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12/26/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: W. David Herbert DPM


 


I have two cousins who many years ago became dentists. Today, there are individuals called "denturists" in some states who can take dental impressions and make dentures without a dental referral. In a couple of states, dental hygienists can practice privately, and in one state can even fill a tooth without a dentist's supervision. In a number of states, a certified nurse anesthetist may practice independently without medical supervision. Also, in some states, a physical therapist does not have to have a doctor's referral to see a patient.


 


Any person rendering a service that can be construed as the practice of medicine will be held to a medical standard of care while so doing. This is true in all of the jurisdictions that I am familiar with. I still say it is more important that a podiatrist be defined as a physician than that he or she be granted an unlimited scope of practice. You do not find orthopedic surgeons delivering babies or ophthalmologists performing bunion surgery, even though it is in their technical scope of practice. They are limited primarily because of liability issues.


 


W. David Herbert, DPM, JD, Billings, MT

Other messages in this thread:


10/16/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Kudos to David Arkin, DPM


From: George Jacobson, DPM


 


With the posting of so many of our colleagues recently passing away, I'd like to congratulate Dr. David Arkin, CCPM Class of 1983, on his retirement. Live long and prosper. When you retire, do it while you have good health, so you can enjoy all that you worked so hard for. Enjoy retirement Dave; you deserve it. 


 


George Jacobson, DPM, Hollywood, FL

09/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B


RE: CMS' Discrimination Against Podiatrists


From: Jeffrey Kass, DPM


 



The Sept. 10th deadline is around the corner. CMS has proposed some devastating reimbursement policies that could cripple some practices. The single code for E&Ms has already been discussed. More devastating is the visit and procedure ruleCMS is proposing to reduce the lower allowed amount by 50% of either the E&M visit or procedure when billed the same day with a -25 modifier.


 


If anyone values their financial future, you must take action! I have provided the link to write a complaint in your own words (Some feel sending repeated templates has less effect.). This is not the time to make assumptions that because you belong to an association, the problem will be taken care of for you. This is the time to take two minutes out of your day to potentially save thousands of dollars from being taken out of your pockets for the hard work you perform. Please spare the moment.


 


Thank you to everyone who participates and tries to make a difference.


 


Jeffrey Kass, DPM, Forest Hills, NY


09/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A


RE: CMS' Discrimination Against Podiatrists


From: Lawrence M. Rubin, DPM


 


The decision of the CMS policy-making gurus to try to save some federal dollars by cutting payment for E & M medical care provided by podiatrists is, to say the least, ill-founded and discriminatory. I believe in healthcare cost-containment measures, but only if they conform to existing rules and regulations. This proposed rule does not do this. For it to conform, Medicare would have to first change its definition of the word "physicians." 


 


APMA is expertly representing us in its efforts to maintain parity with the other professionals designated by Medicare as physicians – MDs, DOs, optometrists, and chiropractors. With this in mind, I believe what CMS is attempting to do with podiatry should be a “Heads Up!” to optometrists and chiropractors. If CMS gets its way with podiatry, I bet optometrists and chiropractors will be next on its attack list. I hope APMA is keeping this in mind and discussing this issue with the optometric and chiropractic national professional organizations. Together, we could be stronger. We could be a united force in trying to convince Medicare to maintain present Medicare parity regulations.  


 


Lawrence M. Rubin, DPM, Las Vegas, NV

09/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Doctors' Pay Cuts Never Mentioned


From: Jeffrey Kass, DPM


 


On Thursday, President Trump announced that he wanted to cancel pay raises for civilian federal employees who were due for a 2.1% increase. He wanted to do this to save money as the federal budget deficit continues to skyrocket. Why should any federal workers get raises at all, while doctors continue to get docked 2 percent while we are still in sequestration (Not to mention the 2 percent to lose if the new E&M proposed guidelines go through)? 


 


Any time news like this hits mainstream media, the medical community has an opportunity to tell America how they have been taking a 2 percent hit for years, yet never is anything mentioned.


