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From: Elliot Udell, DPM


Many of us have been led to believe that when the new scope of practice laws in New York State take effect, it will not just affect bone surgery of the ankle, but the treatment of soft tissue problem in the adjacent areas.


I, for one, have no intention, at this stage of my practice, to study for or to become certified to perform ankle surgery, however I don't see why the new law would require colleagues like me to complete a residency in ankle surgery in order to treat a verruca which happens to be above the lateral malleolus.


Elliot Udell, DPM, Hicksville, NY,

Other messages in this thread:



From: Lisa Merkow, CPC


Since I posted the suggestion to use to help collect from patients who skip out on high deductibles, Dr. Beaton has been besieged with questions about the service.  I wish I could address them all, but here are answers to the most FAQs.


1) HIPAA doesn't apply to collections. does not share any patient medical information and HIPAA is therefore not applicable. You can't tell which patient saw which doctor. You can only see if a patient was posted by another doctor as a non-payer.

2) You do not need the patient's email address.

3) You can pay the annual fee and just utilize the database to identify patients who don't pay their bills. You do not need to use the notification letter; however, we find it to be very effective and much more affordable than a collection agency.

4) They don't have a phone number that is public. We figure it's because they don't want patients calling. They are very accessible through their email address.


Lisa Merkow, CPC, Office of William Beaton, DPM, St. Petersburg, FL



From: Michael L. Brody, DPM


The incentive is for using certified technology and meeting meaningful use. It is for the provider who met meaningful use. That being said, the money can be assigned to any entity. In order to attest for you, the group must have access to your PECOS username and password. The only way they have this is if you provided the group with this information.


In many cases that I have encountered, there was some sort of agreement between the group and the employed podiatrist. The group has access to all of the documentation necessary to allow you to attest for meaningful use, and you have access to your PECOS credentials. Generally, I would advise against giving out your username and password for any account as important to you as the PECOS, In the situation you present, much depends upon your employment agreement. This situation can get even more complicated when a provider works part time for different groups and the data from each group must be aggregated to allow a provider to attest for meaningful use.   


It is possible that some time in the future, you will be audited for that meaningful use attestation. If you do not have all of the necessary documentation to pass the audit, it is YOU who will be responsible for refunding the incentive payment to CMS. It is imperative that you obtain copies of all documents necessary to respond to an audit now, because if you leave that group it can become difficult to get the documentation in the future. You may wish to consult with an attorney to properly protect yourself in case of potential future audits.


Michael L. Brody, DPM, Commack, NY



From: Elliot Udell, DPM


The relationship between podiatric physicians and narcotic-seeking patients is far from being a black and white situation. Not every patient is a faker. There are many patients suffering with chronic painful conditions who will probably be on morphine-based drugs all of their lives. On the other hand, in my state, authorities are not happy with us writing for these drugs. A friend of mine who is a hematologist wrote a script for an opioid for a patient suffering with sickle cell anemia pain. Authorities swooped down on him. He was exonerated, but only after he paid 50K+ in legal fees and a year of aggravation.


In our practice, I do not write for these drugs even if a patient comes in sucking on Fentanyl lollipops justly prescribed by another doctor. I refer these patients to pain management specialists who have carte blanche with prescribing these drugs, and I will restrict my therapies to other aspects of foot and ankle care.


Elliot Udell, DPM, Hicksville, NY



From: Elliot Udell, DPM


Many physicians are faced with this same problem. They do not admit too many patients to their local hospitals yet need to verify that they are on staff of a hospital for the purposes of insurance credentialing. What our local hospital system has done was to create an on-staff privilege, which does not allow the doctor to admit patients but allows him or her to read charts and visit but not treat patients. It is a win - win situation for the physician and the hospital. On one hand, the doctor no longer feels impelled to admit more patients than is necessary and on the other hand the hospital still makes their share of dues from each practitioner.


Elliot Udell, DPM, Hicksville, NY



From:  Jim DiResta, DPM, MPH


It has been my experience that credentialing committees will accept activity at another facility where you maintain privileges in lieu of not seeing enough patients at their particular facility where you lack the minimum 20 patient encounters over the 2-year period. This is a fairly common occurrence and protects the hospital in recredentialling you for medical staff membership. Often there are two parts to this. One is hospital membership where you need patient contacts, i.e. inpatient consults, out patient treatments, OR procedures, or activity in the hospitals wound care center. The second is surgical privileges. Many surgical departments are now requiring certain volume thresholds of surgical procedure activity to renew providers privilege cards. Satisfying that request is more daunting.


