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11/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: ABPS Maintenance of Certification Lifetime


From: Michael McCormick, DPM


 


$900 to take a self-assessment exam. What a joke! It’s absolutely ridiculous to waste any of our remaining days on this Earth going to an ultra-secure testing facility, by appointment, with multiple forms of identification, to take a self-assessment test, which no-one but no-one cares if you pass or fail, will likely never be evaluated by anyone, just to be able to state "Board Certified” on your letterhead and keep your hospital privileges.


 


I get it if passing or failing is important and the data is needed for educational purposes, but for a self-assessment? How about we join the 21st century and do it online for free? We already pay enough for annual dues. Just my two bits. I'm happy this is my last time having to perform this stupid exercise.


 


Michael McCormick, DPM, Venice, FL

Other messages in this thread:


11/17/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: James Koon, DPM


 


I can easily suggest the SIUI CTS-550 from Fisher Biomedical. Great unit. Great price. Great company. Buy a used Sony printer off Ebay and you will be good to go. 


 


James Koon, DPM, Winter Haven, FL

11/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Marcaine/Bupivacaine Strategies  


From:  Robert D. Teitelbaum, DPM


 


We are all having difficulty getting these drugs in our offices. A rep at Moore Medical stated in a decisive way that Marcaine will not be available until nearly 2020. Henry Schein currently does not have it either, but they are selling a package of ten 1ml ampules of epinephrine, 1:1000, for $138. That's about $7 per half an ampule, which is all you need to add to a 0.25% bupivacaine multi-dose 50ml bottle. It turns out to be 10 micrograms of epinephrine per ml of bupivacaine. 


 


Where can you get that? Clint Pharmaceuticals. They sell a rack of 25, 50ml bottles for a good price with a limit of one rack per doctor. Now, I'd rather use 0.5% bupivacaine, so I am using 0.25% which is something new. I will listen closely for patient feedback on duration and effectiveness. But I also have personal experience with dermatologists who think nothing of using 1% lidocaine--and it works just fine--so that tempers my anxiety about the lesser strength.


 


Robert D. Teitelbaum, DPM,  Naples, FL

11/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Ed Davis, DPM


 


The lack of studies on this subject may be due, in part, to it being classified as a “rare” disease.  I am not sure if it is really that rare. Diagnosis codes may be used to track disease entities and there is no unique code for Ledderhose disease.


 


I have been using serial ultrasound-guided injections of hyaluronidase mixed with triamcinolone acetonide for about 20 years with very good results. I would be happy to share my protocol with any interested podiatrist.


 


Ed Davis, DPM, San Antonio, TX 

11/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Dealing with Pay Reductions for Multiple Procedures


From: Allen Jacobs, DPM


 


There is actually a CMS rule that addresses performing procedures on multiple days to increase reimbursement. It is in Chapter I (Page 8) General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. “Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits”. 


 


Even though this is CMS/Medicare policy, many insurance companies utilize these guidelines.  


 


Allen Jacobs, DPM, St. Louis, MO

11/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Allen Jacobs, DPM


 


Injectable collagenase may be helpful for plantar fibromatosis, although neither robust nor long-term studies are available for reference. My personal approach is as follows:


 


1. Confirm the diagnosis with MRI, ultrasound, or percutaneous needle biopsy prior to treatment;


2. Daily BID application of a compounded mixture of 5% lidocaine, 5% diclofenac, and 15% verapamil (EBM);


3. Stretching of the plantar fascia (night splint and/or active stretch);


4. Avoidance of hard insoles or rigid orthotics. 


 


My experience (for many years) with the utilization of this technique for non-aggressive type fibromatosis has been nothing short of excellent.


 


Allen Jacobs, DPM, St. Louis, MO

11/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Ira Baum, DPM


 


I’m taking an opposing position than most of the previous posts. I think there is a place for altruism, but I believe podiatrists must be pragmatic. I don’t think that the decision to perform multiple procedures in one session based on one variable is appropriate. Podiatrists and healthcare providers dependent on third-party payors have been financially battered with no real potential recourse. So, if patients depend on a third-party paying for their care, then by implication, they should also expect the care their payors are willing to pay.


 


Podiatrists have overhead responsibilities. If those obligations can’t be met, then I don’t see how this benefits anyone. I am not a proponent of putting patients at increased risk, but I am also sensitive to the financial predicament put on our providers.  


