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Saturday, December 17, 2016

Ankle Sprain? How do I treat an ankle sprain?

It is a common scenario, you step off a curb and you feel it, your foot and ankle turn in when it shouldn't! Within seconds your outer ankle starts to swell, get red, and very painful.  If you stand up and can walk I still would recommend you see your foot and ankle specialist.  It is absolutely best to see a specialist that can take an X-ray of your foot and ankle to make sure you have not broken anything.  Your specialist can give you advice on what you need to do to get better, write for a medicine if necessary and offer you devices that may help in the aid or care of your foot or ankle injury.    The reason I stress that you should see your foot and ankle specialist is because there are 6 plus different bones you could possible break with this type of injury. Also, a well thought plan of care is going to be better than your own self diagnosis and treatment. Just "googling" your symptoms, more often than not results in sub-optimal results in your health, and taking your neighbors advice on your foot problems yields pretty terrible results!

So you see your doctor and X-ray shows no fracture, SWEET, right? Well, though I think breaking a bone is not ideal, soft tissue injuries can take some time to get better, and some people struggle for an extended duration.  Convalescence of a foot or ankle injury is very important.  If you do not treat it right, it will not treat you right!

If you have been diagnosed by your foot and ankle doctor with an ankle sprain, these are our recommendations:

1.  ICE, ICE, ICE: not for the first 24 hours but everyday, at least twice a day, for 2 weeks.  There are so many great icing products that are better than the old school ice system of the ziplock bag. Below I have a link to my favorite ice pack!


2.  Support is the next piece of the puzzle and depending on the damage, one of a couple options may be best for you. Make sure you ask your doctor about an Aircast splint versus a cam walking boot to help calm down your foot and ankle pain. If you need temporary immobilization all you may need than an Aircast splint, but if you are having difficulty putting weight on the foot than a waking cast would most likely be more suitable. There is a link below for the cam walking boot we use for ankle injuries below!

Some people struggle for months and years with ankle sprains, so choosing the right course of care can make all of the difference in the world! Most people who seek treatment swiftly, take their doctor's advice and follow through with their plan of care have the absolute best results!

If you would like to learn about any other foot or ankle pathology or problems after injury visit:
http://centeranklefootcare.com/








Monday, December 5, 2016

What is a bone spur on the foot?

What is a bone spur or heel spur?

This is a question I get daily from patients that come into the office.  They will describe classic symptoms that we see all the time with heel pain/plantar fasciitis.  They get out of bed in the morning and they will feel intense horrible pain in their foot that often the describe as crippling or horrific! They come to the office and we take an X-ray to confirm there is no fracture. Then they see a big spur on the bottom of the heel bone and freak out, that this is the reason they are in so much pain!

Not everyone who has a heel spur or bone spur, like pictured here, has plantar fasciitis or heel pain.  But many people get a spur when their fascia is tight.  The plantar fascia is a tight band on the bottom of the foot that commonly gets tight just due to our anatomy of our lower leg.  The plantar fascia attaches the heel bone to the flexor tendons of our toes. Our calf muscle becomes our Achille's tendon that inserts across the ankle joint into the middle third of our heel bone.  When our calf muscle is tight it pulls abnormally on the heel bone which in turn pulls abnormally on the plantar fascia. When this band get tight and contracted and you take a step, the fascia pulls on a thin membrane around the heel bone called the periosteum.  This lifts or tents up and new bone is formed.  This process usually takes a long time, it is your body's mechanism to try and spare you pain, but eventually if you keep ignoring the tightness of your lower leg you eventually are going to feel the pain of plantar fasciitis and it will most likely be the soft tissue that is your problem, not the bone!

Explaining this to patients is very difficult sometimes because we like to see proof of why we hurt. But on X-ray you can not see soft tissue and it is not satisfying sometimes to the patient to accept this because, let's face it, plantar fasciitis really hurts! But even when patients have no bone spur they also are so upset because they can not believe something so simple is their problem!

Treatment is the same for me when I treat patients with the symptoms with plantar fasciitis no matter if they have a heel spur or not.  The hallmark of getting your heel pain better is stretching, icing and great support!

There are cheater ways of stretching that I favor myself like a plantar fascial night splint. This is a device you can wear while you are sleeping, but some people can not stand wearing it all night.  I had plantar fasciitis and I wore the splint whenever I was sitting down at home, so I would get at least 4 hours of stretching when I was watching TV or doing paperwork at home.  This was one of the best ways to help stretch out that fascia and help your bone spur pain.  Of course icing the foot and wearing a good support in your shoe help too! For more information about plantar fasciitis and bone spurs check out our website at http://centeranklefootcare.com/heel-pain.html.



Friday, December 2, 2016

Center for Ankle and Foot Care Blogspot: Heel pain is the worst! Here are my favorite piece...

Center for Ankle and Foot Care Blogspot: Heel pain is the worst! Here are my favorite piece...: You wake up, step out of bed and then BAM! You feel it, a sharp undeniable  pain on the bottom of your foot near your heel.  Were you asle...

Heel pain is the worst! Here are my favorite pieces of advice for patients suffering from heel pain that I know work from experience!