The other issue Dr. Borreggibe raises as to whether you should voluntarily relinquish your privileges or allow the facility to not renew them is a question that I would seek out legal counsel as you will be asked this question on numerous renewals for third-party payer contracts, ACO involvement, healthcare privilege applications and license renewals, etc.. and it would appear taking a proactive course of voluntarily giving up your membership and privileges would be wiser with a reason that you simply no longer need use of that facility for non-renewal rather than allow them to "take your privileges away" and have to continually explain that to other parties in the future. 


Jim DiResta, DPM, MPH, Newburyport, MA 



From: Tom Zoldowski, DPM

I have gone through this same situation with hospital privileges. I met with the hospital credentialing committee, explained that I don't do a lot of surgery, that I do use the hospital facilities and services for out patient testing, that this hospital is where I do 90% of my surgery, and  I am involved in the residency program. The committee then allowed an exception.

Tom Zoldowski, DPM, Toledo, OH



From: Michael J. Schneider, DPM


If you think you might work as a podiatrist in some way after retirement, I would advise you to keep every form of license you have. You can never tell what opportunities arise (locum tenens, etc.)...even when you think you are done...done....done. "Been there...done that."


Michael J. Schneider, DPM, Denver, CO



From: Donald R Blum, DPM, JD


"....When I received the new patient paperwork, an arbitration document was included in the packet for me to sign. It basically stated that if I felt dissatisfied in the care I received and I was considering a medical liability claim, I could arbitrate the matter with the institution where the care was provided instead of a seeking legal counsel." 


I think the key word in the notice is "could". To me, this is giving you the option to arbitrate versus making it the only option. Please do not construe this to be legal advice. I also suggest asking them the meaning of the notice. 


Donald R Blum, DPM, JD, Dallas, TX 



From: Elliot Udell, DPM


A friend of mine called me over the weekend asking me about similar paperwork she had to sign in order to gain admission to a motivational seminar in New York City. I could not imagine anyone suing them over not "being motivated"; however, what they may be concerned with is if she is not happy with the program, leaves early, and wants her six hundred dollars returned.


This would go to arbitration. This might be what is so with the orthopedic group. With high co-payments with the new insurance plans, many patients might run up a bill for a couple of thousand of "out-of-pocket" dollars and look for ways to not pay the bill. Some patients truly believe they are covered for all services, and then refuse to pay even though the visits went toward a four thousand dollar deductible. In other cases, the patients might claim they do not owe money because their knees or shoulders did not feel better. I cannot see a court allowing a patient to sign his or her rights to sue for professional negligence.


Elliot Udell, DPM, Hicksville, NY



From: Gary Hoberman, DPM


I think the elephant in the room is not what criteria is needed for a home visit but the fact that most doctors we interview to work in nursing homes who are currently doing home visits are billing for an E&M visit EVERY single visit along with the at-risk palliative care they may be providing. Somehow they find tinea, or some other emergent problem that just happens to pop up on the 60-day cycle with the necessary and presumed covered palliative care. This leads to a higher average fee per patient and a competitive advantage for those practices seriously engaged in home visits. I’m glad these E&M codes are now being more closely scrutinized.


Gary Hoberman, DPM, Chicago, IL



From: Al Musella, DPM


I also received three of these letters from Medicare. I found this in the guidelines from Medicare: " For home services provided by a physician using these codes (99341-99350), the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit."


United Healthcare Medicare has this in the guidelines: Home Visits (House Calls)

o Home visits made by a physician to a member’s private residence may be covered when medically reasonable and necessary and not for the convenience of the provider or the member.

o Although the member need not be confined to his home for the physician’s home visit services to be covered, the member’s condition must satisfy Medicare’s definition of ‘homebound”, and the medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. 

o Generally speaking, a patient will be considered to be “homebound” if he/she has a condition due to an illness or injury that restricts his/her ability to leave his/her place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if leaving home is medically contraindicated. (For details, see the Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 30.1.1 - Patient Confined to the Home.)

o For more specific Medicare guidelines, refer to Medicare.


All of my housecall patients are elderly and cannot get to my office by themselves without assistance, so I feel they qualify. I Will soon find out if Medicare agrees!


Al Musella, DPM, Hewlett, NY



From: Steven J. Kaniadakis, DPM


I suggest that you confirm the permeability of the product brand or generic material. Barrier products, like surgical masks, have various allowances for particulates, including bacterial organisms. Dental procedures are not typically required to have a sterile field, since most are "dirty procedures." The fact that the dental profession uses the material in reference to your intended use is not a wise one. So, I respectfully disagree with Dr. Block.


