PM News –February 18, 2006 #2,513 Editor-Barry Block, DPM,
JD
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**********EDITOR'S NOTE *********
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---------PODIATRISTS IN THE NEWS--------
DPM On Medical Mercy Mission to Nicaragua
Before he leaves for the airport tomorrow night, DR. CHARLES
MORELLI
needs to figure out where to pack the Tyienol, vitamins,
antibiotics
and, of course, the Imodium AD. That's not even half of the
$155,000
worth of medicine he's bringing with him to Nicaragua. The
local
foot surgeon will be among the 24 parishioners from the
United
Methodist Church leaving Saturday morning for Matagalpa, one
of the
country's most indigent cities.
Morelli, who arranged for the donated 30 boxes of medicine
and
medical supplies the group packed in the church last night,
expects
to perform two or three surgeries per day during the
weeklong
excursion.
Last year, during the church's first mission to Matagalpa,
Morelli
learned what little supplies the government-owned hospital
had when
he asked for a delicate surgical blade and was handed a bone
saw
that could cut through a small tree. "I was told that
was the blade
for the entire hospital," Morelli said. "Here, I
can get any size
blade I would ever want."
Source: Candice Ferrette, The Journal News [2/16/06]
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------------MEDICARE NEWS ----------------
Leavitt Vows To Reform Physician Pay By Year-End
HHS Secretary Mike Leavitt told the House Energy and
Commerce
Committee that he would work with federal lawmakers to
reform the
Medicare physician payment system by year-end. Committee
Chairman
Joe Barton (R-Texas) said freezing rates effectively cuts
physician
reimbursement and current rates don't accurately reflect
the
services doctors provide. Leavitt said physician
reimbursement is "a
perplexing and difficult problem" and the federal
government will be
on a "perennial collision course" regarding the
issue unless a
solution is reached. He said effective performance
measurement is
crucial to determining the right reimbursement rate.
Source: Matthew DoBias, Modern Healthcare [2/16/06]
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---------DIABETES IN THE NEWS-----------
Height a Factor For Amputation Among Patients With Diabetes
Patients with diabetes mellitus are at risk of leg ulcers.
These
eventually become infected, respond poorly to treatment and
often
require amputation of the foot or part of the leg. Several
factors
combine to increase the chances of a leg ulcer developing.
One of
these is the loss of nerve conduction to the lower extremity
so that
patient's don't feel symptoms of a developing ulcer (pain)
and don't
recognize its early presence. It is also known that such
neuropathy
(declining nerve function) occurs most frequently and
earliest in
longer nerves, such as those going to the legs.
In this study, the authors looked at rates of amputation
among close
to 100,000 patients with diabetes mellitus and found that
height was
a strong predictor of amputation. In the whole study
population,
every 10-cm increase in height was associated with a 16%
increase in
risk of amputation. In the subgroup of patients for whom
data on
fasting plasma glucose levels and dyslipidemia were
available, the
risk of amputation was even greater (79% relative increase
in risk
of amputation. This finding was independent of other factors
such as
the adequacy of diabetes control.
These findings, particularly that the risk of amputation was
present
even among patients who had good control of their diabetes
and other
risk factors, should prompt clinicians and patients to be
alert to
the increased risk of neuropathy and diabetic ulcers in
taller
patients.
Source: Canadian Medical Association Journal Feb, 2006,
Diabetes
Care 2006;29:73-77. via Diabetes in Control
-------- MEETING NOTICES/ COURSES --------------
Does your practice produce too many headaches and not enough
income?
Consider learning the skill of functional manipulative
therapy at a
two-day hands-on workshop in Napa, California, where Rue
Tikker,
DPM, teaches the therapy he's been practicing for years. He
discusses its place in an integrated practice, demonstrates
the
manner in which it's applied, its efficacy in the treatment
of
sprains, and its utilization in the relief of neuroma pain,
metatarsalgia, heel pain, and tired, aching feet. You earn
15 CE
contact hours through the California PMA, a CPME-approved
sponsor.