You wake up, step out of bed and then BAM! You feel it, a sharp undeniable  pain on the bottom of your foot near your heel.  Were you asleep for a hundred years, or did you rapidly age overnight?  No, you have plantar fasciitis, most likely.  As a foot doctor we see patients with heel pain about 15 times a day.  It is one of my favorite problems to treat, because people are always in shock on how easy it is to get better if they just follow some simple instructions.

This topic is very close to home for me, because after 2 weeks of a new exercise program P90X3, I developed plantar fasciitis!  The doctor is now the patient! This exercise program is a lot of jumping and up on your heels for different exercises.  It is a great program, but I would recommend some extra stretching of the calf muscles before and after to avoid getting plantar fasciitis.

Many people find it hard to get into the doctors office, but when your foot hurts it sometimes is unavoidable.  If you think you have plantar fasciitis or "heel pain" I would recommend seeing your foot and ankle specialist. But I will share with you what I have done from Friday of this past week, when my pain first started, until today Tuesday, just 4 days later.  My pain has gone from an 8 out of 10 Friday morning to about a 2 out of 10 Tuesday morning.
What Is Plantar Fasciitis?

Plantar Fasciitis is an injury sustained as the result of repetitive stress placed on the bottom of the foot. More specifically, its damage sustained on the fascia—a thin layer of fibrous tissue that protects
other tissues within your feet. Many people develop Plantar Fasciitis from long periods of standing, running, or performing various load-bearing activities. For me it was a new exercise program with a lot of jumping.

 Plantar Fasciitis Symptoms

The most common symptom of Plantar Fasciitis is pain. This can be burning, stinging, stabbing or throbbing pain. Many people experience a dramatic amount of pain when they first get up in the morning, with the sensation lessening throughout the day. For others, the pain is consistent. The pain can be isolated to an area in the middle of foot, or it can radiate outward towards the toes. The heel is the most common area for Plantar Fasciitis pain to show up. Plantar Fasciitis pain can be very stubborn and last for months or even years. Since walking and standing cannot be completely avoided in our lives, the injury can cause serious disturbances in professional and private life.


 Causes of Plantar Fasciitis

The causes of plantar fasciitis can be multi factorial, as you can see below.  But the anatomy of our lower leg plays a major role as well.  If you look at your calf muscle as compared to the front of your lower leg, you will notice a big disparity in muscle size.  The back of our leg muscles are bigger because they have the responsibility of pushing our body forward with each step. But the more we walk or exercise with out stretching, the tighter this muscle group gets!

Several different things can cause Plantar Fasciitis, which makes classifying the condition somewhat difficult. For example, bone spurs, flat feet, high-arched feet, and hard running surfaces are all very different—but each one can be a cause of the condition. Individuals in professions that require you to stand for long periods of time—nursing, for example—are at a higher risk for developing cause Plantar Fasciitis. Another very common cause of Plantar Fasciitis is the type of shoe you choose to wear. Older or poorly constructed shoes can place your feet at a higher risk for stress. Shoes that don't have adequate padding for the heel and arch can be a problem as well. Finally, overweight individuals are at a higher risk for developing Plantar Fasciitis. As you gain weight, this naturally places more stress on the tissues of your feet, and the fascia tends to bear the brunt of this.

 Treatments

Below you will find my recommendations regarding treating and making your heel pain go away
People find it hard to believe that stretching, icing and support can be the perfect combo to relieve and help get rid of their heel pain, but it's true!!!! I know from experience over the last 4 days!

What I always tell patients when they come into the office with heel pain or plantar fasciitis, is that even though it hurts so darn bad the cure really does revolve around stretching believe or not, in most cases.  Sure it can require a medicine by mouth or even a shot with some extra support in shoe gear but it is usually a simple fix.

The fix is simple but, depending in how long it takes you to seek help to get better, could be the deciding factor on how long it actually takes you to get better.  The sooner you seek care, start the stretching exercises and put good support in you shoes, the sooner you are on the road to recovery.

Here are my classic three stretches performed by my lovely stick figure drawings, but simple is always better. I have done these three stretches 4 or 5 times a day for the last 4 days.  Stretching is important for your Plantar fasciitis to get better and stay away.  Yes, that is right, I tell all of my patients that they need to stretch daily after having Plantar facsiitis to prevent it from coming back! These three basic runners stretches should be performed 3-4 times a day when you have Plantar fasciitis.  You should stretch both sides for completeness sake and hold the stretch for 15-20 seconds with no bouncing.

Icing is another thing I tell people to do when they have acute Plantar fasciitis.  But how you ice can be a real key to your success.  You need get a little plastic water bottle and freeze the water inside, then take it out 2 times a day rolling it under the arch of the foot back and forth.  I tell patients this is like physical therapy without a copay.  It is a natural anti-inflammatory and stretches the arch very effectively. I currently have three ice bottles in my freezer and have been rotating the bottles for ice massage non stop when I am home.

These are the two main ways to start treating your Plantar fasciitis right now: stretching and icing. They have been the hallmark of my own treatment over the last 4 days.  But I also have used the following to  help support my fascia while I was standing like inserts and slippers.  Also, there is something called a Plantar fascial night splint that I have worn every day for the last 4 days while I was sitting.

Some people get home and kick off their shoes and then strain the fascia walking barefoot around the house.  Support, even at home has a very positive effect in your outcome and feeling better sooner. Something like a spenco slide or slipper can be a foot saver and is what I have relied on the last couple days to protect  my feet around the house.

