The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

April 09, 2009 #3,515 Publisher-Barry Block, DPM, JD

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HI Podiatrist Discusses Foot Health Month

April is foot health month. Foot problems are a lot more common than you think, but there are many ways to prevent them. “A lot of people tend to ignore their feet for the simple reason that they are covered with shoes,” says Dr. David Yee of the Hawaii Foot Clinic at Straub Hospital. “People tend to endure low-grade foot pain. They tend to just grit their teeth and bear it.”

Dr. David Yee

“A lot people use over-the-counter foot products, but they should be aware that if their foot condition is not getting better after a few days, they need to see a podiatrist.,” says Yee 

In Hawaii, a large number of people have diabetes. “Diabetes affects many systems of the body. Diabetics tend to suffer nerve damage, so, for example, they may step on a piece of glass or get an infection and not be aware of it. Diabetics also tend to get dry skin, which can crack and lead to infection. Because their immune system is affected, diabetics have greater difficulty fighting these infections, which can lead to foot and leg amputations.,” says Yee.      

Source: Ramsay Wharton, KGMB-9 TV [4/7/09]

GA Podiatry Group is Largest in Southeast

Village Podiatry Centers has grown into the largest podiatric surgical practice in the southeast and one of the largest nationwide. The practice currently has 26 surgeons and over 100 support staff in 23 metro Atlanta and middle Georgia locations. Five of the surgeons serve as faculty members of The Podiatry Institute, an internationally recognized teaching foundation for foot and ankle surgery based in Atlanta. 

Dr. John Ruch and podiatric surgical residents performing a tendon transfer at DeKalb Medical Center in Atlanta

Dr. John Ruch leads the foundation as Director of Medical Education.  Many of the Village Podiatry Centers’ staff physicians participate in the surgical residency training program affiliated with DeKalb Medical Center. Dr. Alan Banks is Director of Residency Training. He and Dr. Ruch have played primary leadership roles in the program which has been in place for 40 years. Over 100 surgical residents have graduated from the program with 50% staying in the Atlanta area to practice.

“We have a range of experience that includes doctors who have literally written the surgical textbooks for the podiatric field.” said Dr. David Helfman. “They are pioneers who have trained many of the podiatric surgeons today in the Atlanta area.” Village Podiatry Centers experiences more than 90,000 patient visits annually.

Source: M.D. News [March/April 2009]

Query:  Current Protocol for Patients on Plavix

What is the current protocol of elective surgery on patients on Plavix who are 6 plus months post-stent insertion. My patient’s cardiologist won't let him stop it for the recommended 5-7 days prior to surgery until he is two years post-stent insertion. Is this the current standard?

Mark Hiskes, DPM, Brownsburg, IN
 

Query: Ritter Chair Repair

Does anyone know of a repair service for older Ritter chairs?

Bruce Pinker, DPM, Suffern, NY

RE: Ehlers-Danlos Syndrome (R. Denis Russell, DPM)
From: Todd Lamster, DPM

With respect to the large HAV deformities, he has severe metatarsus adductus, and although I cannot see the rearfoot, it looks as though he may have a skew foot as well. I don't believe there is any perfect surgical procedure for this patient that will address most or even some of his foot deformity. However, if the patient is still interested in fixing his bunions, a first metatarsocuneiform fusion is really your only option. 

My fears for performing this procedure at all is: 1) failure to fuse, 2) possible wound healing issues, and 3) future recurrence with severe ligamentous laxity. You may want to perform a naviculo-first cuneiform fusion as well in an attempt to prevent recurrence. One thing you must do prior to any attempt at surgical correction is to ensure that you and your patient's expectations are realistic. Inform the patient of the severity of the deformity and tell him that you are doing this to lessen the pain, help with footgear issues, and that it will never be a normal foot. Ultimately, the best thing to do is fix the one thing that's bothering him most, fit him with special shoes, orthotics, etc., and see what happens as he ages.

Todd Lamster, DPM, Highland, NY, tlamster@gmail.com

RE: Scanners for Orthotic Fabrication (Larry Huppin, DPM)
From: Bruce Williams, DPM

With all due respect to Dr. Huppin, who I regard very highly, I have yet to have seen one shred of evidence to match his claims that an orthotic must be captured in a non-weight bearing neutral position so as to allow for plantar-flexion of the 1st ray.

