LETTERS TO THE EDITOR
***New Doc and EMR***
I started my practice about 10 months ago and decided to use EMR from the start. I went with Medinotes-e. There are many custom templates built in which other
podiatrists have built. While there is still a learning curve to creating your own templates, it is a manageable software package. Once you start programming your
own phrases such as in the Plan, you can click on Plan and you can have it say “Plan is updated as follows: Today I injected a 1:1:1 mix of Celestone
Soluspan:.5% plain marcaine:2% plain lidocaine into the anterior lateral aspect of the ankle joint.” Along with this, you can automatically link the CPT codes
20605 (injection/aspiration of medium joint) and J0702 (Celestone Soluspan) and these codes will automatically forward to the E&M billing grid.
I know most people think Medinotes is too time consuming. However, if you start with it as a new practitioner in a new practice, it does allow you time to get your
speed up. In addition, used in conjunction with Lytec practice management and billing software, all of the E&M billing codes from Medinotes get forwarded back
to Lytec to be sent to an electronic clearing house. When used with such clearing houses as Gateway EDI, insurance payments can automatically be uploaded and
posted back to each patient's account which eliminates the time it takes for a person to have to sit and go through the EOB and manually enter the payments.
While there are many cons that people see with EMR, I feel that if you take the time to learn the software and customize it to your practice, the speed will come.
Unfortunately, most practitioners want to follow the last patient out the door. The amount of money and time that it takes to convert a paper practice to electronic practice
is overwhelming and most older practitioners don't want to spend the money it takes. Good luck with your future conversion.
Kent E Stahl, DPM
[email protected]
***New Doc and EMR***
I am finishing this year and opening a practice. I have looked at some EMR programs for my office. Do you use EMR in your office? If so are you happy with the system
and if not which would you suggest? Thanks for your reply.
Brian Brausa, DPM
[email protected]
EDITOR'S RESPONSE
I've mentioned in a past editorial that I unfortunately do not use EMR in my current practice life. As an associate to a much older physician who never updated his office,
I am bound by his limitations. I would LOVE to use an EMR program in the office, but I think that will have to come with time. I refer you to the above submission as a
good place to start. If anyone else has recommendations for EMR programs please write in and educate those of us still in the stone ages.
Jarrod Shapiro, DPM
***Deposition***
Thanks so much for the insight, by sharing your experiences we can all avoid the same difficulties and can also share in your triumphs.
Did the deposition affect your relationship with your employer?
Thomas Javorsky, DPM
[email protected]
***Deposition***
Nice column and all good points. I would agree that the very nature of legal matters is probably one reason why many of us chose a career path in medicine. I would
like to make one clarification point to your statement on not providing expert testimony. DEFENSE expert testimony is a very different ballgame than those who take on
plaintiff work. I have done some malpractice defense work and I can tell you that being able to properly argue a case and clearing a wrongly accused podiatrist from
charges is a very rewarding endeavor. In contrast, I have chosen not to take any plaintiff cases because of the very reasons you mention.
John S. Steinberg, DPM
Assistant Professor, Department of Plastic Surgery
Georgetown University School of Medicine
EDITOR'S RESPONSE
If I can prevent others from making the same mistakes I've made, then this editorial is truly a wonderful resource. Hopefully, there will be more triumphs than difficulties.
On the deposition issue: no, it didn't affect my relationship with my employer. First, I wasn't being sued. You'll find in medical practice that workmen's compensation cases
are often quite complicated and may end up with you giving a deposition. Second, my boss coincidentally had a deposition for a worker's comp case the following week.
Jarrod Shapiro, DPM
***Medicare/Medicaide***
You can't be a physician today and not see Medicaid patient. If you're dropped from Medicare/Medicaid, then you are hosed when it comes to insurance. Being dropped is
the kiss of death. I guarantee you'd get a call from the government asking why aren't you seeing these patients...Could you elaborate on how you plan on not accepting
Medicare/Medicaid?
Per your discussion, I would've gotten clearance or a second opinion from another PCP. One that would allow you to proceed as YOU see fit since YOU are the expert. But
before that, I'd want to know what was done for that toe prior to that consultation. In fact, I wouldn't have done the consult without it.
Laurence Cane, DPM
[email protected]
***EDITOR'S RESPONSE***
Let me respond to both of your points separately. First, the Medicaide issue. I do accept Medicare, so that part is moot. However, my employer had, over the past several
years, stopped accepting Medicare and was only taking private insurers without any difficulties (either monetary or governmental). As for Medicaide, over the past 29 years
he has never accepted these patients with no adverse consequences. So, as far as I know I am not required to accept these patients. I am not in an underserved area,
which allows me to chose. If anyone else has an educated voice in this matter we'd all love to hear from you. This is an important issue.