 


Jeffrey Kass, DPM, Forest Hills, NY

08/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Lawrence M. Rubin, DPM


 


Name Withheld believes that CPT code 99214 should not be billed by podiatrists. I disagree. Medicare and generally other insurance payers consider podiatrists to be foot and ankle physicians licensed to practice the "medicine" referred to in our Doctor of Podiatric Medicine degree. E/M code appropriateness is based primarily upon the "nature of the presenting problem" and the depth of the history, examination, decision-making, and in some instances, time expended. This applies to all physicians who provide E/M services. Podiatrists are not excluded. 


 


For example, we are frequently faced with having to make complex diagnostic and care management decisions, especially in older, high-risk patients who present with debilitating manifestations of several chronic diseases and their co-morbidities. E/M care for this class of patients could meet the standards necessary to bill higher level codes. I suggest that those who believe that podiatrists should never use codes for providing higher level E/M services review the E/M coding requirements carefully. 


 


Better yet, the APMA and some independent podiatric consultants offer marvelous correct coding seminars and workshops. Their costs are very reasonable, and what you will learn will probably immediately pay for the cost of attending. Just one caution. Higher level codes should not be billed indiscriminately. And when there is an established treatment plan that does not require providing future higher levels of history, examination, decision-making, or time spent in counseling -- they should not be billed. 


 


Lawrence M. Rubin, DPM, Las Vegas, NV

08/24/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Jeffrey Kass, DPM


 


There has been a lot of discussion regarding illegitimate billing on this forum the past couple of weeks. Perhaps, the answer is universal healthcare with one insurance company with salaried positions for all doctors. While, readers may not like this idea, fraudulent billing is completely eliminated, because there is no billing. 


 


This concept not only eliminates fraudulent billing, it eliminates discrimination in payment. The fact doctors in large groups get paid higher rates than solo practitioners for the same service is equally appalling to me (and should violate anti-trust issues). No system is perfect, but at least with salaries paid, no one will be recouping money.


 


Jeffrey Kass, DPM, Forest Hills, NY

08/23/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Name Withheld


 


I commend Joseph Borreggine, DPM for revisiting the WSJ physician compare websiteI think it behooves all of us to visit this site and search your city or geographic area to see what kind of billing is being done out there. It is eye-opening and appalling. In my city, there are some DPMs billing hundreds of new patient level 4 (99204) office visits and getting paid for them! How can that be when all the billing seminars/billing gurus out there say that this level of office visit is not even billable by podiatrists? 


 


Why is Medicare paying for these codes? It is clear Medicare is not enforcing its own rules. I hope some of the billing gurus out there will chime in on this. Other DPMs bill almost all...


 


Editor's note: This extended-length letter can be read here.

08/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Kristin Happel



 


Dr. Hofacker asks if the type of billing he saw on his patient's invoice from another podiatry office is the norm. No, it is not, at least not with podiatrists I bill for in various parts of the country. The Medicare allowed amount for a 11308 in Ohio is $190.97 when performed in an 


office setting. Leaving aside whether or not this was actually performed (I doubt it was, and should have been billed in the 1105X range, if at all), it would appear several things could be at play here to result in this patient having such an outrageous bill. 


 


Without seeing the actual invoice, my guess is one of two things (or both) is going on: 1. The podiatrist she saw is not contracted with her insurance company, and she has no...


 


Editor's note: Ms. Happel's extended-length letter can be read here.


08/20/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Richard M. Hofacker, DPM


 


I am the first to believe that podiatrists (and doctors in general) are completely abused by the insurance companies. Our expenses continue to go up, while our reimbursements continue to go down. Having said that, I recently had a patient come into my office because she felt she was being overcharged by another local podiatry office to the tune of $2,000. 


 


I immediately explained to her that it doesn't really matter what the physician charges, but rather what the physician is actually paid by the insurance company for the services rendered. Her reply was, "no, I was billed $2,185.83 for the part that the insurance did not pay." When I looked at her invoice, I was SHOCKED to see that...