Here is a link to our webpage, with our top recommendations for heel pain and plantar fasciitis.  I put my favorite helpers for heel pain available below, my secret trick was the night splint with a gel ice pack in the foot bed of the splint from about 7pm until 11pm while I was doing computer work.  This was great because I could not sleep with the splint on but I got a great stretch for 4-5 hours every night while I was really doing nothing:
    
http://centeranklefootcare.com/plantar-fasciitis-helpers.html


Monday, October 3, 2016

To Fix or Not To Fix My Bunion!!!! The Real Deal On Bunion Surgery!!!!



If you have just left your doctors office and they have told you that surgery is your best option for your foot deformity, you may want to read this and listen to our podcast above first before going through with the surgery.  Now full disclosure Dr. Henne and myself are Board Certified in foot surgery and perform surgery weekly.  That being said we will be the first people to try and talk you out of having unnecessary surgery.  More importantly we make sure you fully understand the post operative course (how bad it really is).  We never SUGAR COAT anything.

Many people come into the office with a bunion or a hammer toe and want it fixed.  But unless they pass a very strict set of criteria to be a candidate for surgery, we turn them away.  I will jump right into the nitty gritty here folks.  Number one reason to not have surgery is NO PAIN!  Yes the old adage if it ain't broke don't fix it still stands. If you do not like the way your feet look, surgery is never the answer! Feet are for function not for entering beauty pageants.  If you want pretty feet, foot surgery will give you pain and may never guarantee a beautiful foot.

When do I operate on someone? The answer is simple: if they have pain that has not improved with a normal course of conservative care and I know that there is a great chance their foot will feel better after surgery.  I never tell someone that their foot will look so much better only that their foot will feel better. I believe the unrealistic expectation that your foot will look better after surgery plays a huge role in why some people are very unhappy after foot surgery.

Bunions are a great example of the type of deformity a lot of people have but do not have a lot of pain with it.  They present with the big bump on the side and want their foot to look thinner but have no pain.

A bunion is a enlarged bump on the inside of the foot at the base of the big toe.  A bunion, in its simplest definition, is a imbalance at the 1st metatarsal phalangeal joint(the big toe joint). A contracture of the lateral side of the joint and stretching of the  medial side of the joint further contributes to the bone getting more deformed.
Over time a bunion can become a progressive deformity that can lead to other deformities like hammertoes, blisters and more. But if you have no pain other than the bump being irritated in some shoe gear, then do not have surgery. The fix for the non-painful bunion is really an adjustment in shoe gear.  Go for a wider toe box and get a mesh sneaker, stay away from constricting leather.  The mesh will give unlike a leather or pleather material. The less pushing you have on the big toe the better to prevent any further progression of the deformity. Also if you just have to wear those fabulous shoes for the day then just do it. Yes your foot is going to hurt after, but just wear good shoes after that! 

 Hammer toes are a very similar situation to bunions as far as a guide to when to fix and when to just wear a more suitable shoe for your foot type. The hammer toe that is most common is the 2nd metatarsal joint(joint at the base of the 2nd toe) hammer toe.  People often come in and complain of a contracted toe that rubs on shoe gear on the top of the toe.  After a thorough examination, if they have no pain but just the nuisance of shoes that they want to wear not fitting right, I tell them to get new shoes.  I explain that the pain they will have after surgery and the aesthetic result they want to have may not line up to what they expect in their mind.

 There are many instances where people have hammer toe surgery and their toe is still kind of deformed looking and much stiffer than they would have expected.  My criteria, which if you are contemplating foot surgery please read closely, no pain in the toe means shoe gear adjustment and using gel sleeves to protect the toe with activity in enclosed shoes.  If there is real pain in the toe and the joint that is unable to be treated with conservative care, then we consider surgical intervention.  I tell all of my surgical hammer toe patients, "You may never be able to wear heels again, and all shoes will not be able to fit just because your toe was fixed."  I always explain the end result is functionality when you have foot surgery not beauty.  

Again, for hammer toes and bunions they make extra-depth and extra-width shoes, that don't look like ugly orthopedic shoes.  They just cheat the extra room where you need it in the shoe with out making the shoe look like it should be on Frankenstein! 


Now, I will tell you that I perform foot surgery weekly on people but only on those who truly need it. If you go see a foot an ankle surgeon and the first thing they offer you for your bunion or hammer toe deformity is surgery, you should run out on your non painful deformed feet and go get some new shoes.  I leave you with this last thought, feet are not pretty.  Feet are for transportation not to be entered in a beauty contest.  I have never seen the foot competition in Miss America for a reason, most people have ugly feet!

If you would like to learn more about other foot and ankle deformities visit our website at http://centeranklefootcare.com/services.html
Michele McGowan DPM
Center for Ankle and Foot Surgery @2014

Friday, September 16, 2016

Cracked Heels? We have a cream suggestion that just might help you!

So summer is almost over, how do your heels look?  Are they dry and cracked from all the sandal and flip flop wearing?  We see many patients a day that come into the office for all different types of foot and ankle problems. A very common issue that is mentioned by patients after treating their foot problem is, "Hey doc, what to you recommend for dry, cracked heels or dry skin?" For years I would direct them to their local neighborhood pharmacy with a prescription for 40% Urea cream.  But about two or three years ago I started to have many angry patients who would call the office upset that I would give them a prescription for something so expensive and that was not covered!!! That is right, insurance companies stopped covering this very effective and safe way to get rid of cracked heels and dry skin.  I gave up on this for a while, sending patients to get some junk at the pharmacy that just wasn't as effective.