On the next issue I couldn't disagree with you more. Your approach to this would lose you more than one potential referral source which might not matter to you, but if
you're a new practitioner then you don't have the leeway to pull that kind of stunt. This patient had been referred to me by this physician in trust. In fact, the PCP had a
30 year history with his patient and was trying to do what was best for her. I am not about to steal a patient from a referring doctor and send them to someone else
unless I strongly thought her health were at risk.
So, what did I do exactly? I did gather a complete history prior to instituting treatment, which I do on all of my patients. I then diplomatically spoke to the PCP and
educated him on the endovascular options for which he was not aware, emphasizing the minimal risk of complication from this procedure versus the risk of doing nothing.
After a respectful conversation, he agreed to my plan and the patient is now doing fine after her Silverhawk procedure.
Yes, I am the expert, as you put it, and I did my job as a doctor, which is to educate others, including the medical community. If your methods are to steal other people's
patients and come across as “THE EXPERT” with that kind of attitude, then I recommend you take some diplomacy classes. Treat your patients and your
physicians with respect, and you'll be a more satisfied and busy physician in the future.
Jarrod Shapiro, DPM
***An Attending Physician Discusses Office vs Surgery***
I have read you articles since the inception of New Docs. I have a couple of thoughts for you.
First, you do not charge enough for a lapidus; use the tarso/metatarsal arthrodesis code.
Office work does make more than surgery, less liability, more happy nights for you. You must however, sell products. The American Academy of Podiatric Practice
Management is a good place to learn about how to make money in the practice of podiatric medicine and surgery. It is an important realization, I like what I do but I need
to make the living I expected.
Jeff Hetman, DPM
[email protected]
***EDITOR'S RESPONSE***
Thank you for your coding insight. Previously, I used code 28297 (correction of bunion with lapidus arthrodesis) which pays $718.62 according to the Medicare 2007 fee
schedule. I believe the code mentioned above would be 28740 (midfoot arthrodesis single joint) which pays $762.88. Either way, if I charge $1500 I'm still not being paid
enough, however, I wouldn't turn down the extra $44.26. If you know how I can improve the reimbursement rates in general I think we would all benefit.
Jarrod Shapiro, DPM
***Bringing Income Into the Practice***
Hello, I'm a 2nd year podiatric medical student. I enjoyed your thoughts in the bringing income into the practice. I do have a question though....what options are there for
nerve conduction studies and arterial/venous studies for podiatrists??? This is a topic that arose in a neurology class last semester that seems very promising in our field.
Kevin C. Bryant
Barry University Class of 2010
[email protected]
***EDITOR'S RESPONSE***
I know we can do arterial and venous studies in the office. You have to document your findings graphically, i.e. on paper. If you don't have the appropriate training, I'd
recommend obtaining it from any of the companies that supply the equipment. Remember, training is important. You have to be able to adequately interpret the test
results. As far as EMG/nerve conduction studies, I'm not sure. My guess is that we can't because it's out of our scope of practice. I could be wrong, though. If anyone
has info on this, email in and let us know.
Jarrod Shapiro, DPM
***Office vs Surgery***
Great article...but you forgot to mention a KEY component of surgery or procedures.... GLOBAL period. If you take that into account, I think per hour rate for surgery is
MUCH less than seeing patients in the office. In my humble opinion, I think the pods that are financially successful are the ones that do NOT perform too many surgeries,
rather knows how to effectively treat in their offices.
David Baek,DPM
Laurel, MD
[email protected]
***Office vs Surgery***
I just read your comparison of office reimbursement vs. surgical reimbursement.I was surprised to see that the surgical pays more per hour.
This is totally to the contrary of what I have found. The only thing I do is review every single EOMB that comes to my office. And just off the top of my head, I can see that a
surgical procedure at a hospital or surgery center does not nearly pay as much as seeing office patients for the same amount of time as it takes to:
1. Drive to the hospital
2. check in the wait for them to put your patient on the table
3. scrub in
4. do the procedure
5. I have residents so I don't even do any of the pre or post op paper work or dictations.
6. speak with the family members that are waiting for the patients to finish surgery
7. drive back to the office etc etc etc.
Also, in you summary, you did not write the actual CPT code you were using for the surgery. And I don't think you accounted for the several and sometimes many post op
visits that go unpaid because it is paid on a global basis for three month of follow up visits.
That would have helped some. But regardless of what code anyone uses, I know for a fact that surgery DOES NOTPay more than a day at the office.
I welcome your response.