Try contacting Johnson & Johnson Barrier products. They might be helpful. Although "community standards" might be different, "standard of care" is your concern, right? If you get a case of osetomylitis or any other post-op issue, this might well be the first thing investigated. Be proactive and take the time to find out, or it may cost more time for you in the future.


Steven J. Kaniadakis, DPM, St. Pete, FL



From: Jeffrey Kass, DPM, Elliot Udell, DPM


I fail to see how "name withheld" is a serial malpracticer when no judgment was made against him. I would have taken issue with the hospital. 


Jeffrey Kass, DPM, Forest Hills, NY


When I first started in practice, podiatrists were getting sued, and our premiums were sky high. Why? Insurance companies were willing to settle every lawsuit, whether it had merit or not. Every negligence attorney knew that suing a podiatrist meant a quick settlement with very little work. For the insurance industry, it was cost-effective to settle every case and raise everyone's premiums at the end of the year, and even add on more profits for themselves. They did not care one iota that settling an unwarranted med mal case would be on a doctor's record and interfere with his or her ability to be on staff of certain hospitals. Today, carriers fight back and, unlike the past, they cannot force doctors to settle bogus, nuisance cases.


Elliot Udell, DPM, Hicksville, NY,



From: Seth J. Steber, DPM


There is a group you can join called Doctor's Advocate: For less than your state and national dues, you can become a member. Their attorneys and staff will handle independently any potential lawsuit, PR issues, threats, slander, etc. Since they are not an insurance company, they can contact your potential plaintiff and their attorney directly to discuss the matter and "educate" them on frivolous lawsuits and potential for counter-suits. 


Seth J. Steber, DPM, Carlisle, PA,



From: Name Withheld


Several years ago, I saw the same cellulitis reaction in a patient who missed some work time. Her husband came and demanded compensation, and implied that if I didn't pay, I would be sued. I contacted my insurance company. I never heard about the matter again until 3 years later, when I applied for hospital privileges. During my interview, I found out that this episode was listed on my record as a malpractice claim. I had one other previous claim which was decided in my favor. I was turned down by the hospital because I had multiple claims and was a serial malpracticer.


Name Withheld



From: Elliot Udell, DPM


Dr. Jacobs is correct when he states, "In-office compounding has been around a long time." My dad is a retired pharmacist. When I was little kid in the 1950s, I remember visiting his drug store. In those days, pharmacists were not highly educated professionals. Their roles were often reduced to taking pills out of a stock bottle, counting them out into a small plastic bottle, and slapping  a label on it. In those days, all physicians  wrote for compounds, and my father showed me how he would hand-make ointments, cough syrups, pills, and suppositories based on physicians' prescriptions (which were always written in Latin). With compounding pharmacies, the profession has come full circle and pharmacists are once again doing the work that measures up to their years of intense training.


Elliot Udell, DPM, Hicksville, NY,



From: Allen Jacobs, DPM 


In-office compounding has been around a long time. There is nothing wrong with compounding selected pharmaceutical ingredients in your office for patient treatment. The issue your question raises is not about Stark Law. It should be about medical liability, kick-back laws, ethics, and not jeopardizing your in-network medical status with payers. 


1. Liability is a major issue. When a pharmacist dispenses a drug to a patient, they hold 100% of all patient liability for safety around allergies, drug to drug interactions, contraindications and... 


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



From: David E Gurvis, DPM


Yes, you are allowed to refuse to see a patient, but you had better not ever say you declined due to an ADA-covered disability. The government says (you do not have to agree or embrace or otherwise like) that YOU, not THE PATIENT, not INSURANCE are responsible to pay for an interpreter. You may ask if the patient will allow for written communications, and if so, fine. If not, YOU PAY for the sign interpreter. A family member is not a good idea, as they may not be familiar with medical terms.


The idea is, the cost is spread out over a large population of providers, and "therefore" no one gets too big a financial hit.  Do I think this is fair? Is it the law? You don't want to test it and find out. If you decline this patent for a reason other than deafness, you had better be sure you are bulletproof. The enforcement of this law is by civil suit and that can hurt.


David E Gurvis, DPM, Avon IN,



From: Victor Chen, DPM


I had a similar issue twice, in 2000 and recently last year, as highlighted in PM News. In 2000, I was told I treated a person (and received payment) in 1998 who was deported in 1996, therefore I had to refund Medicare almost $1,000 since he was not in the U.S. Turns out, the patient had to go to Social Security for an interview, but he had unfortunately expired. Medicare consequently dropped this case. Last year's "Messycare" debacle was highlighted in PM News by a TV investigation on my behalf by Arnold Diaz, Investigative Reporter.  


