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The Lazy Man's Guide to treating your Heel Pain!

9 Mar 2017 14:13


My name is Dr. Michele McGowan, and much like the President for the Hair Club for Men, who is not only the president but a member of the organization himself because he has no hair, that is how I feel about heel pain or plantar fasciitis. I am a foot doctor who treats heel pain multiple times daily and has struggled with heel pain a couple different times in my life.  I help people get better all the time for this yet my inability to take my own advice was my downfall.
I can say that over the last 15 years of private practice in podiatry in Clermont Florida, the frequent flyers we see with heel pain that suffer longer or take longer to get better take all shapes and sizes. But they have one thread in common, which is they are usually too lazy to keep up with a stretching program to get better or stop stretching the moment the foot feels better. When I suffered with heel pain the first time I was a bad patient! I tell my patients all day long that they need to stretch but I suffered with heel pain for longer than I needed to due to my lazy streak and not wanting to stretch. 
Of course, once I started stretching and icing for my heel pain I started to get better and once I felt 100% better I stopped stretching! In order to ward off the return of this horrible pain you have to keep stretching.  This I find super annoying to say over and over again to the same patient year after year, whether the patient is a frequent flyer or myself.  Recently my paradigm has shifted in how I teach the lazy like myself to get better and stay better.
In 2015, when I had plantar fasciitis where it hurt so bad to walk, I decided to purchase a night splint.  This is a pretty simple device that you wear when you sleep that holds your foot in a complete stretch while you are sleeping, genius right? Well turns out this device is not super comfortable to sleep with it on.  This device spent more time with my toy fox terrier dog cuddled inside of it at bedtime then on my leg for the first few weeks.  But then my heel pain got so unbearable that I had to do something, because even the dedicated times during the day that I was stretching was yielding absolutely no result.  
I decided that I could no longer live like this and out of desperation I started to wear my night splint any time I could.  As I do not have a sit down job in one place going from room to room to see patients, my husband thought it was unrealistic to even bring the splint to work but I did.  But he was totally right, I couldn't wear it while seeing patients, but I put on around 11:45am until 1pm during my lunch break.  I would then lug that boot home( I was too cheap to buy 2 boots to keep one at work and one at home) and after soccer, track and music lessons for my girls I would put the boot on again when I was reading, watching TV or finishing up paper work from the office. 

At night I had a very particular regimen,  at about 8 pm I would prop up my leg on a couple of pillows and add a gel ice pack into the foot part of my night splint, place the night splint on and watch TV or finish up my work.  I did this for 2 months and my heel pain went completely away.  Until it came back a year later because I stopped stretching! 
So now I wear my night splint when I am sitting down in my house relaxing watching a movie or playing on my computer.  I currently have no heel pain but I feel like even the couple times a week I wear the splint it prevents me from having to have that sharp pain in the morning feeling and keeps my foot healthy! 
This is basically a little life hack for the lazy who have heel pain.  If you have any other foot problems feel free to learn more at our office website at http://centeranklefootcare.com/
Michele McGowan DPM
3190 Citrus Tower Blvd Ste A
Clermont, FL 34711
352-242-2502

So you have a Bunion! What do you do?

6 Feb 2017 17:58


Bunions are very misunderstood by patients in many cases.  Patients want to believe that the big bump on the inside of their foot is just skin.  I mean, they push on it and feel it's hard but want to deny the facts that are really going on here. A bunion at its core is a bone deformity, yes there is some imbalance at the joint from the capsule being overstretched on one side and over contracted on the other.  But the bone is ultimately the biggest problem that causes a patient to stroll into our office.

Some patients just want to know what's going on with their foot and some are convinced they need surgery immediately! If you have a bunion it might be worth reading this before seeing the doctor, we have broken down the most common type of patients that come in with a bunion. Knowing which one you are could save you from unnecessary foot surgery!

Not All Bunions Are Created Equal

1. The no pain bunion but someone has convinced them they need to do something before it gets worse. These patients usually are just curious what is wrong with their foot and want to make sure they are not going to be disabled if they do nothing.  These patients are educated on shoe gear and we explain that if you stay away from bad shoes, this may be what their foot is like for the rest of their life.  This visit usually ends with a relieved patient who is happy to not have to have surgery.