Over the counter, in the last couple of years, many great new Urea 40% creams have become available without a prescription but are not available in stores.  My favorite, which is available on Amazon is Revitaderm 40. What I love about this product is that, out of all of the creams available on the market for dry cracked heels this one comes with a pleasant odor while still being extremely efficient at making your skin smooth and get rid of dry cracked heels. This product has Chamomile, Tea Tree Oil and Aloe Vera which gives is a great odor.  Many other products seem just oily and a little smelly.

Urea Cream 40 / RevitaDERM - 8oz

I now just direct my patients to Amazon.com to buy the cream. Many times they can get it the next day, with out having to go to the store and hunt around for something you can not find there!  If you go to your local neighborhood pharmacy, the closest they come to this product is 10% Urea creams.  I would say this may be O.K. for areas that you do not bear weight on, but would not be effective for the problem areas like dry cracked heels and thick skin under the ball of the foot.  The 40% Urea creams will be very effective over time to get your heels and problem areas smooth as a baby's bottom:)

If you have really thick skin on the bottom of your feet, a trick I tell my patients about is the following. Before bedtime, place the Reviatderm 40 on the affected foot and (I know this is going to sound really weird) gently, not tight, wrap Saran or cling wrap around the foot and place a clean sock over it and go to sleep, take wrap off in the morning and go about your business.  If you have really bad calluses or thick dry skin you could see a big change in as little as a week doing this daily.

The link below will take you to Amazon for purchasing the RevitaDerm 40 cream.  I can say that I have seen many people have great satisfaction with this product and that is why I am sharing it with you! This product is safe for diabetics as well. Calluses on a diabetic foot can lead to ulceration (open wound) if left to continue to build up.  I consider this product an ounce of well needed prevention on the diabetic foot!

 If you have a foot or ankle problem and would like to learn more, feel free to visit our website at http://centeranklefootcare.com/

 

Thursday, September 1, 2016

Diabetic and don't have a foot doctor? Quickly three reasons why you need a foot doctor!!

If you are diabetic, you can not avoid the thought in the back of your brain of someone who had a limb amputated due to diabetes.  Everyone has a story of an uncle, aunt or grandparent who suffered with an amputation due to complication of diabetes.  Every 20 seconds someone loses a limb due to diabetes according to Armstrong, et al, Diabetes Care 2013.

Top 3 reasons why you need to see a foot doctor:

1. Peripheral Neuropathy

  • when seeing a foot doctor at least quarterly your sensation will be assessed and evaluated.  The doctor can perform a simple in office test to make sure your protective threshold is still intact
  • More than 90% of people with diabetic peripheral neuropathy are unaware they have it, according to Bongaerts, et al, Diabetes Care, 2013
  • So if you do not know your sensation is not intact, you run a much higher risk of ulceration and/or limb loss
2. Ulceration
  • According to a study in the Journal of American Medicine in 2005: up to 25% of those people with diagnosed with diabetes will develop a foot ulcer. More than half of those have the risk of becoming infected and 20% of the infections will go on to amputations according to Lavery et al Diabetes Care 2006.
  • Seeing your podiatrist quarterly, they will inspect your feet, identify any pressure spots that could predispose you to an ulceration and offload these spots to prevent the calluses from forming that often develop wounds if not routinely debrided in the diabetic patient.
3. Amputation
  • Again, every 20 seconds someone loses a limb due to complications of diabetes
  • Diabetes contributes to approximately 80% of the 120,000 nontraumatic amputations performed yearly in the United states, according to Armstrong et al. Amer Fam Phys 1998
  • Podiatric Medical care in people with a history of diabetic foot ulcer can reduce high level amputation between 35% and 80%, Gibson, et al. Int Wound Journal, 2013
  • Insituting a structed diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality Weck, et al. Cardiovascular Diabetology, 2013
Learn more about diabetes and your feet at:http://centeranklefootcare.com/diabetic-feet.html











Monday, July 4, 2016

Lily's Road to the Junior Olympics



During the first week of August our daughter, Lily, will be competing in  the  AAU National Junior Olympics in Houston Texas for Pure Athletics Track Club. Lily
 is not a typical track story, this is her first year to ever run track and has only been doing so for 5 months! She has her own fan club in her  younger sisters that support her all the way!


In March of 2016 our oldest daughter Lily, who is super active in soccer among other activities, asked us if she could run with her middle school track team as a sixth grader.  My husband and I rolled our eyes, as the thought of one more after school activity for parents with three children is sometimes overwhelming! Lily insisted and we caved. 

My first thought was, "Maybe after she loses a couple races she may decide that tracks not her "thing"." But the very first race she ran, with no training was the mile and is was a sub 6 minute pace.  We knew then she would be hooked! It was great, like discovering a hidden talent and watching her develop that talent with a dedication that I do not possess at 42 years old and she was killing it at 11 years old!

New to track, we did not fathom that Lily would even be on the radar to qualify for the Junior Olympics this year in Houston.  But, Lily ran the 3000m and 1500m in an AAU Regional meet the last week in June to qualify for this honor. 

