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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: 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,



From: Richard Rettig, DPM


The legalities concerning compounding pharmacies and the ways for them to "distribute" money to the prescribing physician are multiple and have been discussed here before. In my opinion, gray area or not, they do not pass the "stink test." Dr. Kass summed it up by saying the "incentive dollars (in any form) are nothing more than a kickback/scam." If that isn't clear enough, and you want to proceed, first read about today's indictment in L.A.    


Richard Rettig, DPM Philadelphia, PA



From: Richard W. Boone, Sr.


This inquiry actually raises two issues: 1. Can the physician own the pharmacy? and 2. Can a physician sell drugs to his or her patients from a pharmacy that he or she owns?


The answers to both questions will depend upon the law of the state in which the physician practices. In my home state, Virginia, the second question is easiest to answer: A physician may not sell drugs to his or her patients unless he or she is also a licensed pharmacist. [Code of Virginia § 54.1-2914.]  I suspect the answer will be the same in the majority of states but, as noted, each state has its own rules and you have to determine what your state's rules permit or prohibit.


The first question can be a little more difficult to answer. I suspect that Virginia would permit a physician to own a minority interest in a pharmacy, provided that the pharmacy doesn't sell drugs to the doctor's own patients. (In other words, there can't be any connection or business relationship between the doctor's practice and the pharmacy.) However, any business connection between the clinical practice and the pharmacy which tends to direct the doctor's patients to the owned pharmacy is probably impermissible. But, once again, it all depends on your state's law.


Richard W. Boone, Sr., Fairfax, VA,



From: Paul Kesselman, DPM


My advice is to use 7-Zip, a free utility which comes with 256 bit encryption. It is usually pre-loaded on new computers (or you can download it for free from a myriad of safe websites). Ask your vendor for a recommendation. Simply encrypt the document and then provide it to the patient with a password.


Send the password under separate cover, or better yet, provide it to the patient verbally prior to sending the email. Once they receive the document, when they go to unzip it, they will be asked for the password. Once entered, the document can be opened and saved by the patient in any fashion they want.


Paul Kesselman, DPM, Woodside, NY, 



From: Raymond F Posa, MBA


This doctor's story is disturbing, and while we don’t want to distrust our employees, in the medical field with the sensitive nature of the data we have, we need to have protocols in place to prevent such occurrences. They should be articulated in your HIPAA security manual.


When an employee is going to leave your practice, the protocol should be to pay them two weeks’ severance and immediately lock down all of their user accounts as soon as they give notice. I have experienced another situation where the employee leaving the practice took lists of all of the practice's patients so as to use them at another practice. That final two weeks tend to be very unproductive weeks on behalf of the outgoing employee, and leaves the practice vulnerable to all sorts of mischief and possible damage.


On a second point, the doctor mentioned that the employee deleted all of the mail from the Gmail. For the record, Gmail and Yahoo and any other free email accounts are NEVER to be used for the communication of ePHI. Only domain email accounts which are encrypted may be used. Also, had this doctor used domain e-mail, even if the employee had deleted the mail and emptied the trash folder, you would still be able to go onto the e-mail server and get your e-mails.


Raymond F. Posa, MBA, Farmingdale, NJ,



From: Pete Harvey, DPM, Jack Kay, PhD


Isn’t your info backed up on a cloud or hard drive? The emails should be there even if they were deleted by Google. If it is not backed up, then start TODAY! A forensic Information technologist might be able to recover the data if your own IT team can't.


Pete Harvey, DPM, Wichita Falls, TX,


I am not an attorney; I do not dispense legal advice. But allow me to offer the following — In Massachusetts, to cite only one example, there is something called the Massachusetts Wage Act, which subjects an employer and its entire board of directors to three times the amount of wages withheld. I doubt very much that the Massachusetts judges who administer this court would care a whit as to the rationale for withholding such wages; as a group, they tend to be employer-hostile. All podiatrists should seek legal counsel before embarking on a risky course of action such as this.


Jack Kay, PhD, Woodmere, NY,




I just took the course provided by the FPMA; however, the deadline for taking it with them was March 1st. The Barry University College of Podiatric Medicine did not offer it this year as a home study.


Don R Blum, DPM, JD, Dallas, TX,



From: Olga Luepschen, DPM


This discussion brings up an interesting point. What percentage of our colleagues carry $250,000/750,000 vs 1 million/3 million coverage? I was under the impression that $250,000/750,000 coverage was adequate.


Olga Luepschen, DPM, Sebring, FL,


Editor's Comment: This will be the topic of next week's PM News Quick Poll question. As previously stated, we believe that $250,000/750,000 coverage is inadequate.



From: Joseph Borreggine, DPM


Here's a follow-up to the matter regarding BC/BS wanting their money back for a surgical procedure they deemed an "investigational or experimental procedure." I was under the impression after my conversation during a requested peer-to-peer interview with the DPM who initially reviewed the case that my claim should have "no problem being paid" if I just resubmitted a "corrected or addendum" operative report as to why a metallic implant had to be used during a joint salvage arthroplasty of the 1st MPJ utilizing CPT codes 28111 and 28126. 


I did just as he requested and the union insurance plan with BC/BS as its TPA stated that all claims paid past, present and future will not be paid and...


