RE: ESWT As “Investigational” (Arden Smith, DPM) From: Multiple Respondents
Regarding ESWT, FDA approval only indicates a procedure is safe to do what it claims. It does not deem a piece of equipment effective enough to warrant coverage. Insurance companies now require that techniques not only be effective but that they be either equal or less costly that comparable treatments. Insurance companies have determined that ESWT will be vastly more expensive than other comparable treatments.
APMA, during my tenure on the board, met with people from Dornier and Ossatron and urged them to do the double blind studies necessary for coverage. Now, about five years later, studies are being produced, but the decisions made by companies will be very hard to change.
I perform insurance peer reviews for multiple insurance companies across the US and ESWT therapy is usually denied for the various reasons previously stated in earlier posts. I agree that the main reason driving the denials is monetary. I think that when we started using ESWT we overcharged tremendously. It is still not unusual in San Diego for podiatrists to charge $3,000 procedure fee, plus $6,000 (usually billed by the equipment provider) for use of the machine. In addition, there often are outpatient surgery center charges. I have seen many bills of $12,000 for total expenses for these procedures.
This isn’t the first time that opportunistic behaviors by the early users of a new modality have tainted its long-term acceptance. I believe ESWT would have been generally accepted by the insurers if we had originally charged the same for ESWT as we did for open or laparoscopic plantar fascial procedures, and the companies providing the equipment had considered much reduced charges for use of the equipment. It is conceivable that ESWT may be accepted in the future, but it will be at rates matching (or less than) other procedures used for surgical treatment the same conditions. There’s a lesson here.
The FDA has one job with regard to medical devices: Quote from their mission statement. "there is reasonable assurance of the safety and effectiveness of devices intended for human use" They do not guarantee payment.
If you believe ESWT works so well then charge cash for the procedure. When the patient returns, thrilled with the outcome, they will spread the word. Then we will see the real success numbers. No strings attached.
I just treated four feet this week with ESWT and i think it is a great non-invasive modality. My patients pay cash and we do it in the office. There are some new studies out that justify it usage. I believe that the insurance companies just do not want to pay for it knowing that all of us have hundreds, if not thousands of patients who would benefit from the procedure if it was approved. It was like that in Michigan for the short period when the Blues paid for the procedure. Now it is almost impossible to get a company to bring a machine into our state.
It is not ESWT that insurance companies are after, it is podiatric medicine. Insurance companies almost never cover items considered "experimental" or "investigational" by the FDA. Movies and TV shows have been done about this. So, we do have to wonder what actual standard of care insurance companies are applying FDA-approved modalities like high energy ESWT? I had one medical director cite literature saying ESWT did not work, but when questioned further, he said it was a study, or report, on low-energy treatments. Are we responsible for the blurring of lines as to the difference between high-energy ESWT and low-energy ESWT. Are the insurance companies deliberately using the "blur" to deny coverage of high-energy ESWT ?
Of course, then there is the rapidly decreasing coverage of prescription function foot orthotics, another podiatry mainstay. I am sure you have all received letters from CIGNA stating that this is "experimental" and or "investigational" lacking large population studies. What is "large"? Which groups (quasi professional, and or retail) benefit by these blanket denials? Are we being singled out as a profession?
I had the pleasure to have been a resident trained by Dr. Canter. He was a true professional who represented the podiatric profession well. He was a high energy individual who always focused on high quality patient care and resident education and training. Rest in peace my friend.
Stephen Musser, DPM, Cleveland, OH
RESPONSES / COMMENTS (OBITUARIES)
RE: The Passing of Janusz Swark, DPM
Janusz was a true gentleman and a loyal friend. He was loved by all and will always be remembered. Rest well my friend. Mary Ellen, we are a phone call away.
I have used Cetylcide-II for more than 20 years without staining. Two things to always do: 1) use distilled or de-ionized water and 2) use “Anti-Rust Powder” that is manufactured by Gordon Laboratories (one oz to one gallon of solution).
The policy that we instituted requiring a credit card for first time patients has worked extremely well. Our front desk can figure out when an elderly patient says they do not have a credit card and they act accordingly. This policy is for the tire kickers or potential new patients who abuse the system. We used to get a few that would give us a false credit card number. Now that we actually charge the card beforehand, we know if the card is good or not. These tire kickers know we are on to them and hang up or do not make an appointment, which is good.
Our no-show rate with our new policy for new appointments is about zero now. As far as us being on time, we are. We run a tight ship.
