin is slightly whiter and mildly elevated. It is non-keratotic, and there is no interruption of the skin lines. His health is good, no Rx's, etc.   

Harry Cotler, DPM, Soldotna, AK

Query: Cryo-Probe Hand-Held Device

Can anyone relate their experience using the Cryo-probe hand-held device? Where was the unit purchased and what is the approximate cost with cartridges?
 
Michael A. DeVito, DPM, Oak Lawn, IL

Query: Electronic Prescription Incentive Question

We have started using an electronic prescription program in our office. According to Medicare, to get credit for your e-prescriptions, you must add one of three "G" codes. They say to add the codes to all claims to help ensure you meet the 50% successful reporting requirement.

My question is, do you just report the code, or do you add a dollar amount ($00.00) so the whole claim or the "G" code line is not rejected?

Bruce N. Block, DPM, Kew Gardens, NY

Response: Use a zero $ amount for all 3 codes - but they must be used with an E/M code.

Richard Papperman, MBA, CHBME, Cape May Court House, NJ
 

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

RE: Unidentified Lesion (Michael Cohn, DPM)
From: Multiple Respondents

Dr. Cohn’s remarkable photo most likely captures Kaposi’s sarcoma in all of its stages – macular, popular, and nodular.  Depending on medical and mental status, consultation with an oncologist is the best way to go. I do not think a biopsy, even in view of the non-palpable pulses will be problematic and it should be done for confirmation of the diagnosis.

Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org

Effective treatments start with the right diagnosis. When dealing with a suspicious lesion (and this looks very suspicious) everyone will tell you to biopsy. Even if he has no pulses, the photo presented does not look grossly ischemic. Get a Doppler and if audible sounds, go ahead and do a 2 mm. or 3 mm. biopsy (punch biopsy is fine), or get the blessing of a vascular specialist, but get tissue to examine. I have biopsied recurrent wounds that have been treated (and so-called cured) at the local wound care center and picked up at least 3 cases of cancer. My guess, especially if he is an elderly man of Mediterranean descent, is Kaposi's sarcoma. I have referred these patients to radiation oncology after the proper diagnosis.

Pat Caputo, DPM, Holmdel, NJ, capstops@aol.com

You need a biopsy. From the photos alone, I'd bet on Kaposi's sarcoma. If it is, curettement-style biopsy should heal quickly in a patient with adequate blood inflow. At 85 years of age, a patient with Kaposi's may not generate a lot of excitement about aggressive treatment, even from oncology, and palliative removal of symptomatic lesions over time may well be the course you choose, even after appropriate consultation.

Dave Mazza, DPM, San Diego, CA, dsmazza@pol.net

RE: Surgical Closure of First Metatarsal Growth Plate to Correct For a High IM Angle (Sarah Naglich, DPM)
From: Elliot Udell, DPM, Charles Morelli, DPM

Dr. Naglich misquoted me. I did not state that there is no literature to support this procedure. Be it as it may, a review of many of the comments made by other esteemed podiatric surgeons on this topic supports that this procedure may not be the ideal surgical option for the patient described and for the surgeon considering it. The risks may outweigh the potential benefits. Dr. Ribotsky says it all when he wrote that he published in JAPA on this topic but since completing his residency has not performed the procedure. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

Based on the x-ray that was shown, her main problem is her hypermobility, evidenced by a rather large met-cuneiform split. This foot is begging for a Lapidus arthrodesis. It is the procedure she needs, not an epiphysiodesis. If you do not address her hypermobility, whatever procedure you choose will be doomed to failure. She's only 11 yo and you need to be aggressive, or be clear with the family if you choose to stage her procedures.
 
You may want to wait a bit to do a fusion. Make her a pair of orthotics first to see if you cannot give her some relief. If not, then you can discuss surgery with the family. If you choose to do a fusion and her growth plate is still somewhat open, then she can be fixated a number of ways that will not interfere with the growth plate (staples, K-wires, casting).  
 