This has more than changed our summer plans, it has shocked them a little.  Besides being a pretty good athlete with soccer and track, Lily is an accomplished student.  She was nominated this summer for the National Junior Leadership Conference in Washington D.C., which will take place third week of July.  Lily is a straight A student and also was nominated into the National Junior Honor Society this last academic year.  Lily is dedicated and has a laser sharp focus on any activity she participates.  

This trip to Washington D.C. was a very costly trip that we funded personally costing thousands of dollars between airfare, hotel and program expenses. 

We are hoping to help decrease the expenses for the Junior Olympic trip with just some small donations.  This is our first time ever using a funding site and was not sure what type of response that we may get.  But I figured it was worth a try to help fund her dream with out us having to eat canned good for the next year:)

Any money raised will be used to help fund the expenses for Lily on her road to Houston.  We have calculated between travel, food and lodging alone just for Lily it will be very expensive.  Lily has 2 races she has qualified for in Houston, and these two races and will require her to be in Houston for at least 5 days.  

Lily's road to Houston officially starts the first week of August and any little bit of money donated would be greatly appreciated!  Lily has already started talking about the 2020 Olympics, as she has figured out that you have to be 15 by the end of 2020 for her to qualify, which she will be!
Lily is training several days a week, and in her spare time 
enjoys destroying her parents in a mile race beating us with many minutes to spare.  She would love to be able to come back from the Junior Olympics with a win and would be so appreciative of even the smallest donation! Thank you!

Tuesday, June 14, 2016

Podiatry ICD-10 coding: The basics you need to know to be useful straight out of residency for billing!!!

So you have just graduated from your podiatry residency, or you are wanting to seem more marketable after you are done your PSR-36.   Remember, everyone you are competing against has completed a PSR-36 residency!! How do you make yourself stand a part from the rest?  If you want to make yourself more marketable, know something about the codes that will make you money seeing and treating patients.  Your future partner, or associate in a group, is a part of a business and you need to have an understanding of the ICD-10 codes in order to make money for them and yourself. Since October 2015, when the shift to ICD-10 took place we implemented our new ICD-10 Superbill or Encounter form. We have been extremely successful and continuing to treat patients and bill without having any interruption of payment for services. As we are approaching the one year anniversary of using this form we wanted to offer a reference form, at a small cost to you, to help you acclimate to the business/doctor world out of the ivory tower of academia.    As a podiatrist, you know you have to be a little more scrappy than the other specialties.  We know modifiers, as we have the craziest modifiers and are a modifier specialty in our procedure codes.  So you should not fear the new diagnosis codes that are followed by: A D G S for the trauma fracture codes for example.

After one week of billing you will remember easily that when seeing fractures these letters will trail your diagnosis:
  • A, Initial encounter for closed fracture
  • B, Initial encounter for open fracture
  • D, Subsequent encounter for fracture with routine healing
  • G, Subsequent encounter for fracture with delayed healing
I struggled in the beginning to the level of specificity that is truly needed for your claim to be considered clean in the shift from ICD-9 to ICD-10.  I can tell you, if you bill 73630 for example, for x-rays right side for a right foot 2nd metatarsal fracture non-displaced, the exact code is S92.324A.  There is also a code of S92.301A that is fracture of metatarsal closed right foot that would most likely get this claimed covered for you as well. On my superbill I did not included every fracture of every bone.  My recommendation is to have a cheat sheet for fractures of metatarsals laminated and put in your office and at every desk in your office where staff members sit. We have this cheat sheet available and included with our Podiatry specific ICD-10 Superbill.  This is available at our website at:http://centeranklefootcare.com/icd-10.html

But at the end of the day, what you need to make sure you know how to bill inside and out is your most common diagnosis with your most common procedures.  Sure I see trauma, but I see a lot of plantar fasciitis, posterior tibial tendonitis, peroneal tendonitis, ankle sprains, ulcers and diabetic foot care.  I will tell you that these are clear and very straightforward for the most part in ICD10. We are all in this together and should not be overwhelmed by the bean counters. 


 In my own practice, I can tell you that my world did not come crumbling down when the ICD-10 codes took over, and claims from all payers are coming in the normal standard fashion.  All of my at risk foot care or diabetic foot care claims have all been clean with no problems. Normal every day tendon injuries like peroneal tendonitis, Achilles tendonitis, posterior tibial tendonitis and plantar fasciitis claims are going through as well with no problems.

The only claims that I had kicked back to me in the beginning were my diabetic foot ulcers.  After a short time we worked out the kinks and the following is what you need to know to bill a diabetic foot wound correctly:

1.  You will need the diabetic foot code associated with if the person is Type 1 or Type 2 diabetic and has a foot wound

  • E11.621- Type 2 diabetes with foot ulcer
  • E10.621- Type 1 diabetes with foot ulcer
2.  You will need the code for the specificity of the site, laterality, and depth.  L97.5 is a non pressure wound other part of the foot(toes) and L97.4 is a non pressure wound on the heel or midfoot adding a 1 or 2 gives the laterality, right or left foot respectively. But the addition of depth is included in the codes below to give you the most specificity for these codes to be covered and paid. 