 


Ira Baum, DPM, Naples, FL

11/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Hal Ornstein, DPM, Tip Sullivan, DPM


 


I agree with Dr. Jacobs to always tell the patient the truth when it comes to performing all services. In teaching practice management most of my career, I have always professed what we call “The Mother Test”, doing what one would simply do if the patient were their mother. What many successful practices have in common is that they are always driven by what is best for the patient. Our podiatric oath should be out guiding light to do what is best and safest for the patient and not driven by what one gets paid. Whether one believes in this or not, our actions come full circle and karma can be quite rewarding.


 


Hal Ornstein, DPM, Howell, NJ 


 


I agree with Dr. Jacobs. The truth will set you free, but if you are not doing multiple procedures (if they are needed) just because you don't want your payment diminished, then your heart is not in the right place. To make a patient go through multiple surgeries and the associated surgical risks of each surgical intervention is wrong. Your financial gain does not come before the patient’s well-being. I can remember when I would see patients who would tell me that their previous hammertoe surgery was done one toe at a time at different times. I am certainly not against staging procedures when the decision is based on the patient’s welfare and not financial compensation of the physician.


 


Tip Sullivan, DPM, Jackson, MS

11/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 3



From: Jeffrey Kass, DPM


 


I echo the sentiments of Drs. Fellner and McCormick. I also had issues with my computer malfunctioning during my exam. An error message popped open telling me the computer disconnected. This occurred with little time left and my diagnosis sitting in the queue. I called the proctor over, informing him of my concern that my answer be recorded. The proctor decided to take control of my mouse and burnt my time out.


 


When contacting the Board, I was told my answer was...


 


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

11/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Ira Baum, DPM


 


I cannot speak to the use of collegenase, but I will share a technique that I used with a high degree of success. First, let me define success. Resolving a plantar fibroma via any injection technique is rare. However, reducing the size of the fibroma to resolve symptoms is what I  consider success. Having said that, the needling technique is as follows: Block anesthetize around the target lesion. Once anesthetized, with great care, using a 20 g needle, needle the lesion multiple times until it is palpably soft and reduced in size and depth. Finally, inject the lesion with an acetate type of steroid. Then place a mild, almost a venous heart-like compression dressing.


 


Inform patients that they may have discomfort and black and blue around the area for several days. I also suggest a very soft insole and a follow-up visit in 7 days. It may take several weeks to see the final result. Take great care (inform the patient of the risks) when needling the depth of the lesion to prevent injury to the medial proper digital nerve and a potential future rupture of the medial band of the PF.  


 


Ira Baum, DPM, Naples, FL

11/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Allen Jacobs, DPM


 


It is not appropriate to willfully misrepresent facts to a patient. Tell the patient the truth. You are paid less for multiple procedures performed concurrently. You are not willing to accept the reduced payments. The patient should be made to understand that you utilize the same degree of care, time, cost, and expertise for each procedure. 


 


If you are found negligent in the performance of a second or third procedure, I do not believe the jury award or settlement by the carrier is reduced 25 or 50 or 75 percent. Just tell the patient the truth. Misrepresentation is always unethical regardless of any well-intentioned reasons for doing so.


 


Allen Jacobs, DPM, St. Louis, MO

11/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Dieter Fellner, DPM


 


I empathize deeply with Dr. McCormick and his frustrations. The problem is, however, much more pervasive. Primary certification, with this exam is frankly absurd. I have over 30 years’ experience. I know my 'stuff' and I keep up-to-date. In 2016, I sat for their exams, as required. The system is flawed. I want to challenge those sitting comfortably on their lifetime certificate to submit to the same process (without cheating). 


 


Let me be quite plain: the computer simulation is ridiculous. The marking of answers is inherently biased against the examinee. The hapless test taker is required to search frantically for those elusive buzz words that resonate with the marking. Doctors: that has nothing to do with clinical and surgical competency. The computer systems also tend to malfunction. 


 


I have practiced surgery for decades. I have never been sued. I know of exam-taking superstars who get sued repeatedly. So, what exactly does the Board Certification provide? It is not clearly a yardstick for surgical competence. In England, where I first practiced, we have a system of periodic peer review. Assigned podiatric surgeons will visit the facility every two years for an on-site evaluation of surgical practice. This is a supportive function, as much as it is an audit. After 4 years of school and 3 years of residency and endless exams, when will America have confidence to allow their doctors to be doctors? 


 


Dieter Fellner, DPM, NY, NY

11/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Cynthia S. Ferrelli, DPM


 


I really don’t see how we can afford to do multiple procedures and still stay in business. I only do one procedure at a time. For instance, when performing a matrixectomy, I tell the patient that we need to see how the area heals, how they react to the anesthesia and phenol, how they heal before I will perform this on another toe. Most patients accept that without issue. If they don’t come back for the other toe, I don’t feel like I have lost out, because another patient needing the procedure is right behind them. We don't not get paid enough as it is for procedures; therefore, I am not willing to accept 50% for an additional procedure.