Your total investment is $1,500, or $2,500 for two
partners/friends
in one workshop. Dates by arrangement. Podiatrists who've
used this
technique report 75 to 80 percent of patients get amazingly
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relief and they've boosted monthly practice income
$8-10,000. E-mail
rtik napanet.net, phone 707-265-6333, http://www.podiatrywo
rkshop.com
---------
Scholl College of Podiatric Medicine to Host History Taking
and
Physical Examination Review Course March 3-4, 2006 Annual
continuing
education activity offers podiatric professionals an
opportunity to
improve clinical efficiency.
The Dr. William M. Scholl College of Podiatric Medicine at
Rosalind
Franklin University of Medicine and Science will host a
continuing
education course entitled "State-of-the-Art History
Taking and
Physical Examination Review: Improve Your Clinical
Efficiency" on
March 3-4, 2006 in North Chicago, IL. This 18 continuing
education
contact hours is designed to help podiatric physicians
refine and
enhance their skills in performing history and physical
examination.
The course will be held in the University's Education and
Evaluation
Center, which will provide standardized patients to portray
a
realistic patient encounter. For more information or to
register,
call 847-578- 8410 or e-mail ellie.wydevenrosalindfranklin.edu
------------
For a list of all meetings go to:
www.podiatrym.com/meetings.pdf
-------------QUERIES--------------
Query: Free Medicare Billing Software
Has anyone had experience with the free electronic billing
software
Medicare has started providing?
Larry Aronberg, DPM, Lake Worth, FL, lwp01bellsouth.net
--------- CODINGLINE CORNER --------------
Query: Codes for Adhesive Tape and Coban
What are the correct codes for adhesive tape and Coban
supply?
How would be bill an insurance (non-Medicare) company for
these
items? I am aware most will not cover these items, but some
patients
insist we submit a claim before they will accept it.
Sandy Kramer, Winona, MN
There are various A codes in the HCPCS book detailing
specific
supplies.
You are correct that most insurance plans will not cover
items they
feel are incidental office supplies - e.g., tape, gauze, a
needle,
the syringe, alcohol wipe, gloves (all of which, by the way,
have
HCPCS A codes assigned) -- which would be included in the
basic
office expense allowance of CPT service or procedure codes.
Tony Poggio, DPM, Alameda, CA
-----RESPONSES / COMMENTS------------
RE: Neurontin for Neuromas (Norm Wortzman, DPM)
From: Elliot Udell, DPM
Neurontin as well as Lyrica are both effective in the
management of
neuropathic pain. I have known of patients with severe
radiculopathies who were managed well with Neurontin. My own
clinical leaning however is to reserve this class of
medications for
cases of chronic nerve pain where there are either none, or
very
limited permanent solutions. In the case of Morton's
neuroma, we
have many other clinical choices that give lasting relief.
In my
clinical practice we first try the 4% alcohol injections as
espoused
by Dr. Dockery. If this fails, we try Sarapin injections
mixed with
dexamethazone, orthotics, physical medicine, and possibly
some of
the surgical options. If all else fails, only then would we
resort
to a long-term medication.
Elliot Udell, DPM, Hicksville, NY, Elliotuaol.com
-----------
RE: Ultrasonic Guidance for Injections (Tony Poggio, DPM)
From: Larry Kollenberg, DPM
About 5 years ago, I looked into this and was shocked to
find the
heavy American and European literature associated with
ultrasound
guidance involving the heel, neuromas and other structures
of the
foot. We were actually considering it for nerve guidance to
blocks
associated with some nasty wounds at the time. There is much
that
was published on the ability to see the small structures of
the foot
with the proper training and interpretation of the
ultrasound
systems of the late 90's. I suggest that you redo this same
type of
literature search so that if you decide to perform
ultrasound guided
injections then the literature will back you on medical
necessity as
recommended by Dr. Poggio.
Larry Kollenberg, DPM, Jacksonville, FL, lkollenberghotmail.com
------------
RE: 900 Number for Insurance Verification
From: Paul Kesselman, DPM
A patient with Excellus BC BS of Central NY presented for
orthotics.
When our office called to check on coverage, we were told we
would
be connected to a carrier in Nevada. Prior to the phone
connection
being made, there was a recorded announcement that we would
have to
agree to a $4.50 connection charge for the privilege of
connecting
to this 900 number. We asked the patient to check into this.
He got
right through, and supplied us with the information that he
was
covered and did not require pre-certification. My staff
repeated his
steps (as though we were the patient) and sure enough, no
charges,
no fees.