One caveat, I run a concierge practice where we do not take any insurance.
Many doctors and dentists penalize patients for missing appointments irrespective of whether it is the first or a subsequent visit. One rheumatologist in my area is even bolder. If a patient misses a single visit, he sends them a letter letting him or her know that he or she is persona non grata in his practice and should find another rheumatologist. I know he does this because two patients recently were upset at me for referring them to this doctor. Because of his behavior, I am now reluctant to refer any more patients to him.
Several years go, I missed a dental appointment and his office manager called me and told me they are charging me a hundred dollars. I let the dentist know that I would pay him what he asks, but would no longer use his services. He retracted the fee and since that time he has done a number of crowns for me as well as other dental work. Had he gotten the hundred dollars out of me, he would have lost thousands.
The bottom line is that if you are prepared to penalize a patient for missing a visit, you should also be prepared to suffer the consequences of angering a patient. In my practice, when this happens, I bury my ego, give up being right, and continue rendering podiatric care to my patients.
With sorrow, I learned of the passing of my friend and classmate Sheldon Weintraub. Several weeks ago, I was having dinner in Delray Beach, Florida when I heard a voice that was so familiar. I turned and sitting at the next table was Leonard Labush, a classmate from Temple University School of Chiropody, 1959. We talked through dinner, reliving old memories.
When I got home, I decided to call Sheldon, for we had not talked for several years. My call went to voice mail and was not returned. I completely forgot about the call, when on March 7th, my phone rang with an unfamiliar area code and number. This would normally go to voice mail but for some unknown reason, I chose to answer. It was Marge Weintraub who filled me in on what was happening and asked if I would call Sheldon around 2PM. I called and spent close to an hour catching up on family , friends, and old times. Just before the call ended, I promised to call again in a month. This call is on my calendar for Tuesday April 11. Needless to say, it is a call I wanted to make but will never have the opportunity to do. My deepest condolences to Marge and family. They have lost a truly unique man.
Find each price list by typing in your search engine "Walmart $4 list", "Publix free prescriptions", "Target $4 generic drug plan", etc. There is a link to their PDF file and/or website. I created a file on my computer and store the PDFs there. The pricing for most of the OTC and common drugs that I recommend is just in my head. The OTC price may very in your area. When you are shopping in any store with a "foot products aisle", just take a gander at what could benefit your patients as well as what you would not recommend. This will also give you an idea of what patients may have tried before ever seeing you.
I have counted more that 20 different shoe inserts in many drugstores. Some are just inserts; others are arches. Some may be comparable to what you dispense from your office. I hope not. Three tubes of Biofreeze are $23.77 on Amazon, so I don't sell it in the office anymore. A search of Amazon even yields 40% urea cream for less than $14; walking cast boots and post-op shoes all sell for less. So, if you dispense products, it may behoove you to know costs elsewhere, especially on Amazon. Amazon Prime can be helpful to your practice. I needed a closed post-op shoe for a postal worker and got it in two days with Amazon Prime.
George Jacobson, DPM, Hollywood, FL
RESPONSES / COMMENTS (PUBLISHED ARTICLES)
RE: Longitudinal Arch Load-Sharing System of the Foot
From: Kevin A. Kirby, DPM
I recently had a paper published online titled “Longitudinal Arch Load-Sharing System of the Foot” in the Spanish Podiatry Journal, Revista Española de Podología, a journal which most podiatrists in the U.S. are probably not aware of. This journal, edited by Javier Pascual Huerta, PhD, publishes all articles in both Spanish and English and has been in existence now since 2015. Previous authors such as Craig Payne and Alan Banks, along with a number of Spanish authors have also contributed papers to this new and upcoming international podiatric journal.
Those who want to read my paper on “Longitudinal Arch Load-Sharing System of the Foot” can access it by clicking here.:
Kevin A. Kirby, DPM, Sacramento, CA
RESPONSES / COMMENTS (OBITUARIES)
The Passing of Sheldon Weintraub, DPM
Dr. Sheldon Weintraub
Dr. Weintraub was a fine and decent human being. You can read his obituary by clicking here.
Arthur E. Helfand, DPM
RESPONSES / COMMENTS (YOU CAN'T MAKE THESE THINGS UP)
RE: Nothing Can Keep "California Girls" Off the Beach (Keith Gurnick, DPM)
From: Martin V. Sloan, DPM
Whether following strapping, casting, or surgery on the extremity, Castguard works fantastically in keeping the extremity dry. It's available at CVS Pharmacy and other outlets. No more walking down the hall with a Baggie full of water after a shower.