I regularly utilize a digital scanner and take partial weight-bearing scans. I am confident to say that my casts do in no way come out with any varus component in the FF as compared to how I would cast utilizing plaster and the neutral non-wt-bearing position. In fact, I took great care to modify my casting technique prior to switching to a flatbed digital scanner to assure myself that my technique would be equaled as much as possible.

I look forward to the publication of Dr. Huppin’s article, but as I stated initially, I do not know of any publication that can ratify his claims against weight-bearing or partial weight-bearing scanning technique.

Bruce Williams, DPM,  Merrillville, IN,uwalk4me@comcast.net

Potential conflict: I have been sponsored by a company that produces and utilizes a digital scanner but am not in their regular employ. I have purchased and do utilize daily their scanner.

RE: New DME Changes Go Into Effect
From: Paul Kesseman,DPM

The following changes went into effect April 1, 2009:
 
Elastic braces are no longer a covered benefit. This would include HCPCS code L1901. The new policy also has made code L2770, any material, invalid for claim submission. The old incorrect HCPCS code for therapeutic shoes in the AFO policy has been replaced with the current codes of A5512 and A5513.

Effective June 1 2009, the KX modifier must be used for the BASE codes for AFO's and the addition codes. Presently, the KX modifier is only required on the addition codes. Please notify your billing staffs.

The KX modifier simply indicates to your DME MAC that you have sufficient documentation to support reimbursement for the products you have dispensed. It is very important that your chart documentation matches your orders and the description of the device which is being dispensed. Please discuss this with your suppliers so that your invoice contains the same or similar verbiage as your order.

Paul Kesselman, DPM, Woodside, NY ,pkesselman@po.net 

RE: Denial of GraftJacket (Amy Jelinek, DPM)
From: Greg Caringi, DPM

I am on the panel of a prominent case review organization. We are beginning to see numerous appeals following rejection of GraftJacket as being experimental and investigational. Although I confident that this will change in the near future as more and better studies are published, there is presently only scant information concerning the use of GraftJacket in applications pertinent to foot & ankle surgery. Several of the papers commonly referenced are internal white papers from Wright Medical.
 
GraftJacket is donated allograft human dermis and is "FDA regulated" as human tissue for transplantation. As such, it is not technically "FDA approved" for the indications given by Wright Medical, which includes supplemental support, protection, and reinforcement of tendon and ligamentous tissue. I am sure that this will change as the literature on its use becomes more widely available.
 
I have to admit that, as an operating surgeon and also a case reviewer, I was surprised that an implantable material used as part of a surgical procedure was being brought into question as being non-covered. I am not aware of insurance companies rejecting the cost of other implantable materials, e.g., 1st MTP implants, arthroeresis plugs, anchors, plates, screws, bone grafts, drains or specialized sutures. I suspect that the $4000 per use cost of GraftJacket has brought on this special attention.
 
It is an unfortunate circumstance at present. I think Dr. Jelinek has done everything properly by attempting to get a pre-certification before the surgery. Hopefully, she recorded the name of the individual who told her that pre-certification was not necessary.  Many of the appeals I see are retrospective. As surgeons, it is part of our responsibility to see that all services - and apparently specialized materials too - are pre-certed and covered by the individual insurance policies before the surgery is performed.  
 
Greg Caringi, DPM, Lansdale, PA,  drgregc@msn.com

RE: Child Without Health Insurance (Adam Cirlincione, DPM)
From: Howard R. Fox, DPM

Call your hospital’s social services (social work) department and see if they can obtain emergency Medicaid for your patient. Many hospitals who are “forced” to admit uninsured patients from their ER, obtain emergency Medicaid, even retroactively, to get reimbursement.  I’m not sure what you mean when you say “protect yourself” if you are (admirably) willing to waive your fee.
 
Howard R. Fox, DPM, Staten Island, NY, foxhr@yahoo.com

RE: Health Net Denials in CT, NJ, and NY for Diagnostic Ultrasound
From: Dave Mullens, DPM, JD
 
I am posting this to ask the podiatric physicians in Connecticut, New Jersey , and New York whether you have received Health Net denials for payment of diagnostic ultrasound studies during the past three years. If so, please let me know. 

