The Voice of Podiatrists

September 29, 2006 #2,701 Editor-Barry Block, DPM, JD

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Flip-Flops Ideal for Showers: IN Podiatrist

Dr. Lawrence Conway of Lafayette Family Foot Care suggests wearing protective shower sandals or flip-flops in communal areas. "I encourage students to dry their feet after exercise, especially in between the toes," said Conway. "Also, students can use a foot powder to help with perspiration."

Dr. Lawrence Conway

The shower and other communal areas, such as bathrooms, are breeding grounds for contagious fungus, said Conway. If the fungus is contracted, Conway said to try an over-the-counter remedy before visiting a podiatrist. "The podiatrist will test skin samples for evidence of fungus particles; if found an oral and topical medicine are usually prescribed," said Conway.

Source: Manda Ramirez, The Exponent (Purdue) [9/27/06]

WY Podiatrist Supports Smoking Ban

Dr. Jason Levitre believes the health of Evanston residents is the foremost argument and supports a full city wide public smoking ban.

Dr. Jason Levitre

Levitre, a podiatrist, told those in attendance that he believes the health benefits outweigh any other arguments.

“Think of the strong message we can send to our children,” Levitre began. “If we show them with this ordinance that smoking is a big deal and it is dangerous, maybe they will see they shouldn’t do it.”

Source: John Shank, Uinta County Herald, WY [9/27/06]

Wrong Shoe Size Can be Hazardous to Diabetics: Robertozzi

Buying the wrong size shoes can be hazardous to your health -- especially if you have diabetes. Researchers looking at a population of 440 veterans found that only 25 percent of the test subjects wore appropriately sized footwear. Individuals with a foot ulceration or loss of sensation due to diabetes -- a condition known as neuropathy -- were more than five times more likely to wear poorly fitting shoes.

"I encounter this with patients every single day," said Christian Robertozzi, a Newton podiatrist and president-elect of the American Podiatric Medical Association. "People with diabetes often have no feeling in their feet, and they don't know their shoes are the wrong size until they get an infection."

Dr. Christian Robertozzi

Robertozzi, who was not involved in the study, added that it is a mistake for diabetics to simply take their shoe size for granted. "They feel, I have always worn a 9, so they go out and buy a 9, when they should be in a 10 or 11," Robertozzi said, noting that men are as guilty as women when it comes to misjudging their shoe size. "Wearing the wrong size shoes can create an ulcer that can become infected," Robertozzi warned. In the shoe-size selection study, the researchers concluded that greater accuracy in the shoe-foot match can be useful in reducing the risk for these ulcers.

Source: Angela Stewart, Newark Star-Ledger [9/25/06]

Query: Scherosing Veins

There has been some discussion lately about various sclerosing methods for veins. Where does one learn this technique and what are the potential complications?

David E. Gurvis, DPM, Avon, IL, Deg1@comcast.net

Query: Bundling Separate Surgical Procedures

We have a patient who had a bunionectomy with implant (CPT 28293) and a 2nd toe hammertoe correction (CPT 28285) performed on same foot. Anthem bundled these 2 surgeries together, and paid about 1/3 of what the doctor charged. I called Anthem, and the claim went to review. After 4 months and 5 phone calls, I found out that Anthem is upholding the decision to bundle these two surgeries.

I have never had this happen with any other insurance company. Should I appeal this, or is Anthem correct to bundle these two surgeries?

Amy Ellis, Evansville, IN

Response: Anthem is technically correct in bundling those two procedures together (there is a Correct Coding Initiative edit that bundles CPT 28293 and CPT 28285). Many bundling software programs are based on the CCIs, and likewise will bundle these two codes together.

What you did not mention in your post is if you used any modifiers to try to correctly "unbundle" the procedures. Using a "T" modifier and/or "-59" modifier on CPT 28285 (hammertoe correction) should allow payment of both procedures.

I would recommend you review your billing for application of these modifiers (the bunionectomy procedure should have been modifier with either "RT" or "LT" to identify the location of that procedure). If you did not, I would recommend you send in a corrected claim with an appeal.

As far as the low reimbursement, that would depend on the coding acceptance and the contract you signed.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found at http://www.codingline.com/subscribe.htm

RE: Obesity and the ADA (Bret M. Ribotsky, DPM)
From: Andrew Schneider, DPM

I too have had a very similar situation. I had two obese patients sit on my chairs and break the hydraulic cylinder. Very expensive to repair!! These patients are very nice people who are aware that they are obese and openly talk about it. It's nice not having to talk around them. I did not tell them, however, that they broke my chair. In one case, two cylinders were broken and, believe it or not, insurance covered it.
Our standard operating procedure with an obese patient is to try to keep them in their motorized chair. Otherwise, if they insist that they be on the examining chair, do not raise or tilt the chair. That is what will break those cylinders.