These articles are sickening. Most responses focus on two issues: 1. Fraud and 2. Aggressive (or overly aggressive) post-payment audits. Fraud hurts every podiatrists and is fuels the fire for overly aggressive post-payment audits. No one can condone that. Overly aggressive post-payment audits negatively affect the doctor-patient relationship, increase physician psyche on practicing defensive medicine, and cause a reaction from third-party payers (not only the federal government). The response adversely affects the provision of healthcare, and potentially dangerous outcomes for patients. Regulations can be made that are impossible or impractical to follow. The enforcing, or not enforcing these types of regulations is a method of control and intimidation.
Drilling down the issue to services in nursing homes or geriatric patients, Medicare guidelines are antiquated, unjust, and need revision. It's simply unfair for those podiatrists who provide these needed service, and for the patients who need the care, but don't meet the regulatory requirements. Contact your legislative representatives and explain why these services are needed and why the regulations need to be more humane. Unfortunately, it is the only process that may lead to a resolution.
From: Paul Kesselman, DPM, Richard A. Simmons, DPM
Aside from DME audits, reviewing claims for total or partial nail avulsions really is a slam dunk for carriers. Dr. Rosenblatt is very much on target when he suggests that DPMs benefit insurance carrier auditors by not documenting proper procedure(s) when it comes to nail removals (CPT 11730).
The following documentation should be placed in the patient's chart:
1) A consent form - If the patient cannot sign this for whatever reason, that information should be placed in the chart;
2) Notation of the name and dose of injectable anesthetic (unless you document neuropathy);
3) Removal of a substantial portion of the nail (total border from distal to proximal, or the entire nail)
4) Written post-op instructions should be provided and signed by the patient (give your office patients a copy) or write these orders in the NH or hospital chart.
5) The use of digital photography, while not mandatory by most MCR LCDs and private insurance carriers, is highly recommended.
For some MCR carriers it is mandatory for lessor toenails 2-5.
In the excellent letter written by Dr. Rosenblatt concerning the billing for CPT 11730 part of the procedure that he stated was necessary for correct billing required that the surgeon to “Remove a section of nail that includes eponychium.”
In Florida, our LCD 29318 does not require removing any of the eponychium, but it does require “the entire length of the nail border to and under the eponychium." This is not a procedure that I perform with any great frequency (probably less than once every sixty days); however, I have never done this procedure where it involved such extensive removal of the matrix region as would be required with excision of the eponychium. Is the excision of the eponychium a new requirement by CMS?
This case is thought-provoking and certainly challenging. In the photo, hypertrophic scarring exist at the previous surgical sites. Additionally, the left foot appears to have a giant cell tumor in the plantar aspect of the 3rd toe. Providing an x-ray would be helpful in accessing whether the proximal phalanx head is plantar-flexed or if this is scarring/giant cell.
Treatment will require very fastidious attention to detail, paying homage to hurdles set by previous surgeries. My recommendation would be to perform a through and through minimally invasive osteotomy of the proximal phalanx to allow the toe to slightly float dorsally. Preceding the osteotomy, reduce the phalanx head/fusion site by percutaneous ostectomy. Then redo your flap and cross your fingers.
Perform lesion-marked x-rays. Use a little tip of a paper clip and tape it over the lesion. It is likely these are transfer lesions from adjacent toes or metatarsals. Compare your clinical presentation to the radiographs before planning your surgery. This is especially the case in flatfoot conditions or reafoot to forefoot relationship is unequal in what appears to be a normal longitudinal arch. Remember, if underlying pathology is more cartilage, it not as obvious on your x-Rays. However, use your index of suspicion and fine analysis. Do not waste your patient's time with pads and things.
What is disconcerting about this case history is that it appears that after futile attempts at debridement of the lesions, deep skin followed by tendon and osseous surgical procedures were chosen. Why wasn't a biomechanical exam performed along with an attempt at the judicious use of orthotics? The lesions are symmetrical and on weight-bearing surfaces and if abnormal biomechanics turns out to the culprit, short of amputation, no surgery will alleviate this patient's problems.
Again, we have seen a recent publication of a podiatrist who will serve prison time due to a fraud conviction. His life and family are devastated. Healthcare auditors and prosecutors now regard podiatrists as one of their most accessible and easy sources for personal career advancement. All they have to do is generate computer printouts on repetitive Medicare claims for ingrown nail surgeries, especially in nursing homes. They concentrate on those who have the greatest numbers.