2. The no pain bunion but the patient hates the way their foot looks! These are sometimes the most frustrating patient to really help.  They have no pain yet they are contemplating surgery because they think their foot will be prettier.  There is a 50/50 chance this patient walks out of our office angry because we refuse to perform unnecessary surgery on a foot that does not hurt at all. We explain to the patient that even if we were to perform surgery, there is no guarantee that they are going to fit into a narrower, "cuter" pair of shoes after surgery. Some patients appreciate our open and honest opinion and others are just pissed they paid a $40 copay for me to tell them "wear wider shoes"!

3. The painful bunion that only hurts in certain shoes.  This patient demographic is identical to the #2 above, but these patients often present in a high heel stiletto with a foot that is identical to Fred Flintstone! They literally do not want to accept that their foot is just not meant for the shoes they are wearing.  Many of these patients, if they just switch to a mesh athletic shoe or wider shoe have no problems.  But getting this patient on board with this simple solution is sometimes difficult.  I explain that in order to fix their problem I have to cut their bone with a saw, move the bone over to correct the deformity and then put a screw in it.  I explain that they can not get it wet for 2 weeks and they have to wear a post-op shoe for 6-8 weeks.  Almost everyone of these irrational patients say, "can't you just shave the bump?" Because they are now the expert!  I have to almost always explain that we have to correct this problem at the level of the deformity so that the problem does not recur because I like to do my job right. These patients usually leave frustrated and seek the care of another podiatrist who decides that this a great patient selection for surgery. The patient that go to have surgery by another doctor are usually the horror stories you read when you google bunion surgery.  See if you do not have pain before, performing surgery is just cruel and unusually punishment that could lead on to lifelong disability. Pain in and out of all shoe gear is the requirement to have surgery and be happy.

4. The last bunion patient is the painful bunion in and out of almost all shoe gear.  These patients have pain that does not completely resolve with the absence of shoe gear.  This is ultimately the type of patient that does great with bunion surgery.  These people are so happy to have a realigned pain free joint and are accepting of some tingling or numbness that can occur with surgery in this area. But even these patients can decide to keep looking for the shoe that offers them comfort.  



Treatments for Bunions
Again there really are only two treatment options for bunions:

1. Modify shoe gear(go into wider shoes)
2. Surgery



There really are no great in between options for fixing a bunion.  If you have a bunion and you take away pressure to the big toe joint you get rid of what is causing the deformity to get worse and for some take away the pain. If the bunion is mild you can try something like the Yoga toes, but there is no guarantee this product will yield a great result but it may help stretch that over contracted part of the joint. Also, using a gel toe spacer may also yield some minimal improvement but both of these options are much better than surgery that may not be necessary.  If the foot is killing you and you are unable to be comfortable in and out of shoe gear, then bunion surgery may be a good options for you.  If you are looking to learn more about foot and ankle problems feel free to follow the link to our website at http://centeranklefootcare.com/services.html

Michele McGowan, DPM

If you live in the Central Florida area, it may be worth your time to take the drive to our office in Clermont to evaluate your bunion to see if surgery is really necessary or not. We are located at:

3190 Citrus Tower Blvd Ste A
Clermont, Fl 34711

Our number is 352-242-2502 if you would like to call to schedule your evaluation.





Ankle Sprain? How do I treat an ankle sprain?

17 Dec 2016 13:21


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/









What is a bone spur on the foot?

5 Dec 2016 19:50


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.



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

2 Dec 2016 14:11


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!

2 Dec 2016 14:10


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



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

3 Oct 2016 09:39



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

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

17 Sep 2016 01:03


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/

 


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

1 Sep 2016 14:22


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


Lily's Road to the Junior Olympics

4 Jul 2016 16:17




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!


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

15 Jun 2016 02:17


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

South Lake Animal League Pet Supply and Food Drive

23 Apr 2016 13:35


     

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?

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)

20 Apr 2016 12:32


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/

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

13 Apr 2016 16:54


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


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

27 Feb 2016 14:44


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/

 


ICD-10 Coding for Diabetic wounds, what you as a podiatrist should know.