Since I stopped trying to operate the chairs with them in it, I haven't had a problem. I would imagine discharging this patient would lead to headaches for you. Even if they are unfounded charges based on ADA rules, it will cause time and aggravation that you don't need.

Andrew Schneider, DPM, Houston, TX, AJSDPM@aol.com

RE: Shoes for Child With Sensory Integration Problems (Noah A. Blumofe, DPM)
From: Peta Minerof, DPM

Both of my children have sensory issues, one quite severe, the other very subtle. Although anecdotal, my experiences with my own kids, patients and from discussions with other parents facing the same issues suggest that there are things that can be done to improve toe-walking. Of course, toe-walking has many causes, but in the absence of any physical issues, it's cautious to suggest a visit to the neurologist.

Kids with sensory issues adopt habits and postures to adjust the sensory input to the brain. Occupational therapists who are experienced with sensory issues are a great resource in helping these patients. Pediatric physical therapists may also provide some help. OTs/PTs can help by incorporating stretching and brushing routines to increase sensory input and prevent contracture of the posterior compartment.

Some types of orthotics can be helpful for these kids. A simple off-the-shelf insert, called the "Patti-Bob" (I'm not kidding) seems to give some more sensation and allows kids to have a more typical gait. Soft, flexible AFO's might also help.

Cascade Labs http://www.cascade-usa.com/ has an extensive line of pediatric products for mild to severe pathology. Ironically, Cascade doesn't seem to have approached podiatrists at large. I have found them to be very helpful when working with these issues.

Peta Minerof, DPM, Chicago, IL, Pminerof@aol.com

RE: Query: Digital Scanning For Orthotics (Robert Scott Steinberg, DPM)
From: Craig Payne, Bruce Williams, DPM

Dr. Steinberg is wrong to claim that digital scans are weight-bearing and
cannot pick up a forefoot varus or valgus and has misunderstood Dr.
William’s comment about just what "program in" lateral forefoot wedges is.

Scans of the foot are processed with the prescription variables wanted in the final orthoses that is generally milled or direct cut. Forefoot posting or wedges is programmed in then for milling, which has noting to do with the methodology of the scan. This is not different to a lab adding a forefoot varus or valgus post.

There are just as many optical or digital scanners on the market that are non-weight-bearing and allow the foot to be held in STJ neutral and do capture the posterior aspect of the calcaneus, making them no different to plaster casts (except being quicker and cleaner). Clinicians are free to put the foot in whatever position they choose, whether it’s a weight-bearing or non-weight-bearing scanner, based on the available evidence and their clinical experience.

Craig Payne, Australia, c.payne@latrobe.edu.au

No program detects forefoot varus or valgus, we as clinicians make the determination as to whether it exists or does not exist within a patients foot function. This is not a deficit of information from the standpoint of a digital scanning device, but only of the skills of the interpreter. My reasoning to “program in” a forefoot valgus wedge is not made from the scan, but from a functional Matscan test that I do prior to casting. That information will tell me whether I need to load the forefoot laterally to increase the load sub 1st MPJ, thereby helping to eliminate the problems associated with functional hallux limitus. That determination can also be made in other ways not utilizing pressure mapping technology, but it is much more difficult to confirm.

My scans with the AMFIT digitizer are not done full weight-bearing, but partial weight-bearing with the patient sitting and their foot loaded onto the flatbed scanner. As anyone who has performed this type of casting technique utilizing a foam block knows, there is ample opportunity to control the STJ in neutral or near neutral position as the clinician may desire. You just have to become comfortable thinking about the positioning from a different perspective and understand that you must position the knee while keeping the foot flat and loaded onto the scanner.

I’ve seen plenty of clinician’s who can’t determine whether a foot has a true forefoot valgus/varus component, or how to cast the soft-tissue position out of a foot that “appears” to have one of those components. Is this then a “shortcoming” of our podiatric casting system as is currently being taught and utilized? Come on, a program or a scanner is only as good as the person using it, just the same as is plaster, water, and a foot in STJ non-weight-bearing neutral position.

Bruce Williams, DPM, uwalk4me@comcast.net

RE: Comfort Level for H&Ps (Elliot Udell, DPM)
From: Tilden H. Sokoloff, DPM

The most important part of a physician’s ability is to ascertain normal from abnormal. A history and physical examination performed for hospital admission or surgical procedures is strictly that;. a screening function to determine whether your patient has the ability to go through with what you are proposing to do.