 


Cynthia S. Ferrelli, DPM, Buffalo, NY

11/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Vincent Marino, DPM


 


I have been treating Workers Compensation patients as well as performing medical legal evaluations on them for the past 25 years in California. However, the federal government Workers Compensation laws (for which a postal worker falls under) are quite different than any of the state laws. What you need to determine is whether or not the occupation of this postal worker acts as an aggravating factor rather than as an exacerbating factor.


 


In other words, does the employment simply temporarily increase the symptoms or does the employment increase the symptoms requiring further treatments and accommodations? If it is the latter, then it is considered an industrial injury. In your case, most likely your patient will have a legitimate industrial injury since weight-bearing is such a large part of their job requirements - regardless of weight, pronation, equinus, etc. Even for these to be the CAUSES, the person needs to be weight-bearing. I hope this helps explain the issues.


 


Vincent Marino, DPM, San Francisco, CA

11/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Dealing with Pay Reductions for Multiple Procedures


From: Tom Silver, DPM


 


When we do more than one procedure on a date of service, we typically get a 50% reduction on the allowed insurance amount on the second procedure and about 75% reduction if a third procedure is also performed on the same time. For example, we recently did a wart excision and ingrown nail excision on a patient at the same visit and received only $121 for the ingrown procedure. I did bilateral bunions at the surgery center and was allowed $550 for the first bunion and $275 for the second! It's frightening to see how little we get paid on the 2nd or 3rd hammertoes when more than one toe is done on the same date of service!


 


As a result, my billing/collection staff keep requesting that I don't do more than one procedure at a time on our patients whenever possible. If a patient has two or more of anything, such as two ingrown toenails or hammertoes, they want me to do only one toe or procedure at a time and have them back for the additional procedure(s) so that we can get 100% of the allowed amount for each procedure.  


 


I do not want to have to practice this way - one toe at a time, but we are losing a lot of money otherwise. How are others dealing with this dilemma? Are you just doing everything that patients need on a date of service and not worrying about (and accepting) how little you get reimbursed on the multiple procedures?


 


Tom Silver, DPM, Golden Valley, MN

11/02/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Elliot Udell, DPM


 


I feel Dr. Borreggine's frustration and anger when a patient walks out of the door and never pays his or her bill and, in some cases, has no intention of ever paying it. We had one patient who not only told me that the check would be in the mail, but he took a whole bunch of foot creams and never paid for them either. I physically and emotionally write off these cases by saying to myself that I took an oath to be a healer and that money is secondary.


 


What got me really angry was when that patient who never paid for the visit nor the foot creams popped up in my office a month later demanding that I give him a copy of the x-rays so that he can go to another doctor. Legally, I had to give him his records and x-rays. I suspect he probably travels from doctor to doctor doing the same thing.


 


Elliot Udell, DPM, Hicksville, NY

11/02/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Charles Morelli, DPM


 



With total respect for Dr. Borreggine, I am surprised that question is still being debated. With the exception of those who only take cash and do not contract with any insurers, the business of medicine and the times have certainly changed from what we all were accustomed to. They changed years ago.


 


Many will give examples of going to the store and asking to only pay 80% for their groceries, while others will comment on shopping at the mall and asking the lady (sorry "person") at checkout if they can pay when they come back to shop again in 2-3 months or they will suggest...


 


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


11/01/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Edmond F. Mertzenich, DPM


 


Over the years, I have tried to find what the median salary for a podiatrist is. I too found large discrepancies. Looking at statistical information requires careful consideration about where the numbers are coming from. One must be careful of all sources. For me, the most likely trustworthy source is from Bureau of Labor Statistics Occupational Outlook Handbook (read up about podiatrists and other medical professionals). This book gives all sorts of information about a wide range of fields.


 


Also, remember median is a statistic that indicates that ½ of a group of people earn above or below the median. So, there are people who earn way more, and there are some who earn way less. So, if an associate desires a salary increase, look for what they are bringing in financially, what personal value they bring to the practice, and make the judgment if that person will be increasing the value of the practice. Median salary is only a starting point.


 


Edmond F. Mertzenich, DPM, Rockford, IL

11/01/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Collecting Fees Upfront


From: Joseph Borreggine, DPM


 


This is a worsening quandary day by day in my office: collecting fees upfront from the patient when services are rendered. The old adage says, “It is easier to collect money from the front door than it is from the back door.” But, with ever increasing deductibles into the $5-10K range, many of the medical services and minor surgical in-office services are not usually covered by an insurance carrier until the deductible is met. 