11 Dec 2015 17:27


We are now a 2 full months into the ICD-10 code take over.  In my own practice, I can tell you that my world did not come crumbling down, 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 have been my diabetic foot ulcers.  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. For $75 we will email it to you with our metatarsal fracture cheat sheet and our power point on billing diabetic foot care. Our website is listed here   http://centeranklefootcare.com/catalog/c14_p1.html
this is an editable rtf and pdf format.

Good luck with your billing!

Michele McGowan, DPM


Ingrown toenail, we can fix it so it never bothers you again at the Center for Ankle and Foot Care!!!

5 Dec 2015 15:26





Ingrown toenail keeping you from really enjoying this Holiday Season?   Limping while looking for that ultimate Christmas gift for a loved one due to a painful toenail?  This does not have to happen!  At our office, The Center for Ankle and Foot Care, in Clermont Florida, we can fix that the same day. Like the video above says, Dr. McGowan and Dr. Henne are available daily and can get you in quickly to help you with whatever your foot or ankle problem may be.

Read on a little more to see if what you have is an ingrown nail.  If your symptoms sound familiar to below it would be wise to get in to see Dr. McGowan or Dr. Henne so you can continue to look for your gifts for friends and family without the pain!

People describe the pain as severe at times, and even describe difficulty sleeping due to the lightest touch like that of their sheet. Below are commonly described symptoms with an ingrown nail.

   The following symptoms may be present with ingrown toenails:
  • Pain
  • Redness and swelling
  • Drainage
  • Odor
  • Prominent skin tissue (proud flesh)
At the Center for Ankle and Foot Care, just like in podiatrist offices across the country, we have a simple in office procedure that literally only takes minutes to correct your  problem forever! (Unless you start to wear bad shoes or have trauma to the area!) 
Don't wait until it gets too bad to get in.  On the right you can see we only take a small portion of the nail. We put a medicine under the skin so the offending border of nail no longer grows.  In most cases you can barely tell you even had this simple in office procedure performed! Once the nail is ingrown there are not too many things you can do for yourself at home to make this better.  Call your foot doctor and get in right away!
If you would like more information about our office or our doctors visit our website at
http://www.centeranklefootcare.com/index.html





Running with plantar fasciitis, you can get better and keep running!

3 Dec 2015 17:39


Plantar fasciitis or heel pain is a real bugger to have for anyone, but when you are a runner it is 1,000
times worse.  I speak from experience.  This summer I began to run 4-5 times a week and increased my mileage to about 4 miles a run after a month or two.  Running is one of my favorite activities to do now, other than playing with my children and hanging out with my husband!  A year ago I would have never said those words about running.

After the second month of running, it happened, I got out of bed one morning and felt the very familiar stabbing pain on the bottom of my foot, known as plantar fasciitis.  I couldn't believe that I, a podiatrist, would get what so many of my patients come in to have treated. The good news was I immediately knew what I had and I started to treat myself. Below I have wrote my steps down for other runners who may be experiencing the same problem and would like some simple advice.  My one disclaimer is, if you do not know if you have plantar fasciitis, I would recommend seeing a foot doctor before you start a treatment program. There is a small possibility of a stress fracture in the heel bone

It is also important to note, that from August until November, I experienced some symptoms on and off of the heel pain.  I continued to run and on some occasions increased my mileage.  The running , I believe was not the source of aggravation of my plantar fasciitis, the resting after running and lack of stretching were the biggest culprits!

Step 1: Stretch
Your calf muscle is a big powerful muscle group of the lower extremity.  This is also a muscle group that does the majority of work when you are running below the knee.  This muscle group plays a huge role in pro pulsing you forward with each step while you are running.  These muscles need extra attention or they will let you know they are not happy with you.  I have included the perfectly illustrated stretching exercises you should be doing before and after running and maybe two other times a day.  Also, purchasing a night splint is a nice way to get  static extended stretch while you are resting, watching TV or sleeping.   Another great tool for a deeper stretch is using a Pro-stretch.