 


Editor's note: Dr. Hofacker's extended-length letter can be read here

08/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: The -25 Modifier With and Without Nail Care


From: Allen Jacobs, DPM


 


Regarding the discussions on the use of the -25 modifier with nail care, or the use of the E/M codes generally, consider the following:


 


1. You decline to utilize the -25 modifier for fear of triggering an audit. In doing so, you deny patients of needed E and M services.


 


2. IF you re-appoint the patient for a separate office visit, you have created unnecessary inconvenience for the patient, having them return for services which could have been provided at the same time. This is particularly troublesome for the elderly or those for whom transportation needs are difficult to arrange.


 


3. You are unfairly depriving yourself of...


 


Editor's note: Dr. Jacobs' extended-length letter can be read here.

08/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Stephen Doms, DPM


 


While I find the APMA e-advocacy admirable because it is quick and easy, I don't think that "canned" identical emails will get much attention from CMS. I, my staff, and my patients have written letters and mailed them to CMS, our two U.S. senators, and our U.S. representatives in Congress. Podiatric advertisers and sponsors should also write, as podiatry's survival means their survival.


 


A paper letter will be opened, handled, and read by someone at CMS. We customize every letter and emphasize different concerns about the proposed changes to the fee schedule. We also write about identical diagnoses that would be treated identically by DPMs, MDs, and DOs. Equal work, but unequal pay in the proposed changes.


 


Mailing address: Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, PO Box 8016, Baltimore, MD  21244-8016.


 


Stephen Doms, DPM, Hopkins, MN

08/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Laurence Dorman, DPM


 


I couldn't agree more with my colleague Paul Kesselman's post. This is a huge slap in the face to the most highly skilled practitioners of the lower extremities in the country. I know that I am preaching to the choir. I remember how we struggled to achieve parity in all aspects of health care when I was a podiatric medical student more than 40 years ago. The efforts of the APMA with John Carson as our chief lobbyist led to great breakthroughs for the profession. We seem to be headed backward again for no logical reasons other than the fact that we have different initials after our names. 


 


There are obviously huge concerns here for those of us who have practiced for many years and are thinking about retirement, as well as younger practitioners just starting in their practices, and podiatric medical students. I encourage everyone to follow up on the E-advocacy site and add your own feelings about this issue. Our profession came about because allopathic medicine never paid much attention to the total care of the lower extremities; that has never changed and the medical community, for the most part, has been very happy with our impact in the treatment of their patients with foot and ankle maladies.


 


Laurence Dorman, DPM, Miami, FL

08/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Paul Kesselman, DPM


 


My esteemed colleagues are right on point. The changes proffered by CMS are nothing but a shakedown to podiatry and if left to come to fruition, we (and every DPM who knows or should know about this) have no one to blame but ourselves. Furthermore, if you think it’s just Medicare, I am afraid you are very wrong. Every payer will do this and I predict it won't matter whether you have an equal pay for equal work provision in your state. 


 


I am also curious how CMS predicts this will only result in a 2% reduction in payments to podiatrists. Can they provide us with the formulas on how they reached this? And why should the DPM (or any physician) who is treating a Charcot foot be paid the same as the physician seeing a patient with a simple...


 


Editor's note: Dr. Kesselman's extended-length letter can be read here.

08/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Jeffrey Kass, DPM


 


I agree with Dr. Siegal's comments regarding seeking equal pay for equal work. I also feel this should not be limited to Medicare and their particular payment system. It is ludicrous that all other payers do not have a standard payment system. Different providers within the same specialties are paid at different rates. This is something the medical community at large should have stopped dead in its tracks when it first started.


 


Jeffrey Kass, DPM, Forest Hills, NY

08/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Allen Jacobs, DPM


 



Dr. Adam Siegel states that “looking at the profession as a whole... a large proportion of our profession applies 99212 in addition to the routine foot care codes in an attempt to suck a few more dollars out of Medicare.”