It would be a waste of valuable time and unnecessary expense, to send this class one or two patient to an internist to do a routine screening examination. Read the New York Times or Wall Street Journal to see the tremendous waste of screening exams and tests performed today. If the individual has multi-system diseases, that becomes a different story. If you hear anything other than a normal heart, a consult with an internal medicine person or cardiologist is in order and proper as with any other abnormal findings. Anytime a physician lacks the training or confidence to do something, they shouldn't do it.

There is no argument that the ENT, ortho, neuro or podiatric physicians are better at examining that region of specialization. They better be. The fact is that most hospitals have the H&P performed by 1st year residents, nurse practitioners, or PA's. The anesthesiologist is also going to make his or her own assessment of the patient’s status. Yes, we specialize in an area of the body, but we have the responsibility to understand the overall patient and sign our names to that if we are trained and if we choose to take that responsibility.

Tilden H. Sokoloff, DPM, Ketchum, ID, docsok@healthsearches.com

POSITION WANTED - SOUTHEAST

Seeking position as associate, partner or to purchase practice. Licensed in FL, GA, AL, and TN. 35+ years of active practice in all aspects of podiatric medicine and surgery. Available immediately (770) 403-2874 or handor@aol.com

PRACTICE FOR SALE - TEXAS

Practice for sale in fast growing suburb of Dallas, TX. Fully furnished office in medical building on busy street. General Podiatry, including routine care, orthotics, surgery, etc. Currently part-time office, can be full-time. Hospital privileges available. Excellent Opportunity. Must sell fast. Please respond to: P.O. Box 796757, Dallas, TX 75379 or fax contact info to: (972)267-1815.

ASSOCIATE POSITON - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

ASSOCIATE POSITION-INDEPENDENT CONTRACTOR – FLORIDA

High Income position for ethical hard working podiatrist, great for semi-retired or to supplement office practice, part time. Must have Florida license and active Medicare/Medicaid numbers. FAX CV or Resume to 727-785-4697

WELL ESTABLISHED PODIATRY PRACTICE IN MT. AIRY, NC

Dr. John H. Hodges had a well established podiatry practice in Mt. Airy, North Carolina that is either for sale or in need of an associate/partner to come on board to take over patient care. Dr. Hodges unexpectedly passed away in January 2006, leaving approximately 3,500 patients without a podiatrist to care for them. This is a unique opportunity to be able to begin work in an extremely busy podiatric practice. If interested, contact Carolyn McMackin at (336)577-2886 or cmcmackin@triad.rr.com

ASSOCIATE POSITION - NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

PRACTICE FOR SALE/ASSOCIATE/PARTNERSHIP - WASHINGTON, DC

Established busy practice for sale in hospital's medical building. Fully equipped. All aspects of podiatric medicine/surgery. Large diabetic practice with wound care clinic. Large referral base. Hospital to be renovated and expanded. Charcot, forefoot, rearfoot, orthopedics. Residency required for privileges. Moving - will stay for transition. Associateship until purchase. Unbelievable potential to expand. Will finance sale with adequate down-payment. Serious inquires only. Contact scottr0666@yahoo.com

PRACTICE FOR SALE – FLORIDA

Miami-Dade and SW Ft. Lauderdale, well established surgical practice for sale. This one has everything. Surgery, Orthopedics, Pediatrics, Trauma, ER, General Podiatry. Participates in all local and national managed care plans. $850,000 but will discount depending on amount up front. Mature, serious inquires with business experience preferred. email response to podfootdocs@aol.com

IMMEDIATE ASSOCIATE NEEDED - PHILLY SUBURBS

High volume office-based practice suburban Philadelphia. Full-time office, near hospitals for surgery, consults, and in-house pt. care. Candidate must be hard-working dedicated to pt. care and well-trained. Needs to be personable. PSR12/24/36 Board Certified/Eligible required for a fast-paced, fun atmosphere to work. Email CV and contact info to: mrgpod@hotmail.com Or fax CV to 610-668-5175.

NURSING HOME ASSOCIATE NEEDED- PHILA AREA

Extremely high volume nursing home and home care practice. Well-established and respected Suburban Philadelphia practice seeking an associate who is hardworking. Full-time or part-time available. Very busy practice which can be worked every day and be very lucrative for a hard-working individual. No nursing home further than ½ hour away from office. Email CV and contact info to: mrgpod@hotmail.com or fax CV to 610-668-5175

PRACTICE FOR SALE – SOUTH FLORIDA

Miami-Dade and SW Ft. Lauderdale, well established surgical practice for sale. This one has everything. Surgery, Orthopedics, Pediatrics, Trauma, ER, General Podiatry. Participates in all local and national managed care plans. $850,000 but will discount depending on amount up front. Mature, serious inquires with business experience preferred. Email response to podfootdocs@aol.com

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