Jorge Nasr, DPM
Miami, FL
[email protected]
***EDITOR'S RESPONSE***
I was also surprised by my findings. I didn't know what I'd find when I put this editorial together. I understand the common parlance is that office makes more than surgery.
However, I'd think this would vary by the office. If you do a lot of office dispensing, and your practice is busy it would make sense that office makes more.
In a very informal manner, I bundled most of the above points into the surgical time. All of these vary by day, situation, physician, and location and I didn't have any
benchmarks to work off of. I deliberately avoided the CPT codes because many readers may not be familiar with coding yet. I consider this information, as I mentioned in
the article, with a grain of salt; it was not meant to be complete to the point that I could publish it in JFAS. Rather its intent was to provoke thought and discussion, which it
clearly did. You're right about the global period. Omitting the global was purely an error on my part. If you add this part in alone, it makes it hard to justify surgery as a sole
component for a practice. Thank you for your thoughtful response.
Jarrod Shapiro, DPM
***Patient Education***
Hello Dr. Shapiro,
Last spring I finally completed a large goal after 25 years in practice. With the help of 2 young men locally, they produced a DVD that I have all my patients watch before
surgery at the hospital or surgical center. The DVD has 2 parts - one that covers the pre and post op instructions showing the facilities, what to bring, what to have
afterwards...and the second part that is informed consent. I outfitted an office with a comfortable couch and chairs. They are given a pen and tablet for questions. They
are offered to borrow this DVD if they want to watch again or have family members watch it. It has saved me lots of time. I got so tired of repeating myself. And my staff
members would not always do everything or say everything during each pre-op visit. It would be a formidable piece of evidence in any malpractice case, especially one
involving informed consent. Some of the DVD is found on my website:
www.FootDoctorJane.com They put clips on it for reviewing and they also designed the website
and put a virtual tour of my office. Let me know if you would want any further information.
Jane Graebner, DPM
[email protected]
***Noncompliance***
I understand your grief! I've been in practice for 9 years and have developed an attitude as my patients refer to me as a "benevolent dictator". I'm very strict
in my care and compliance, but it's for the patients best care...explain that to them! I've learned that if you're doing procedures that are complex and need strict NWB...
THEY ALL GET NWB BK CASTS. And if I don't trust them, they will get an AK cast.
Your trust in the 17yo with the Lapidus in a Cam Walker is CRAZY! It needs a good 6 weeks of NWB in a cast for the fusion to be stable enough for WB, in my opinion.
Wait till you have to deal with a nonunion and an irritated patient who has to be told she needs more surgery and more time off of work to fix the problem that THEY
caused. Not fun!!!
Getting more people compliant deals with informed consent and explaining the procedure and Post-op care. If you were to tell the 17yo that it was going to take 6 weeks
in a cast, the 2-4 weeks in a WB Cam Walker with physical therapy and it may take a total of 3 month for the procedure to heal and for her to get back to regular activities,
if she follows instructions, if not it could be longer...your compliance rate may increase. As far as your diabetic patients, GOOD LUCK, they all have a form of
"glycosilated brain matter"!
Sometimes more conservative post-op care is the way to go...you're just gonna have to find out works best for you.
Sean Wilson, DPM
[email protected]
***EDITOR'S RESPONSE***
Thank you for your honesty; I've never been called CRAZY before! However, a friend of mine, Clark Larsen, DPM did an interesting study while in residency in Texas
where they compared WB and NWB as Lapidus postop. They allowed full WB after a 2 week period with a Reverse Morton pad and found no difference in the nonunion
rates. I don't think this was published, but it was presented at the ACFAS conference 2 years ago. I still don't WB my patients after a Lapidus, but perhaps, just perhaps,
I'm not as CRAZY as you might think!
I do agree, though, that as time goes by I'm going to become much more conservative in my care. I can see it already, and I'm not even 2 years into practice!
Jarrod Shapiro, DPM
***Bringing Income Into the Practice***
Hello, I'm a 2nd year podiatric medical student. I enjoyed your thoughts in the bringing income into the practice. I do have a question though....what options are there for
nerve conduction studies and arterial/venous studies for podiatrists??? This is a topic that arose in a neurology class last semester that seems very promising in our field.
Kevin C. Bryant
Barry University Class of 2010
[email protected]
***EDITOR'S RESPONSE***
I know we can do arterial and venous studies in the office. You have to document your findings graphically, i.e. on paper. If you don't have the appropriate training, I'd
recommend obtaining it from any of the companies that supply the equipment. Remember, training is important. You have to be able to adequately interpret the test
results. As far as EMG/nerve conduction studies, I'm not sure. My guess is that we can't because it's out of our scope of practice. I could be wrong, though. If anyone
has info on this, email in and let us know.
Jarrod Shapiro, DPM |