Then, they ask for your chart notes. Sometimes they just go right to the NHs and start interviewing patients. Incredibly, their....
Editor's Note: Dr. Rosenblatt's extended-length letter can be read here.
I have seen about 10 of these lesions in the last 35 years. They are usually on the second toe and many times bilateral. I have had great success doing an MIS partial plantar proximal phalangeal head resections, and occasionally an MIS proximal phalangeal head resection. As far as I know, everyone of these surgeries has been successful in getting rid of these lesions.
Once again, the 9/11 PM News contains a pointed reminder of the evil lurking in our world that so horribly expressed itself that fateful day. The words of the editor, as he attempted to process the events as was witnessed in real-time, are prolific and remain a reminder of the horrors of that day. They need never be forgotten, both for the human losses and some of our very innocence, as well as that the same evil continues to exist in our world today.
But as bad as those events surely were, in the same edition a wonderful story of good a loving concern for others, appears as well. The success of the Musella Foundation, begun by our colleague Al Musella, hitting ONE MILLION DOLLARS, given to help others, is staggering in a wonderful, heart-warming way. This is a true example of good which, thank God, also continues to exist today. And it is in every one of us, giving the opportunity to make real, positive differences. Thanks, Dr. Musella, for being such a wonderful example and an inspiration.
The concern is recurring hyperkeratotic lesions. The pathology report on biopsy stated: “Clavi x2.” I recommend another biopsy (2-3 mm punch) and send the specimens to a dermatopathologist for a more comprehensive report. My office utilizes the services of Bako Pathology.
Disclosure: I have no financial interest or relationship to Bako Pathology.
These keratotic lesions look like foreign body reaction to warts. The skin appears to be moist and there appears to be a small raised lesion proximal to the main lesion on the left foot. A biopsy may prove the culprit. I have seen similar lesions. Shaving the callus may disclose deeper mosaic lesions.
I find the objective findings to be a bit puzzling. If intrinsic muscle i.e., the FDB, plantarflexed the head of the proximal phalanx, the distal portion of the toe would either be through the ground or dorsally subluxed. In the picture shown, the toe looks like an average hammertoe, other than the lesion. There does not appear to be any dorsal dislocation of the distal end of the toe. How exactly could the head of the proximal phalanx be plantarflexed otherwise? In traditional hammertoes, the head of the proximal phalanx are dorsiflexed.
It sounds like you have done all you could. Referring this patient to a vascular surgeon at the outset was absolutely the correct (and possibly the only thing) you could do. Unfortunately, this patient will have to live with this situation for his entire lifetime. Nature undoubtedly will take its course. I have no doubt.
So will the legal system. While you are to be admired for taking on this case, Beware! Any sharp attorney handling this case, will no doubt look to spread the wealth, naming as many parties as possible to include in any legal case.
After you have exhausted topical OTC products, find a physician who will do or does Botox injections to the feet, or radio frequency ablation to the sympathetic ganglion. I have had patients previously who have had the Botox therapy. The Botox injections will have to be repeated 6 or so months later. For RFA, I have only read about.
RESPONSES / COMMENTS (NEWS STORIES) PART 2B (CLOSED)
RE: NY Podiatrist Roughed Up by Former Boyfriend
From: Jennifer Barlow, DPM
In response to Drs. Gordon and Sullivan's comments: I appreciate where you are coming from. However in this case, I don't believe the article reports any regrettable behavior on Dr. Splichal's part. I don't believe pictures had anything to do with what happened. I have to respectfully disagree with the "you are asking for publicity because of these pictures" rationale.
I believe PM News is a valuable resource. I learned of Dr. Splichal's work through PM News, as well as found my current job, and for these things, among others, I am greatly appreciative. I believe in freedom of the press. I just think that good judgment dictates that something of such a personal nature be kept private, unless permission is given. In my opinion, no pictures justified the publication of this information.
I was a consultant for Arthrocare for many years and helped to develop the TOPAZ technique. One of the things I was always asked during lectures was about coding. I think it boils down to how the procedure was performed. Did you use the percutaneous method or the endoscopic method? If you used the endoscopic method, I advocated a "scoring" or partial transection of the medial band by turning off the timer. The newer Quantum generator does not have that ability and therefore requires a bit more effort to accomplish this, yet still possible. I would use CPT 29893 if you used the endoscopic technique. IF you did it via percutaneous method, I would agree with the previous poster.