 


In this day and age, you would think the patient would be more educated about their benefits, but alas, they are not. They are ignorant in thinking that the “co-pay” is their only responsibility and the rest will be...


 


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

10/31/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Danae L. Lowell, DPM


 


It’s important to note that data quoted from salary.com and the annual PM survey are anecdotal and do not in any way accurately reflect current salary ranges. If we are going to have an educated discussion on current salaries, data from MGMA and Sullivan Cotter should be utilized. This is officially validated data that provides accurate salary ranges in quartiles and most importantly delineates between surgical and non-surgical practices. It also goes beyond solo practitioners and includes hospital appointments, group practices, and VA salaries. 


 


Quoting an annual median income for solo practitioner of $123,250 does nothing to promote the practice of podiatry. Indeed, it negatively represents the field. The true scope of practice possibilities and financial prosperity available to today’s podiatrist far exceed the solo practitioner making $123,250. Podiatrists completing a 3-year PMSR, PMSR/RRA residency and advanced fellowship programs have training worthy of much higher salaries and they are getting them.  


 


Regarding the relatively new associate, the $192,738 is within the range of validated data depending on quartile and scope of practice. Pay him what he is worth according to validated data and performance.


 


Danae L. Lowell, DPM, Cleveland, OH

10/31/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: PICA, Name Withheld


 


Providers may or may not charge for copies and supplies necessary to copy depending upon the stipulations in the contract with payors. PICA recommends that you check your contract with the payor to determine if you can charge for charts being requested for audits.


 


PICA


 


I have gotten requests from Ciox a few times. On one occasion, I sent them an invoice of $25/chart for around ten charts. They did send a check. More recently, they requested four charts. I again sent an invoice but have not heard back from them. This was a few months ago. Still waiting. Did not send charts. I don’t want to give erroneous information but I believe a practitioner is entitled to get paid for this before sending chart requests. 


 


Name Withheld 

10/30/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Ty Hussain, DPM


 


Though the topic is revolving around median income for podiatrists, the question has tangentially moved about paying associates. I have been in practice a while now and have seen both sides of income for associates. Unfortunately, income is based on the area of practice. Larger cities with more competition are invariably different (lower) than areas of much needed practitioners.


 


You have already “incentivized” this individual with a percentage of “bonus” on top of a “no questions asked” salary. Doing research and perusing numbers and stating what one desires is best left with an answer of “start your own shop and experience what the rigors entail with all you have stated as hard work.” 


 


Ty Hussain, DPM, Chicago, IL

10/29/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Adam Siegel, DPM


 


As someone who was once a salaried employee of a medium-sized group and now the owner of a podiatry practice, I can answer this question as I have experience from both perspectives. It probably is time to pay this individual a percentage of gross collections. I do not know your expenses so I cannot speak on what percentage to offer him, but this will certainly incentivize him to work harder and potentially make way more money than the current arrangement. You also will benefit greatly from this arrangement. You will be shocked at how punctual he will be when his time is money.


 


Adam Siegel, DPM, Lutz, FL 

10/25/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Brian Kiel, DPM


 


We use Dragon Medical and it does an excellent job of accuracy at normal to fast talking. It also learns new words. For accuracy's sake, I read on the screen as I type and I am able to pick up any discrepancies . 


 


Brian Kiel, DPM, Memphis, TN

10/25/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Charles Morelli, DPM


 




I have been using this program for close to 20 years now. I'm actually writing this message while using Dragon voice dictation. I am not going to reread this, or by going to correct mistakes. Voice dictation has made during my nodes remarkably simple although I've had to correct mistakes on occasion especially when trying to dictate patient's names and using other medical terms that are far into the per gram. You are able to recognize that word so that the mistakes I made the future. What I've chosen to do is just not voiced dictate names but typed in manually. Has been a great asset to my practice, writing notes and doing anything that one would normally have to type


 


Here's what I just learned about the new version of Dragon I just...



 


Editor's notes: Dr. Morelli's extended-length letter can be read here. This note has NOT been edited and has been written exclusively with Dragon Voice dictation. 


10/23/2018    

RESPONSES/COMMENTS (NON-CLINICAL) \


RE: Kudos to Safestep


From: Michael Schneider, DPM


 


SafeStep, though my contact, Christine DiLiello has continued to send 1-4 cases of shoes a month to the needy at the Denver Rescue Mission and Little Sisters of the Poor. Their commitment is truly incredible! Thank you again. You have helped hundreds of unfortunate folks!


 


Michael Schneider, DPM. Denver, CO
ProNich Kneeler