If your wound is on the right side you will be using one of the codes below for a diabetic foot wound on the toes:
  • L97.511-  Right foot non pressure ulcer with breakdown of skin
  • L97.512-  Right foot non pressure ulcer with fat layer exposed
  • L97.513-  Right foot non pressure ulcer with necrosis of muscle
  • L97.514-  Right foot non pressure ulcer with necrosis of bone


If your wound is on the left side you will be using one of the codes below for a diabetic foot wound on the toes:
  • L97.521-  Left foot non pressure ulcer with breakdown of skin
  • L97.522-  Left foot non pressure ulcer with fat layer exposed
  • L97.523-  Left foot non pressure ulcer with necrosis of muscle
  • L97.524-  Left foot non pressure ulcer with necrosis of bone
If your wound is on the right side you will be using one of the codes below for a diabetic foot wound on the heel or midfoot:
  • L97.411-  Right foot non pressure ulcer with breakdown of skin
  • L97.412-  Right foot non pressure ulcer with fat layer exposed
  • L97.413-  Right foot non pressure ulcer with necrosis of muscle
  • L97.414-  Right foot non pressure ulcer with necrosis of bone
If your wound is on the left side you will be using one of the codes below for a diabetic foot wound on the heel or midfoot:
  • L97.421-  Left foot non pressure ulcer with breakdown of skin
  • L97.422-  Left foot non pressure ulcer with fat layer exposed
  • L97.423-  Left foot non pressure ulcer with necrosis of muscle
  • L97.424-  Left foot non pressure ulcer with necrosis of bone
3.  Most of our diabetic patients that have foot ulcers also have some degree of polyneuropathy and coding for that would get you to the highest level of specificity using one of the following codes linking the Type 1 or 2 diabetes with the polyneuropathy:

  • E11.42- Type 2 diabetes with diabetic polyneuropathy
  • E10.42- Type 1 diabetes with diabetic polyneuropathy
For example, from the information above, if you had a Type 2 diabetic with a foot ulcer on their left heel with exposed bone and they have polyneuropathy the only three codes you need to be reimbursed with the correct documentation, would be the following:
  • E11.621
  • L97.424
  • E11.42
This again is pretty simple when you have it all in front of you and organized, As it is almost impossible to have all of these codes on your superbill or encounter form, it may be a great idea to have these codes on a cheat sheet in each treatment room.  It will save you time, not having to scroll through your EMR for the codes, especially of you see high volume of diabetic wounds. 

I hope this helps makes your life a little easier in the ICD-10 new world of billing. I know in my practice I see a lot of diabetic wounds so I was happy to see these codes were not terribly convoluted. If you do not have a "superbill" we have a quick reference sheet, for what we see as podiatrist most common diagnosis, available at our website. 


It seems as though the ingrown toenail codes that are billable to the highest level of specificity  right now are for the right and left great toenails.  I guess this is not that big of a deal, considering most of the ingrown toenails are usually the big toenails.  The old code for ingrown toenail was 703.0 is now L60.0 there is no laterality with this code but I would use this code with the other ones suggested next.  The old code for paronychia or infected ingrown nail was 681.11.  The new ICD-10 code has laterality but only for the great toes.  Right great toe infected ingrown toe nail is L03.031 and left is L03.032.  So if you are billing a 11730 or a 11750 the modifier for the toe should still be used on the CPT code.

Billing 11730 or 11750

Use the following codes:
L60.0- Ingrown Nail
L03.031- if right hallux  modifier on CPT code T5
L03.032- if left hallux    modifier on CPT code TA
M79.609 which is just pain in limb this is the unspecified pain in limb because there is no pain in limb in foot or toes specific.

This is pretty straightforward information, so far as it looks in the new world of ICD-10.  Again, in our practice, this is a procedure that we perform several times throughout the day.  I suggest knowing what you do every day inside out.  If you have a good EMR you will be able to look up the specific code translation from ICD9 to ICD10, and there are so many nice resources available on the web for your reference for the "zebras" that walk into your office.  Remember, know your codes for plantar fasciitis/heel pain, diabetic foot care, ingrown nails, and the other most common patients you see a day.  There is a lot of transparency in what we do, but in a good way.  Many people come to us for very simple problems and we have simple answers to help them in usually a very cost effective way.


This is an easy one, you just need to know the new ICD-10 code from the old ICD-9 code.  The plantar fasciitis, much to my surprise, does not have laterality.  So the old plantar fasciitis ICD-9 code was 728.71 and now is M72.2.

I'm guessing that when ICD-11 hits this will change, but for now it is a pretty simple and straightforward conversion.

So a new patient with right foot plantar fasciitis would look like this:

ICD-10 Diagnosis codes:
M72.2       Plantar fasciitis
M79.604   Pain in limb right limb
M77.31     Heel spur right calcaneus(if on x-ray there is a spur and you dictate it, I would recommend this code as well.)  Being as specific as possible is going to be very important in ICD-10. The M77.31 specifies laterally for right side and the code for left heel spur is M77.32.

CPT procedure codes for this patient would be:
99203       If you have documented well and spent the appropriate amount of time with the patient you have a new patient encounter of this level.
73630 R   If you are taking X-rays in office to rule out stress fracture or evaluate possible heel spur, this is the 3 views of the foot with the appropriate right sided modifier.  But this is where we see our laterally with plantar fasciitis in the x-rays.