I was always under the impression that if my contract says I
should
be able to contact the insurance carrier via a toll-free
number,
that any changes made to this provision, would require some
written
notification.
I certainly will be forwarding a formal complaint to the NYS
Attorney
General's Health Care Bureau and the NYS Insurance Dept.
Paul Kesselman, DPM, Woodside, NY, pkeseslmanpol.net
Editor's comment: PM News does not provide legal advice.
The fact
that an insurance company breaches its contract (as it
appears to
have done in this case) does not mean that it broke the law.
The
remedies for civil torts differ considerably from criminal
violations.
---------
RE: Aetna's Billing Code 64450 Error (Paul Bishop, DPM)
From: Steven D. Epstein, DPM
Podiatrists and other healthcare providers responses to this
and
Medicare's taking until "sometime in July" to
pay the additional
4.4% reduction on claims that Congress "failed"
to prevent are in
stark contrast to how pharmacies have dealt with the
problems of the
new prescription drug program. When the cards didn't work
properly
in their machines, patients had to pay if they wanted their
meds. No
assuming that eventually the insurers would get around to
fixing
things and so give the patient his Rx now and fight to
collect it
later. Card doesn't work, then you have to pay. No money,
no pills.
This created an immediate crisis, threw egg on the face of
the Bush
administration (as if they haven't had enough egg on them
lately),
and dumped the problem in state governments' laps, which
had to come
up with emergency funds to pay the drug stores for the
poorest
people, and had governors begging -- but not forcing --
pharmacies
to give people their meds for now while the system is being
fixed.
It should be noted that the retail pharmacy industry is very
competitive, but the one place that they will not compete is
in
giving away their services for free. While they certainly
have their
lobbyists and trade groups, I doubt they needed those to
make the
decision not to give out meds when cards were denied. In
business,
it is second nature, it is survival, to make sure you are
getting
paid, and you only give something away for free, as charity,
intentionally. Have healthcare providers lost the survival
instinct?
Have we ever had it?
Steven D. Epstein, DPM, Lebanon, PA, sdepsteinyahoo.com
------------
RE: Standard of Care, Plantar Fasciitis (Allen Jacobs, DPM)
From: Multiple Respondents
The lively discussion on plantar fasciitis treatment seems
to have a
very common thread of agreement on the success of
conservative
treatment. I remember a long time ago (20 years) discussing
this
condition with a colleague, and the discussion went south
for me
when he said the following: "Initial visit, x-rays,
6-10 injections,
12 physical therapy treatments, and orthotics are what they
all
get." He then proceeded to tell me that every
fasciitis diagnosis in
my office should generate a minimum of $1.500 - $.2000
dollars.
While I had no objection to his keen sense of practice
management,
all credibility was lost when the same course was prescribed
for the
diagnosis, and not how the diagnosis affected a particular
patient's
life.
I estimate that 30-50% of my new patient visits are for heel
pain,
and 95% of those are diagnosed as plantar fasciitis. The
vast
majority come in after four to six weeks of symptoms. I have
a
substantial subset of these patients, both male and female,
who when
they find out that the problem is mostly mechanical (in the
absence
of identifiable injury), decide on nothing more than
stretching
exercises and footwear advice (Can't afford orthoses, would
never
take cortisone, won't take NSAID's, etc). A very
impressive number
of them get better within several weeks to a year. I make
sure these
patients understand that many treatments are available if
they think
the pain is getting the best of them. This subset of
patients are
very active in referring others with heel pain. In patients
whose
heel pain persists beyond six months, treated or not, I get
a
rheumatoid work-up. These investigations are negative 99.9%
of the
time. If a patient has exhausted all available non-surgical
treatments AND has had unremitting pain for a year or
longer, I am
ready to discuss a surgical option with them.
Bryan C. Markinson, DPM, New York, NY, Profpodaol.com
Even though I perform an occasional partial plantar
fasciotomy for
chronic plantar fasciitis, I certainly think that the
podiatrist
needs to have attempted at least 4-6 months of foot orthosis
therapy
along with the other treatment modalities before one
contemplates
performing this procedure. Plantar fasciotomy should not be
performed unless all other modalities have been attempted
since the
plantar fascia (i.e., central component of the plantar
aponeurosis)
is a very important structural component of the foot that
provides,
at least, ten vital functions to the human locomotor
apparatus.