Step 2: Ice
Icing is really important to help calm down plantar fasciitis, especially when you are continuing to run.  I always say get a 20oz bottle of water and freeze it.  Roll it under your foot for 10 minutes 2 or three times a day.  Giving you a deep stretch and ice it a great natural anti-inflammatory. This is quick, easy & very worth it for the plantar fascia. Other devices are sold kit that can help you get a deep stretch and freeze a foam roller in a Thera-band kit.      
Step 3: No Barefoot and Good shoes
Going barefoot when you have plantar fasciitis is a killer.  I always tell patient they have to have something on your feet while you are walking around even in the house.  A great alternative is a spenco flip flop.  They have a little bit of a built in support in the arch.  Sneakers really are the gold standard to help you get better, as long as they are in good condition.  Sometimes you have to ditch your dress shoes for 4-6 weeks to give good supportive care. Many sneaker have built in support in the arch too. Asics are one of my favorite running shoes for support in the arch.  Just remember that the more miles you put on  a week the quicker you will need to replace your shoe, no matter how great they are, probably every 3-5 months.  Running 3-5 miles 4 times a week I replaced my sneakers after 2 months.  If you have new shoes and just feel like you need more support I would recommend superfeet, spenco or power step over the counter inserts. If you were to go see a podiatrist, they would most likely recommend one of these over the counter inserts.


If you are a runner and have plantar fasciitis, running is usually fine to continue but remember to STRETCH, ICE, & GOOD SUPPORT are the keys to keep you running and help you get better!


Plantar Fasciitis and Peyton Manning, the joys of fantasy football!

16 Nov 2015 23:33


So, we have hit this subject matter on  more than  on one occasion.  As foot and ankle surgeons, it is not uncommon in a typical day to see at least 15 patients that have heel pain or plantar fasciitis.  These people often present with the same core set of symptoms in general. First and foremost, they always describe first step in the morning pain or pain after they have been resting and get up pain.  Some people describe pain in their feet after being up and standing for more than a couple hours, with their pain being concentrated basically at their heel on the bottom.

It's Sunday, it 11am and you are sitting comfortably and getting your last minute adjustments made to your fantasy football team. Then you see it, that capital P, for your rock star player being probable. Probable??? Peyton Manning probable?? What kind of nonsense is that? Upon reading on, you read the two words Plantar Fasciitis.

If you are lucky, you have already had this in your lifetime so you know it hurts but can most likely play through the pain for a couple million dollars.

But actually, if you are one of the lucky ones who has never had this, you may not know if it is worth the risk to play the "P" player who has plantar fasciitis.  We figured as two foot and ankle surgeons that make up the "2 Pods and A Microphone" Podcast, we could fill you in on what is Plantar Fasciitis, and is it something you should bench your fantasy football player or take the chance and play them.

The plantar fascia is a tight band on the bottom of the foot that connects the heel bone, the calcaneus, to the long flexor tendons to the toes. 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 revolves 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 this does not have to be a deal breaker for your fantasy football player.  I have 65 year old patients that can got from a 10 to a 1 on the pain scale with some simple steps.


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!!!!The plantar fascia is a tight band on the bottom of the foot that connects the heel bone, the calcaneus, to the long flexor tendons to the toes. 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.

Steps to getting rid of your heel pain:

1.  No barefoot for the next 6-8 weeks
2.  Static calf stretches (if you do not know what that means check out our Pinterest Page Heel Pain          Helpers http://www.pinterest.com/cafcdpm/heel-pain-helpers/

3.  Get a 16-20oz bottle of water, freeze it and take it out of the freezer at least 2x's a day and roll it           back and forth under your foot with a thin sock on or barefoot(I tell patients all of the time that           this is like physical therapy with out a copay)

4.  Look at your shoes, if they have no arch support ditch them or get a really good arch support like our over the counter arch supports for heel pain like spenco
5.  Of course, if you can take an anti-inflammatory and you have no drug interactions that will also help this feel better for you.


Stretching Exercises Stick Figure Illustrations below
(by Dr, McGowan, she's a podiatrist not an artist, don't judge people)





If you have heel pain or plantar fasciitis, and it has been longer than two weeks you should see a podiatrist.  If you live in Central Florida, of course the podiatrist you should see is Dr. McGowan or Dr, Henne! Our webpage is http://centeranklefootcare.com/index.html where you can explore more about all the different services we offer at all 3 of our locations.