Last year, my law office, in conjunction with another law firm, notified Health Net that we were going to file a class action lawsuit over the Health Net denial of payment policy for diagnostic ultrasound studies performed by podiatric physicians. Health Net has subsequently deleted that inappropriate policy (originally number 03-09-02 and later changed to NMP 31) from its website. We are currently investigating whether Health Net denied claims based on NMP 31 (or 03-09-02) to podiatrists in the states of CT, NY, or NJ. Please contact me if you practice in one of those states and have been denied payment for diagnostic ultrasound studies by Health Net.

You can read the entire - now deleted - Health Net “ultrasound examinations of the foot and ankle” policy NMP 31 by going to: mullenslawoffice.com/news.html

Dave Mullens, DPM, JD, Palo Alto, CA, dmullens@mullenslawoffice.com

PART-TIME NON-SURGICAL PRACTICE FOR SALE - NORTH JERSEY    
 
23 yo practice recently relocated to a spectacular newly-constructed and equipped storefront next to a busy supermarket with ample parking and senior citizens in vibrant downtown. Accepting Medicare and Blues only with great potential. Perfect for expanding to full-time, a second office or new practitioner with means and office experience.  Priced to sell. Financing possible. E-mail interest with contact to Mikedup1215@yahoo.com 

PRACTICE FOR SALE - CENTRAL FLPractice and medical building for sale, in beautiful, high quality of life, growing area, Central Fl.; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion & investment; good insurance climate. 352-223-2713 / E-mail: windnwave@earthlink.net

ASSOCIATE WANTED - FLORIDA

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Partnership opportunity for the right candidate. Preference given to a PSR 24+ resident completing their education this spring/summer, and must have a Florida license. Well-established practice, high tech with EMR and digital x-rays, with specialties in sports medicine, surgery and wound care. No nursing homes or HMO's. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family that is second to none. E-mail: kimvelez@tampabay.rr.com

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

TWO YEAR FELLOWSHIP IN RECONSTRUCTIVE FOOT SURGERY AND RESEARCH

2-year fellowship at Beth Israel Deaconess Medical Center, a primary teaching hospital for Harvard Medical School. Fellows have clinic, perform complex reconstructive procedures (external fixation, flaps, Charcot reconstruction), and conduct clinical research (20%). Fellows train residents and receive appointment at Harvard Medical School faculty. Excellent salary/benefits. Program begins SEPTEMBER, 2009. Must have completed PSR-36 or similar. Submit applications to: Adam Landsman, DPM, PhD alandsma@bidmc.harvard.edu Include CV, letter describing goals and any research interests. Deadline: May 1, 2009.  Beth Israel Deaconess Medical Center and Harvard Medical School are Equal Opportunity Employers. Women and minorities are particularly encouraged to apply.

ASSOCIATE POSITION - HENDERSON, NEVADA

Associate wanted for thriving, well-mixed 3-doctor digital office, leading to partnership. Surgery, diabetic, pediatric, and general podiatry. Great office and location, fun area to live. Need 2+ years surgical residency. Must be energetic, self motivated, great patient skills. Salary plus bonuses. Email CV to gtorgesen@yahoo.com

PODIATRIST NEEDED FOR MIAMI-DADE COUNTY

Multi office practice needs doctor of podiatry for full time and/or part time for private office, clinics, and nursing homes. Great opportunity to grow with and unlimited income potential. Offices in Miami, Hialeah, Westchester, and Cutler Ridge. Email to feetdoctor@aol.com

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

ASSOCIATE POSITION - CHANDLER/GILBERT/PHOENIX, ARIZONA

Seeking a well-trained, ethical and hard working graduate of a PSR 24+/36 Residency to join our growing multi-location practice. This is a practice with a nice mix of 35% surgery/trauma, 20% diabetic/wounds, 25% biomechanics, 20% pediatric. ER Call. Opportunity for partnership at 2 surgery centers. Very modern offices with EMR, U/S, Digital X-Ray, ESWT, Vascular Testing Machine. Excellent referral base, and a well-trained staff. Board eligible/certified a plus. Competitive salary, bonus structure, benefits. Please e-mail CV and references to  FootAnkleAZ@aol.com

OFFICE SPACE/ MRI RENTAL – NYC, LI

Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, and Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

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