Ten Functions of the Plantar Fascia
1. Serves to support the medial and lateral longitudinal
arch in a
higher arched position (i.e. increases the dorsiflexion
stiffness of
the medial and lateral forefoot).
2. Assists in resupination of subtalar joint (STJ) during
propulsive
phase of walking.
3. Assists the deep posterior compartment muscles by
limiting STJ
pronation.
4. Assists the plantar intrinsic muscles in preventing
longitudinal
arch flattening.
5. Reduces tensile forces in plantar ligaments.
6. Prevents excessive interosseous compression forces on
dorsal
aspects of midfoot joints.
7. Prevents excessive dorsiflexion bending moments on
metatarsals.
8. Passively maintains digital purchase and stabilizes
proximal
phalanx of digits within sagittal plane.
9. Reduces ground reaction force on metatarsal heads during
late
midstance and propulsion.
10. Helps to absorb and release elastic strain energy during
running
and jumping activities.
Nearly all of the above functions of the fascia have been
supported
by experimental research, with a few of the functions being
predicted by mechanical modelling of the foot. I have
previously
written an article on this fascinating biomechanical subject
over 10
years ago (Kirby KA: Foot and Lower Extremity Biomechanics:
A Ten
Year Collection of Precision Intricast Newsletters.
Precision
Intricast, Inc., Payson, Arizona, 1997, pp. 45-46.)
Kevin A. Kirby, DPM, Director of Clinical Biomechanics,
Precision
Intricast Orthotic Lab, kevinakirbycomcast.net
I was surprised at some of the comments concerning EPF's
during
the "standard of care "discussion. I have been
performing the
procedure exclusively for seven years and have almost a 100%
pain-
free rate within 7 weeks with no lateral nerve damage.
Almost all
the patients had a great decrease in pain the day after
surgery
compared to the day before. I think the largest cause in
failure of
any surgery is post op care. My EPF's are kept partial
weight
bearing for two weeks and are out of "standing all
day" work for six
weeks. I tell them only walk on it to the restroom etc. I
change the
dressing at 5 days so that they may begin wearing their
regular
shoes and orthotics. They still stay off it as much as
possible
another ten days. They increase activity slowly and are
discharged
at 4 weeks if pain free.
Gary S. Smith, DPM, penndocverizon.net
I agree with many of the posts that conservative therapy is
definitely the way to start as I agree 90% will become
asymptotic
over time with orthotics, night splints, steroid injections,
physiotherapy etc., however when these measures fail
surgical
intervention is always an option. I do not wait for six
months as
that maybe this is a requirement for ESWT, but not for
cryosurgery.
I have performed approximately 175 cryosurgery's for
plantar
fascitis that I believe has a neurogenic component. That is
why
these patients did not respond to conservative treatments. I
have a
92% success rate for eliminating their pain with the
cryosurgical
technique with one treatment; some that required 2
treatments. This
is another option for the patient done in office with a
small 1/8
inch incision, no stitches, no cast, crutches either.
Steven H. Goldstein, DPM, Livingston, NJ, Stevefootdr1cs.com
In my area a standard has been functionally set by our
largest
regional insurance plan which published the following
protocol in
2003 in response to ESWT use.
ESWT… "may be considered medically appropriate for the
treatment of
patients with chronic proximal plantar fasciitis as an
alternative
to surgical therapy in patients who have chronic,
recalcitrant heel
pain syndrome with lack of response to at least three other
conservative treatments (for at least six months) such as
rest,
physical therapy, anti-inflammatory medication, local
corticosteroid
injections, or heel orthotics."
William S. Pierce, DPM, West Seneca, NY, ftdocjuno.com
Editor's Note: This topic is now closed.
-----------CLASSIFIED ADS--------
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Applicants should have at least 2 years of residency
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-----------
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Office podiatry skills (residency experience, office
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-----------
EQUIPMENT FOR SALE - ESWT
If you are using or thinking of using ESWT, I have a new
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a look at http://www.orbasone.com.
Call 1-856-229-2939.
---------
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------------
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