Dez Bryant and why where you break your bone matters

17 Sep 2015 12:57


If you are a fantasy football person like me, you are always checking your players status. Are they injured? Are they not going to play due to some suspension? Ect...But when of your players has a blatant injury like that of Dez Bryant this past weekend, the speculation monsters come out of the woodwork.  Also, now in the world of instant access and social media, the injured player might Tweet how great they feel right after surgery. (after foot surgery your foot is still pretty numb right after, so keep that in mind)  If there is any one piece of advice I can give you regarding an injured NFL player, take all the information you can take in from the most educated people talking about the player's issue.

If you follow football you are hearing a lot about 5th metatarsal fractures and surgery.  The next 6-8 weeks are going to give Mr. Bryant some time to think and invariable take up more time in my office.  NO HE IS NOT MY PATIENT, but my patients know who he is and they are coming in with more questions than normal.(I am pretty sure they are also fantasy footballers too)

We see several fractures a week in our little practice in Clermont Florida.  When I see patients who have had an injury to the outside of their foot near the 5th metatarsal region, I always thinks to myself, "Please don't let it be a Jones Fracture, let it be an avulsion fracture of the 5th metatarsal instead." An avulsion fracture is a fracture of the part of the 5th metatarsal, if you reach down and touch the outside of your foot just past your heel the boney prominence you feel is what kind of rips off the rest of the bone. A large reason I feel this way for the "normal Joe" is if the fracture is an avulsion they don't necessarily need surgery.  Most patients have jobs, family stuff and just don't want to be laid up anymore than they have to.  Surgery puts them at a new risk factor for several problems: post op infection, non-union, complex regional pain disorder and even DVT.  Many times with a non displaced avulsion fracture, a patient can go into a walking cast, no crutches and continue on with many everyday life activities in a boot for 8-12 weeks. These fractures tend to heal very well even in the worst patients.  The blood supply to this area of the bone is very good and lends itself to normal healing.






It has been reported that Dez Bryant has a Jones Fracture.  This fracture is at the base of the 5th metatarsal but a centimeter or so past the 5th metatarsal tuberosity that we mentioned above that is palpable on the outside of your foot.  This type of fracture is a much different beast due to the fact that the blood supply to this region is far less optimal. There is a high incidence of nonunion(bone not healing in this area due to lack of blood supply). The biggest problem for you if you have Dez Bryant on your fantasy football team, is that you really don't know if he had a Jones or an avulsion fracture.  See even though the the average Joe may not have surgery for an avulsion fracture, a world class athlete is going to have surgery most likely for both of these scenarios.  Their livelihood depends on getting back on the field in optimal shape ASAP.

Either way, the recovery for one, the Jones fracture, is slightly more guarded and could even be 12 weeks or more before the player makes it back to practice.  The avulsion fracture repaired could see him back practicing at 6 weeks.  I don't have Dez Bryant in my line up but if I did I would drop him, 6 weeks is a long time to have someone just sitting on your bench and 12 weeks is even worse.  But once he is fully recovered he should be back to business as usual.  Dr. Henne, the other foot doctor in my office, also my husband and in the same fantasy football league as me says he would keep him because even if he doesn't play for twelve weeks he still may be perfect for the playoffs.

More importantly, why you shouldn't waste too much time or money on ICD-10 minutia!

16 Sep 2015 16:02


The answer to why you should not waste too much time or effort on the minutia codes of ICD-10 has a lot to do with how great most EMR's are with the codes.  I was playing around with my EMR as I was seeing an ankle sprain in my office today for an initial visit and this is what I got in a split second after clicking on the diagnosis of ankle sprain:

I have to say, if your EMR is not doing this for you with such ease, you may have more difficulty than it is worth navigating through the ICD-10 changes.

Yes, you should have quick reference for your most common diagnosis and procedures for podiatry.  But don't get lost in all the codes, if your EMR is up to snuff the codes will be there for you when someone walks in with a displaced talar neck fracture.

I recommend playing around with your EMR and making sure it is already set to do this for you, and if not you need to find out why.  This is a process that your EMR should be ready for well before October 1st, 2015.

http://centeranklefootcare.com/catalog/c14_p1.html

Billing Ingrown Nail under the new ICD-10 Codes

14 Sep 2015 16:42


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.  The more common things should be well established in your mind before October 1st, 2015 so this transition is smooth for you.  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.