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



From: Paul Kesselman, DPM


According to the Provider Outreach and Education Department for DME MAC A, they are adding a feature on their website which should address some of the questions raised by Dr. Schaffer.


DME MAC A is adding a "physicians only" portal to its website. This will list the documentation requirements for physicians for various DME products. Echoing the posting by David Mullens, DPM, Esq, the DME MAC cannot list requirements which are contrary to Stark or other CMS requirements.


Check your DME MAC website within the next 3-4 weeks for this information.


Paul Kesselman, DPM, Woodside, NY,



From: Paul Kesselman, DPM


My classmate and colleague asks several questions which are actually quite more complicated than they appear. First off, the issue of Stark and signing off on a podiatric diagnosis are two separate issues, which apparently he/she is confusing as are other MDs/DOs and DPMs. 


The Stark issue is one that I would defer to an attorney to provide a formal legal response. In lieu of that, I have personally spoken with several healthcare attorneys who are well-versed in Stark and I can provide you with a brief explanation. In most cases, as long you are...


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



From: Steven J. Kaniadakis, DPM


My post related to the Banyan® crash cart. We kept it under our surgical suite back table. We also had Armstrong's Medintech® flooring. This is a type of non-conductive flooring. Electrical-type currents  from an AED or electro-cautery require grounding (plates, floors, etc). This is especially true when oxygen is flowing. 


Steven J. Kaniadakis, DPM , Saint Petersburg, FL,



From: Jim Fisher, DPM


911 is your first line of defense, yes. In addition, I bought a HealthFirst mobile crashcart complete with O2 and defibrillator. It is made for the dental profession and is amazingly organized, light, and easy to move. I take it with me to my satellite office. It saved the life of an accident victim I came across on our rural roads two days after I received it. It has everything a crashcart would need and is very cost-effective.


The defibrillator is amazing as well: easy to use, and it tells you what to do, even if that is to do nothing. The 15 minutes I spent with the accompanying DVDs for the crashcart and the defibrillator were well worth it, and it gave me just a tiny bit more peace of mind.


Jim Fisher, DPM, Crescent City, CA,



From: Carl Ganio, DPM


Right out of residency, I trained in advanced cardiac life support. We started out in the office with all the meds, etc. However, as meds and certifications expired, I began to rethink the risk. You should understand that having those meds exposes you to a higher level of scrutiny and expectations beyond our scope of practice. If you feel comfortable, up-to-date, and capable, I admire you. However, understand that perhaps oxygen and an EpiPen are enough. Call 911.


Carl Ganio, DPM, Vero Beach, FL,



From: Steven J. Kaniadakis, DPM


I bought a Banyan® crash cart from a plastic surgeon. I also had an oxygen tank. However, even the MD related that he would "call 911". However, for medical-legal reasons, he related that having a crash cart is useful medically-legally. I thought it was wise practice advice and was lucky enough never to require either. 


DPMs performing surgery should have the supplies, equipment, instrumentation, and the people available as sources and resources. An AED is now affordable for most practices, and you should be at least willing, ready, and able to use one.


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Elliot Udell, DPM


Dr Bergman is correct. We as podiatrists should not be managing anaphylaxis or a myocardial infarction on our own. I imagine that most physicians, no matter what branch of medicine  they practice,  would call 911 if a patient was suffering with a life-threatening emergency in an office setting.


Anaphylaxis is one of the conditions that does not afford the physician the luxury of placing a call to dial 911 and waiting for help to arrive. Emergency treatment has to be started immediately, or the patient might not live to greet the ambulance. An allergist gave me a copy of the emergency instructions that he and his staff use in case one of their patients develops anaphylaxis in their office. I have this sheet hanging in my office along with easy access to appropriate medications. If anyone is interested, I would be happy to forward you a copy of this page of instructions along with the list of appropriate medications you should have on hand.


Elliot Udell, DPM, Hicksville, NY,



From: Jeffrey Kass, DPM


Dr. Kruper brings up a valid point in terms of pathology - that a podiatrist is more likely to see non-bony surgical issues than bony surgical problems. I think full allopathic scope is a pipe dream here in New York. It seems the atmosphere is to take baby steps. Considering we have the oldest podiatry school, one would think our scope would be advanced compared to that of the other states. 


I am trying very hard to understand why it is possible to pass a scope bill to allow 3-year trained RRA certified podiatrists to perform bony ankle surgery and skin and soft tissue to the knee, while the rest of NY podiatrists are deemed incompetent to treat the non-surgical problems (skin and soft tissue) above the ankle. This law seems very "egosurgical-centric".


The surgical trained person gets to perform surgery and non-surgical care, while everyone else is left out. ABPM, where are you? Can you hear me now? Any dues-paying member in the NYSPMA or ABPM should voice their concerns to the societies they pay dues to. The assumption seems to be if you don't call them, you don't oppose what is taking place.


Jeffrey Kass, DPM, Forest Hills, NY,



From: Paul Kruper, DPM


The last time I treated a patient who needed bone surgery of the ankle was... The last time I treated a patient who needed primary care for diabetes, arthritis, or dermatopathology was today, 6 times. New York podiatrists would be far better off professionally and financially to have a full allopathic scope, which would give unlimited potential to expand patient load and employment opportunities. Chasing ankle cases is egocentric and does nothing to fill up the empty spaces in the appointment book.


Paul Kruper DPM, Kingsburg, CA,