I hope this helps makes your life a little easier in the ICD-10 new world of billing. I know in my practice I see a ton of plantar fasciitis, so I was happy to see these codes were not terribly convoluted. If you do not have a "superbill" we have a quick reference sheet, for what we see as podiatrist most common diagnosis, available at our website at http://centeranklefootcare.com/catalog/c14_p1.html
this is an editable rtf and pdf format.

Good luck with your billing!

Michele McGowan, DPM

Saturday, April 23, 2016

South Lake Animal League Pet Supply and Food Drive

     
South Lake Animal League:

 Pet Supply and Food Drive

       Hello, my name is Lily Henne and at home, I have two lovable little dogs and, in my opinion, an adorable bearded dragon. I couldn't even begin to imagine if my pets didn't have a home, food, or love. Sadly, there are some animals that need attention and care. Luckily, the South Lake Animal League rescues about 100 animals every month. Obviously, to take care of lots of animals you would need an abundance of supplies to keep them healthy. Therefore, I have organized a Pet Supply and Food Drive to help the animals in need. I am interested in helping this organization because I have always loved all animals and can't bear to see them sad, sickly, and homeless.

     

  The Pet Supply and Food Drive will be April 29th - May 20th. The drop off location for the supplies is the Center for Ankle and Foot Care. The address is 3190 Citrus Tower - Clermont Florida. The Center for Ankle and Foot Care will be open for drop offs from 8 AM - 4 PM on Monday through Thursday. On Fridays, it is open from 8 AM - 1 PM. I will try to get other drop off locations for the drive. If I get another location I will update my blog.


       


Some supplies that the dogs would appriciate are;

  •  Durable Chew Toys such as Nylabones and Kongs,
  •  Mesh Harnesses, Leashes, 
  • Pedigree Adult Dry Dog food, 
  • Pedigree Dry Puppy Food,
  •  Dog Treats,
  •  Flea and Tic Control for dogs and puppies, 
  • Sheets, Towels
  • Blankets that fit in a washer. 
On the other hand, supplies for cats are;
  •  Cat Treats
  •  Cat Toys of all variety
  •  Purina Kitten Chow
  •  Purina Cat Chow,
  • Flea and Tic Control for cats and kittens
  • Cat Litter
  • Soft Blankets
They are also in need for cleaning supplies like the following;

  •  Paper Towels
  • Toilet Paper
  •  Paper Plates, Paper Cups
  •  Liquid Laundry Detergent
  •  Bleach
  • Fabulosa
  •  Pine Sol or Generic Brand All-Purpose Cleaners
  •  Industrial Mop Heads large 1/4 " tape band, Liquid Dish Soap
  •  Brooms
  •  Rakes
  •  Shovels
  •  Hand Handled Scrub Brushes and Trash Bags; 14 gallon, 33+ gallon, 55 gallon.  
      To conclude, I think that everyone should support the South Lake Animal League, an amazing organization. One great way is to simply donate some pet supplies and food. For as little as 3 dollars you could make a cat or dog very happy. How would you feel if you were without care, food, and a home?


Wednesday, April 20, 2016

Open letter to Primary Care Doctors who tell elderly patients Medicare should cover the cutting their toenail(This is not true, most of the time)

Though I am trained in foot an ankle surgery, I must admit my favorite patients are my elderly patients that just come in to the office for routine foot care.  I see them every couple of months, we talk about their grandchildren, my kids and life in general.  We establish a fantastic long term relationship that is full of amazing conversation, while performing a task they are unable to perform themselves.

But when we see many of these patients as a first encounter they are convinced that this is a covered service by Medicare.  Some people believe this because they have seen a podiatrist for years before they moved to our area and the doctor has been billing this illegally or they have seen their primary care physician and they say, "Medicare covers cutting of the toenails." This simply is not true!

It is true that if you are diabetic, meet certain class findings, and have seen your primary care physician, who is actively treating your diabetes, in the last 6 months, then yes Medicare will cover such a service. But as far as someone who just happens to be elderly with long toenails, no dice! Below is an excerpt from the medicare.gov regarding podiatry services that are covered:

"Medicare Part B (Medical Insurance) covers podiatrist services for medically necessary treatment of foot injuries or diseases (like hammer toes, bunion deformities, and heel spurs). Part B generally doesn't cover routine foot care (like the cutting or removal of corns and calluses, the trimming, cutting, and clipping of nails, or hygienic or other preventive maintenance, including cleaning and soaking the feet)."

This becomes a very big source of contention in our office on a daily basis, over exhausting our resources of our office staff having to explain to patients why this is not covered.  But many elderly people can not perform this service themselves due to: not being able to reach their feet, bad back, bad hip or even they are just too thick for them to cut.  All of these are great reasons for an elderly person to be seen by a podiatrist for this service but insurance will not cover it and the patient has to be prepared for this out of pocket expense. These patient's are given a Medicare Advance Beneficiary Notice that explains that it is not a covered service. 

Encouraging an older person to go to a nail salon can be irresponsible advice from a doctor and a big problem exposing the patient to many community acquired skin and nail infections.  There are only 2 states that require that nail salons autoclave their instruments: Iowa and Texas.  So sending an elderly person into this environment is really not a great idea.

In our office we perform the highest level of care for these patients.  They are seen by the podiatrist, not a tech or medical assistant. The podiatrist will evaluate and treat the patient professionally debriding(cutting) the the toenails and the calluses if necessary.  The patient will leave with peace of mind knowing that they are getting the best possible care and service for their feet.