 


This is an insult for which Dr. Siegel should forthwith render an apology and retraction. Many patients who present to the office of a podiatric practitioner for nail care do so with concurrent illnesses such as PAD or diabetes. The majority of such patients have concurrent potential limb threatening pathology for which evaluation and appropriate intervention may interdict the progression of...


 


Editor's note: Dr. Jacobs' extended-length letter can be read here.


08/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Adam Siegel, DPM


 


Dr. Musella seems to be missing the point. The APMA supports equal pay for equal work. If a podiatric physician sees a complicated patient which requires an in-depth history and physical with complex decision-making, the doctor should be paid an equal sum to that of our allopathic and osteopathic colleagues. I’m not talking about routine care patients; I’m talking about complex, sick individuals who require more time and resources. Some practices have more of this type of patient than others. We should not be limited to these lesser codes only because we have a DPM after our name. Separating us into a different, lower paying bucket, as CMS has done with optometry and physical therapy, sets up for a very scary precedent. 


 


As for the 2% fee drop: this estimate comes from looking at the entire profession as a whole. A large proportion of our profession applies 99212 in addition to the routine foot care codes in an attempt to suck a little more from Medicare. Many in our profession feel that applying a 99212 as opposed to a 99213 will keep us “under the radar” (this is a completely flawed and ludicrous way of thinking). The 2% drop is based off of that average, which I believe is unfairly skewed downward due to our (inappropriate) tendency to add low level EM codes to our routine care codes. I believe if you remove these superfluous 99212 codes billed with routine care, the average EM code billed would be in line with many other specialties. I applaud what the APMA is doing thus far and have full confidence that this situation will be rectified. 


 


Adam Siegel, DPM, Lutz, FL

07/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Source for Extra Large CAM or Bledsoe Boot (David E Gurvis, DPM)


From: Marshall Katz, CO


 


As a certified orthotist, I see many obese patients requiring CAM boots. As a result, I fabricate expansion panels that can be Velcro attached to the existing inner boot. This works great, and can be easily removed. The same is true for the straps. I keep a supply of strap extensions that can be quickly attached and removed.


 


Marshall Katz, CO, Great Neck, NY

07/17/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: MIPS 2019 Payment Adjustment (Alan Bass, DPM)


From: Ron Freireich, DPM


 


Correct me if I’m wrong, but I believe we were required to report on ALL eligible patients (Medicare part B, Medicare Advantage, private insurance, Medicaid, etc.). However, our “bonus” payments in 2019 will be calculated only on the allowed amounts from Medicare part B patients, not even Medicare Advantage patients.  Take that to the bank, or not.


 


Ron Freireich, DPM, Cleveland, OH


 


Dr. Bass wonders if "Exceptional Performers" of MIPS are going to get bonus money. I think it is a travesty that taxpayer dollars would be given to anyone for recording useless information that takes away time and energy from one's occupation, whatever their occupation may be. An exceptional doctor is one who goes above and beyond caring about the well being of their patients. This cumbersome, pointless data entry should be brought to a stop. 


 


Jeffrey Kass, DPM, Forest Hills, NY

06/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


Re: Costco Selling "Custom" Insoles 


From: Robert Scott Steinberg, DPM


 


I posted this on Costco's Facebook page. If you feel the same, please post on your Facebook page and on Costco's page:


 


I was in Costco on Saturday, June 16, 2018, and realized they could save tons of money by getting rid of pharmacists and optometrists! Anyone can read a prescription, count pills, and make people better, right? Digital devices can scan the eye and come pretty close to correcting vision and improving eyesight, right? Of course, they are not going to do that, but they do invite into their stores, people with no licences to advise people that they can make their feet feel better by standing on a mat and have the bottom of the feet mapped. Then produce devices that may cause injury to the foot, ankle, knee, and low back.