Michele McGowan, DPM
The Center for Ankle and Foot Care
http://centeranklefootcare.com/catalog/c14_p1.html


The top 4 foot and ankle injuries we see in our youth soccer players

13 Sep 2015 18:33


Top 4 foot and ankle injuries we see in our youth soccer players:


Week one of our youth soccer season is done in the Central Florida area and we have already seen several young athletes for these top 4 foot and ankle injuries in our office the Center for Ankle and Foot Care.  Our daughter is very excited to be back into the swing of things with her soccer team.  She maybe playing with even more heart than ever before after this past summer's USA Women's National Team win of the World Cup!  
With great coaching and a good supportive team, many injuries can be avoided.  Coaches and parents who focus on conditioning the children before the season really starts can help the children stay injury free.  But sometimes many injuries can happen even with the best preseason preparation.  
Shin Splints



First of all, you might be asking yourself "Self, what is a shin splint?" I will explain.  The most common type of shin splint is inflammation on the front of the lower leg.  The culprit is usually from the repetitive micro-trauma that occurs when one is running on a consistent basis. The anterior tibialis muscle belly becomes strained and starts to pull on the tibia bone causing the most common anterior shin splint.  The inflammation occurs on the bone and on the attachment of the muscle to the bone.  The repeated stress, can over time lead to stress fracture of the tibia if ignored and not addressed. 

How you get shin splints becomes an important question as well. If you want to treat and avoid getting this problem again, you have to understand the root cause.  Some people get shin splints from a very simple culprit, shoe gear. If you have ever played soccer, you may know that soccer cleats are notorious for being a flat insole with very little support. This may be a by product of many cultures playing this sport with out shoes on growing up, once we put the cleat on we still want "touch" on the ball. We tend to see this injury the most when kids are practicing on harder than normal surfaces or as the weather gets cooler and the ground gets harder.
Ankle Sprain  
It is a common scenario in soccer, you cut one way but your ankle didn't get the memo and you feel it, your foot and ankle turn in a way 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 8 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 child's symptoms, more often than not results in sub-optimal results in their outcome, and taking your neighbors advice on your child's 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! It can take much longer for your little athlete to get back on the field with out proper care.
Ingrown Nails


If you do not know what an ingrown toenail is be thankful.  If you "think" you know what an ingrown toenail is you probably do not.  People who have had an ingrown nail know the difference.  If it hurts, bleeds, smells and ruins you white socks, you probably have an ingrown nail! 
Why is your little soccer player more susceptible for an ingrown nail?  The repetitive little micro trauma that occurs while playing soccer is the culprit!  Stopping and starting and quit pivoting motion that is required to fake out your opponent really does a number on your big toes and specifically your big toe nail!    
This can be a very painful problem but can be solved in just one office visit to a podiatrist.  Some kids will not show their parents their ingrown nail until it is very bad. If your child is limping at the end of a soccer game, check their feet out.  Also a good piece of advice is to check and make sure their shoes are not "too" tight.  Again, some soccer players walk a fine line of shoes that are too tight because they want that "touch" on the ball.  If their shoes are too tight ditch them and go at least a 1/2 bigger.  
Calcaneal Apophysitis(Sever's Disease)

This is probably the most common problem I see in soccer players between the age of 9 and 14.  The calcaneus is your heel bone.  What is unique about this age group is that sometime between the ages of 8 and 14 the big growth plate on this bone starts to ossify, or fuse and become a part of the bone.  As this process gradually happens over this 4 year time span, your young athlete may experience this problem more than once in their little soccer career.
Another name for calcaneal apophysitis is Sever's disease, but do not let the term "disease" fool you it is not associated with any true disease process.  But this can be very painful for your young athlete and should be seen by a foot and ankle specialist to rule out any other problem. Your child will tell you they have pain in their heel and you will google heel pain and convince yourself you child has plantar fasciitis.  They most likely do not!  
Treatment for this is pretty simple when confirmed as calcaneal apophysitis.  We have the child ice at least twice a day and put them on an anti-inflammatory for a week or two.  Usually your child's ability to continue to play soccer will truly be based on their pain threshold.  If the pain is bad, we usually will recommend a week or two of rest. 
If you are interested in learning more about other foot or ankle problems please feel free to check out our website at: http://centeranklefootcare.com/index.html. Dr. Henne and myself are Board Certified by the American Board of Foot and Ankle Surgery and treat many different foot and ankle problems. Our goal is always to get you back on your feet as soon a possible and use surgery as a last resort.
Michele McGowan, DPM
Center for Ankle and Foot Care
3150 Citrus Tower Blvd Suite B
Clermont, FL 34711
352-242-2502  

Plantar fasciitis and ICD10 coding, what do you need to know?