What we charge for these services are below:
Trimming of toenails
$60

Trimming of calluses
$60

Trimming of toenails and calluses

$75

Sometimes these services can take up to 45 minutes when someone has very thick toenails and many calluses.  We do not rush through this exam and service because our ultimate goal is to give the patient the best possible outcome.  We see many patients for this type of non covered routine foot care and try to perform this in a way that we can space out the visits so they may only need to visit us 3 to 4 times a year.  

Most podiatry offices offer this type of service and prices range from $50-$75.  The expense may seem steep. but by having a nail care patient in the treatment room the podiatrist is possibly missing much higher revenue of a new patient or even reimbursement for a follow up for an established patient.  Like all other doctor offices we have multiple staff: medical assistants, billing company, insurance specialist, and receptionist. These people all have to be paid for their hard work.  So it really is impossible for us to perform this service for less. If the doctor is performing the service themselves this service is very well worth it for the patient and in the patient's best interest.

If you would like to learn more about our office see our website: http://centeranklefootcare.com/

Wednesday, April 13, 2016

No insurance should not be a reason to ignore your feet!

In the ever increasingly expensive world of health insurance, many people have opted out of the insurance exchange and for good reason, it is extremely expensive.  Some statistics show that in Florida, when the health insurance exchange officially opened, many insurance premiums went up by 40%! My own personal health insurance premium went up by $300 a month more for my family of five, we now pay over $1000 a month for health insurance we only use "in case of an emergency".
Insurance premiums have gone up and interestingly enough reimbursement to the doctors you see have gone down.  This is not meant to be a winy doctor crying poor.  It is meant to inform you that the insurance companies have the upper hand on all of us.

There are many people that have decided not to pay $1500 a month for health insurance.  When your feet hurt, you do not have to ignore them. We have put together our price list for the non insured to take the guess work out of the cost for seeing one of our foot doctors.  If you have foot pain and do not have insurance, you want to cut out the middle man.  Seeing a board certified foot surgeon instead of your primary care physician, urgent care or emergency room visit could literally save you hundreds and hundreds of dollars.

If you live in Florida near Orlando we are conveniently located in Clermont.  This is a very nice location in Central Florida.  We are only 23 miles from Disney World so even if you are on vacation and have a foot problem one of our Board certified foot and ankle surgeons would be more than happy to get  you back on your feet!

We treat ankle sprains, heel pain, ingrown nails, nail fungus, fractures of the foot and ankle, warts and many other foot related problems.  We have on sight digital x-ray, so we are able to answer many bone related problems right away.

Below is the link to our pricing for the Center for Ankle and Foot Care for non insured patients:
http://centeranklefootcare.com/cash-price-list.html

Saturday, February 27, 2016

Cracked dry heels? Get smooth heels now!!!!

We see many patients a day that come into the office for all different types of foot and ankle problems. A very common issue that is mentioned by patients after treating their foot problem is, "Hey doc, what to you recommend for dry, cracked heels or dry skin?" For years I would direct them to their local neighborhood pharmacy with a prescription for 40% Urea cream.  But about two or three years ago I started to have many angry patients who would call the office upset that I would give them a prescription for something so expensive and that was not covered!!! That is right, insurance companies stopped covering this very effective and safe way to get rid of cracked heels and dry skin.  I gave up on this for a while, sending patients to get some junk at the pharmacy that just wasn't as effective.

Over the counter, in the last couple of years, many great new Urea 40% creams have become available without a prescription but are not available in stores.  My favorite, which is available on Amazon is Revitaderm 40. What I love about this product is that, out of all of the creams available on the market for dry cracked heels this one comes with a pleasant odor while still being extremely efficient at making your skin smooth and get rid of dry cracked heels. This product has Chamomile, Tea Tree Oil and Aloe Vera which gives is a great odor.  Many other products seem just oily and a little smelly.

Urea Cream 40 / RevitaDERM - 8oz

I now just direct my patients to Amazon.com to buy the cream. Many times they can get it the next day, with out having to go to the store and hunt around for something you can not find there!  If you go to your local neighborhood pharmacy, the closest they come to this product is 10% Urea creams.  I would say this may be O.K. for areas that you do not bear weight on, but would not be effective for the problem areas like dry cracked heels and thick skin under the ball of the foot.  The 40% Urea creams will be very effective over time to get your heels and problem areas smooth as a baby's bottom:)

If you have really thick skin on the bottom of your feet, a trick I tell my patients about is the following. Before bedtime, place the Reviatderm 40 on the affected foot and (I know this is going to sound really weird) gently, not tight, wrap Saran or cling wrap around the foot and place a clean sock over it and go to sleep, take wrap off in the morning and go about your business.  If you have really bad calluses or thick dry skin you could see a big change in as little as a week doing this daily.

The link below will take you to Amazon for purchasing the RevitaDerm 40 cream.  I can say that I have seen many people have great satisfaction with this product and that is why I am sharing it with you! This product is safe for diabetics as well. Calluses on a diabetic foot can lead to ulceration (open wound) if left to continue to build up.  I consider this product an ounce of well needed prevention on the diabetic foot!

 If you have a foot or ankle problem and would like to learn more, feel free to visit our website at http://centeranklefootcare.com/