Social Security had erroneously labelled him (a deceased patient of three years) an Illegal Alien, setting off a demand from Medicare for refunds. The law states that Medicare can collect monies from whomever they paid; they don't go after the illegal person in question and ask them to reimburse them. If you got paid by Medicare, you are supposed to refund Medicare, and then you have to go after the patient (good luck with that!). I suggest that you get an investigative reporter or lawyer to assist you in determining if Social Security has erred. BTW, I never received an apology letter from Medicare or Social Security for their mistake!


Victor Chen, DPM, Jackson Heights, NY,



From:  Peter Bregman, DPM


It is possible that the patient had an underlying tarsal tunnel syndrome that was exacerbated by this injury. It will be difficult to prove this. It is also important not to rely on EMG/NCV studies and document the clinical presence by Tinel's sign and by provocation. Is also important to look more proximately at the soleal sling as well for tibial nerve entrapment.


Peter Bregman, DPM, Las Vegas, NV,



From: Richard A. Simmons, DPM


The doctor is asking how to chart for an unchanged condition of a painful fifth toe corn every two months, for decades, on a patient not wanting a surgical correction. The patient is happy with conservative care. The answer is simple: you chart the treatment you are doing on a routine basis, whether it is repetitive or not.  


Now, if the patient’s bill is paid for by Medicare, please be sure that the patient meets Medicare’s criteria for “covered” routine foot care (CPT 11055). Do not bill an E&M (evaluation and management) code for each visit. If the patient is not eligible for routine foot care, then this is a cash visit with no bill submitted to Medicare. Check with the criteria for other insurance carriers before submitting your claim.


Richard A. Simmons, DPM  Rockledge, FL


Editor's note: Name Withheld has informed us that the patient was considered at-risk and covered for care of the fifth toe corn.



From: Brian Kashan, DPM


One of the factors in repeated treatments and visits, in my opinion, is if it is for a covered service or not. If it is not a covered service, i.e., routine care in a non-diabetic, I do not believe that repeated notes are as much of an issue. If it is for a covered and billed treatment, I believe there is a definite need for different documentation.


While most repeated visits can be 95% exactly the same, there are small variants from visit to visit. A note of social changes, illnesses, medication changes, or the lack thereof, can be noted. The size and severity of the lesion from visit to visit may change. Some skin irritation or nail subtlety may be present. It doesn’t have to be a huge difference, but just a few words that make that day's visit somewhat different, so someone can determine that day was different from any other day. Patients relate all kinds of things to us during their visits. I suggest jotting down a few words that they relate happened, or that you observe from visit to visit.


Brian Kashan, DPM, Baltimore, MD, 



From: Stephen Musser, DPM


In the subjective part of your note, I would document changes in the patient's PMH and up- coming test/procedures. It's hard to believe there would be no changes after decades of treating the patient. In addition, document (every visit) in the plan that you reviewed the patient's current medications and allergies.


Stephen Musser, DPM, Cleveland, OH,



From: Michael L Brody, DPM


The disclosure of patient information for professional purposes such as board certification is an allowed disclosure under the HIPAA regulations.


1) You are bound by the minimum necessary rule and can only disclose the minimum amount of information necessary to accomplish the task at hand.


2) Patients have a right to an accounting of disclosures, so you will need to log the disclosure and provide the log to the patient upon request.


As long as you are only disclosing the minimum amount of information and are logging each disclosure, you are compliant with the HIPAA regulations. For more information, you can download the HIPAA Omnibus Rule from the Federal Register.


Michael L Brody, DPM, Commack, NY, 



From: Alec Hochstein, DPM


Anti-kickback laws at both the federal and state level make it illegal for a prescriber to benefit financially from referring a patient to a specific pharmacy or other medical service. The federal laws and many states include specific provisions to create a “Safe Harbor” exemption to the anti-kickback laws. Physician Specialty Compounding, LLC (PSC) has worked with a number of law firms to document the steps for creating the “Safe Harbor” required for a prescriber-owned pharmacy.  After the signing of a mutual Non-Disclosure Agreement, PSC is happy to share our lawyers’ legal analysis.  PSC strongly recommends that you consult with your attorney to protect your interests and to verify full compliance with all federal and state laws.


Disclosure: I am a medical consultant for Physicians Specialty Compounding,  LLC.


Alec Hochstein, DPM, Great Neck, NY,
Health Fusion