 


So, what if it has a 90-day guarantee?  The damage from devices like these might not show up for months. If you want to try something quick and easy, and inexpensive for foot pain, pick up a pair of rather stiff insoles at a sporting goods store. If they don't work, you're only out $35-$40 bucks, not the $130 Costco charges for their ridiculous insoles. If you have foot or ankle pain, you deserve to be seen by a licensed expert, a doctor of podiatric medicine and surgery.


 


Robert Scott Steinberg, DPM, Schaumburg, IL

06/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Jeffrey Kass, DPM 


 


Dr. Williams has pointed out there is an alternative to ABFAS. He mentions ABLES. However, unfortunately, ABLES is not according to state law, in some states, going to help you practice above the ankle. For example, here in New York, the law specifically singles out that  one needs to be Board Certified by ABFAS in order to be granted this privilege. One of the largest hospital networks in New York has also recently made ABFAS certification your ticket to OR privileges. 


 


Jeffrey Kass, DPM, Forest Hills, NY

06/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Benjamin J. Wallner


 


I would like to address a few misconceptions that have appeared in the discussion of the VA MISSION Act over the past few days. Dr. Lombardi’s conclusion that only ABFAS-certified podiatric surgeons will receive an increase in pay as a result of the passage of the VA MISSION Act is fundamentally incorrect. Board certification is just one of many factors in determining market pay at the Veterans Health Administration. The section of the handbook that he has quoted refers to how the VA determines whether a physician or surgeon is board certified—not how the physician or surgeon is paid. 


 


The bureaucratic machine that is the VA looks at myriad sources to determine pay, including Sullivan and Cotter, MGMA, Bureau of Labor Statistics, among a whole host of other sources. The podiatry section at the VA now faces the formidable task of implementing this legislation and...


 


Editor's note: Mr. Wallner's extended-length letter can be read here.

06/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Robert Scott Steinberg, DPM


 


Dr. Feldman, I find your post arrogant, smug, and condescending. I suggest you think about those who came before you. There is no reason board costs are so high. Let the boards charge more for re-certification, instead of extracting the "last ounce of blood" from the young DPMs. You owe your colleagues an apology.


 


Robert Scott Steinberg, DPM, Schaumburg, IL 

06/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Richard J. Manolian, DPM


 


Welcome to the opioid epidemic. You quickly will get used to the online Rx history requirement as we have had in Massachusetts for a few years, and it will be enlightening as to what your patients are up to. 


 


I had some patients that we pull up where they’ve had 50 to 100 Percocet or Vicodin just prescribed only a few days before surgery that we are about to perform. I simply tell them you will not be getting a controlled substance prescription following this procedure based on that, and they understand fully.


 


Richard J. Manolian, DPM, Cambridge, MA

06/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Ivar E. Roth DPM, MPH


 


I recently interviewed associates with three years of residency training. The spectrum of graduates training was from excellent to below average. One may ask how a graduate of three years of surgical training could be average or below average. The answer is that many programs just do not have the surgical load or variety that is necessary to come out as a fully trained “surgeon”. Many whom I interviewed felt they needed an additional year as a fellow to feel confident. Sadly, three years of training may NOT adequately prepare graduates for practice and or sitting for the boards. From what I saw from the current crop of residents is  that many were under-trained and not ready to become full scope podiatric “surgeons”.


 


Ivar E. Roth DPM, MPH, Newport Beach, CA

06/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2a



From: Len La Russa, DPM


 


We, as podiatrists, are all worried about the dwindling number of pre-med applicants applying to podiatry school. Could part of the problem have anything at all to do with the 50% passing rate for ABPS certification? Orthopods don't have that problem. Or is it possibly the chance that there might not be a position available for residency? The low passing rate is much easier to fix than the residency crisis, which is less of a crisis now. Another impediment to getting talent to apply to podiatry school could easily be addressed by increasing the pass rate so that it is no longer such an embarrassment. 


 


Len La Russa, DPM, Americus, GA
GSource