11 Sep 2015 15:50


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


If you are a podiatrist, you treat diabetic feet......It's what you do! Know the ICD-10 codes you need to know for treating your diabetic patients.

10 Sep 2015 17:38






 Many people getting lost in the trauma coding but unless you are in a very high trauma practice, these should not be your main focus.
Don’t get distracted by the coders who can’t pronounce calcaneusKnow your most common procedures and know how to code them
At risk foot careBilling 11721You need to document your class finds and have your Q modifiers correctDiagnosis needed:Must have diabetes diagnosisChoices:E11.40 DM2 Neuro CompE11.51 DM2 PVD CompE10.40 DM1 Neuro CompE10.51 DM1 PVD CompMust have Nail pathology
B35.1 Mycotic NailIf Neuro Modifier being used the DM diagnosis had it but would consider using G60.9 which is peripheral Neuropath
   Mycoticdiabetic foot care for DM type 2 with neuro might look like
Procedure code: 11721 Q8Diagnosis codes:
E11.40B35.1G60.9Procedure Codes: 11055,11056 Q8Diagnosis codes:
E11.40B35.1G60.9L84


Mycotic diabetic foot care for DM type 2 with neuro might look like
    Procedure code: 11721 Q
    Diagnosis codes:
E11.51
B35.1
I73.9

Procedure Codes: 11055,11056 Q9
Diagnosis codes:
E11.51
B35.1
I73.9
L84

Mycoticdiabetic foot care for DMtype1 with neuro might look like
Procedure code: 11721 Q8
Diagnosis codes:
E10.40
B35.1
G60.9

Procedure Codes: 11055,11056 Q8
Diagnosis codes:
E10.40
B35.1
G60.9
L84

Mycoticdiabetic foot care for DM type1 with PVD might look like
Procedure code: 11721 Q9
Diagnosis codes:
E10.51
B35.1
I73.9

Procedure Codes: 11055,11056 Q9
Diagnosis codes:
E10.51
B35.1
I73.9
L84

If you are a practicing podiatrist seeing diabetic patients can decrease the possibility of them having a non traumatic amputation tremendously
In the study by Weck, et al, in Cardiovascular Diabetology, 2013. Instituting a structured diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality.
It has been proven time and time again in peer reviewed literature, that these patients who have diabetes that visit the podiatrist are much less likely to have an amputation of an extremity. 
 Podiatric medical care in people with history of diabetic foot ulcers can reduce the high level amputation between 65% and 80%. Gibson, et al, IntWound Journal 2013. 
Ulcer diagnosis in diabetics
If your patient is Type 1 diabetic with an ulcer the diagnosis code is:  E10.622
If your patient is Type 2 diabetic with an ulcer the diagnosis code is: E11.622
These codes are the highest level of specificity for the types of Diabetic Ulcers we see in the office (do not confuse with pressure ulcers, different codes)
This is a good improvement, as all of the ulcer codes used to be jumbled together whether they were pressure, diabetic ect.
Coding for Diabetic Foot Ulcer debridement
11042, 11043 and 11042 use modifier L or R
There is no laterally in the diabetic ulcer codes themselves so laterally is still in your procedure codes
Diagnosis: 
E11.621 Type 2 dm with foot/ankle ulcer
E10.622 Type 1 dm with foot/ankle ulcer

To be specific as possible I would consider also coding their diabetes
Choices:
E11.40 DM2 Neuro Comp
E11.51 DM2 PVD Comp
E10.40 DM1 Neuro Comp
E10.51 DM1 PVD Comp

Yes they have diabetes and an ulcer. But documenting the DM2 Neuro E11.40, for example, is letting them know that the diagnosis of ulcer is “due to” the Neuro Complications
This makes this much more specific


Check out our website at: http://centeranklefootcare.com/catalog/c14_p1.html for a superbill for podiatry most common codes
          
352 242 2502
Citrus Tower Boulevard 3150, Clermont, Florida, 34711, United States
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