Alternatively, you can consider an opening base wedge osteotomy utilizing a low profile Arthrex Cotton Plate (6 mm. is the most common size used). Done properly, it will not interfere with the growth plate. I videotaped this procedure and I now use this opening wedge technique to plantarflex the medial column (Cotton Procedure) or lengthen the lateral column (Evans). It is very stable. (youtube.com/watch?v=zTIN6Dbm0LI&feature=channel_page)
 
For those who believe that her first metatarsal is too long to do this type of procedure, what you will find is that an opening wedge of a first metatarsal does not lengthen it as much as you would think. Try it and take measurements both pre- and post-op. You will see how little the first met is actually lengthened, as it is simply translated laterally, closing down the IM angle.

Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com

RE: Audio Version of Podiatric Lectures (Frank DiPalma, DPM)
From: Alan Sherman, DPM

Many of the lectures on the PRESENT Diabetes website (presentdiabetes.com) are offered as Free Podcasts. They can be downloaded to an iPod, iPhone or other MP3 player and listened to at your leisure in the car, on a plane, or while you're on the elliptical trainer at the gym. Just look for the PODCAST badge in the lecture listing in the PRESENT Diabetes Lecture Hall.

Alan Sherman, DPM, Boca Raton, FL, asherman@presentelearning.com

RE: Medicare Demand For Overpayments (David Mullens, DPM, JD)
From: Bryan C. Markinson, DPM

I read with interest the editor-labeled "first part of a series by healthcare attorney, David D. Mullens, DPM, JD" regarding demand of repayment of Medicare overpayments. I do not know who David Mullens is, but what he writes seems to be a bit paranoid to me, written in the style of the story about the sky falling. Having said that, I do accept that some…

Editor's note: Dr. Markinson's extended-length note can be read at: http://www.podiatrym.com/letters2.cfm?id=27298&start=1

RE: Digital X-Ray Systems (James E. Rogers, DPM)
From: Charles Morelli, DPM

I was not prepared, nor did I want to pay the $18,000.00 - $35,000.00 (and more) that can be charged for these systems. What I did was contact various companies and see if they either had "floor models", or units that were being returned by a leasing company, or units that were being returned because the owner had decided to upgrade.  Regardless of the reason, these deals may be available.
 
I have two digital machines in two offices, and have been using them for a number of years now. You can negotiate service contracts and warranties. I ended up paying a fraction of what they would have cost me new, and to date, they are working beautifully.

Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.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.

OFFICE SPACE/ MRI RENTAL – NYC, LI  
 
Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, Hicksville and/or Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

ASSOCIATE POSITION – MARYLAND

Maryland Eastern Shore Practice has opening for associate with ownership interest. MCR approved ASC, EMR, Ultrasound, Flouro, with Hospital Privileges available. E-mail CV to: patimmons@comcast.net 

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

DIAGNOSTIC ULTRASOUND FOR SALE

Mindray 6600 with Sony thermal printer. Machine comes with a 10 Mhz linear probe. Split screen allows two images on one screen. All digital machine. Comes with factory warranty for 1 year from Atlantic Medical LLC. Price when new is close to $11,000.00. Price for this machine with printer is $5,500.00. For further information see website 

PRACTICE FOR SALE - ALABAMA, GULF COAST

Established 26 year old practice. Owner desires to sell and relocate. Operated 25 hours per week. Mixture of surgery and general podiatry. MD referrals. Surgery center and hospitals in close proximity. Highly profitable. Priced to sell. Will lease office to buyer. Call Mike Crosby at 888-776-2430 or email mcrosby@providerresources.com

PRACTICE FOR SALE – NEW YORK CITY

NY Manhattan, prime location. Upper East Side, 23. Y.O. practice, high visibility-traffic area next to post office, street level, All phases of Podiatry, NO surgery, retiring due to disability. call 516-759-4062 or Paulfxfeet@aol.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. Position includes Saturday office hours. Please send CV to slurie@papapc.net

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 comf-massuda@footexperts.

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