Texas State Board of
Podiatric Medical Examiners

Questions & Answers

The following information is made available by the Texas State Board of Podiatric Medical Examiners as guidance only (resource). If the public or licensees have any question or confusion about the interpretation of the information or for further scope of practice inquiries, please contact the Board's Executive Director at Hemant.Makan@foot.state.tx.us to submit a written request.

Unless otherwise specifically cited, this response by the Texas State Board of Podiatric Medical Examiners is not intended to supersede the authority of any other regulatory Board or entity that may have jurisdiction on these issues. Additionally, this information is not intended to be construed as a "Rule" respective to the rule making process published in the Texas Register. Furthermore, this information is not a formal legal opinion nor advisory opinion, which this Board does not issue.

1. What is a Podiatrist’s scope of practice in Texas?
2. But what specific procedures can a Podiatrist perform?
3. What is the penalty for practicing Podiatric Medicine without a license?
4. Can a Podiatrist write prescriptions?
5. Can Podiatrist’s conduct “History & Physicals”?
6. For regulatory and compliance purposes, what portions of the Board Statute
   and Rules should Podiatrists make sure they know?
7. What does it mean if a Podiatrist’s license is in a “Delinquent” or "Cancelled" status;
   can they still practice?
8. Can Podiatrists sign the written statement that accompanies the application for
   disabled person placards and license plates?
9. Can Podiatrists use the word "Ankle" in an advertisement?
10. Where can I find information regarding the Diabetic Shoe Bill?
11. I'm "Retiring"! What do I need to do in order to properly close my practice?
12. I am a prospective patient, what can I do to research the background of a podiatrist or healthcare provider?
13. I am a Podiatrist who would like to include Hyperbaric Oxygen (HBO) therapy as part of my Wound Care treatments. What are the requirements, scope and regulations for me to perform HBO? What else should I know?
14. I am a Podiatrist who is the subject of a complaint investigation filed by one of my patients. Is it o.k. for me to contact the patient to discuss his/her complaint while the Board investigates the matter?
15. I am a Podiatrist who is having problems with an (private) Insurance Company. I have been denied payment, my payments are not timely and I am having other business problems with the carrier which is having a negative impact on my practice. Who can assist me in filing a complaint to resolve these matters?
16. Can a Podiatrist order and/or supervise the administering of anesthesia by a CRNA (Certified Registered Nurse Anesthetist)?
17. I am a patient who has been the victim of a sexual impropriety/act/crime and boundary violation by a physician. Where can I find assistance and information with victims rights beyond solely filing a complaint with the Board or Law Enforcement?
18. As a patient or podiatric physician, where can I find information related to "Informed Consent Forms"?
19. I suspect Child Abuse/Neglect/Sexual Exploitation. What do I do?
20. What are the Medicare regulations relating to Podiatrist orders and debridement of mycotic/dystrophic nail tissue in a nursing home setting?
21. I am a patient with a billing problem. I had seen my doctor who is an out of network provider for my insurance plan. I am now stuck with a large bill for "usual and customary" rates that are not covered and I can't afford this. What can be done?
22. Can a Podiatrist advertise and promote an off-label non-FDA approved use of lasers (& other drugs/devices) for toenail fungus treatment?

1. What is a Podiatrist’s scope of practice in Texas?

   A Podiatrist’s scope of practice in Texas is defined, at least, in three parts:

   First, Texas Occupations Code (Statute) §202.001(a)(4) "Definitions" provides that: "Podiatry" means the treatment of or offer to treat any disease, disorder, physical injury, deformity, or ailment of the human foot by any system or method. The term includes podiatric medicine.

   Second, Texas Administrative Code, Title 22, Part 18 (Rules) §375.1(2) provides: "Foot"--The foot is the tibia and fibula in their articulation with the talus, and all bones to the toes, inclusive of all soft tissues (muscles, nerves, vascular structures, tendons, ligaments and any other anatomical structures) that insert into the tibia and fibula in their articulation with the talus and all bones to the toes.

   Third, in accordance with Texas Health & Safety Code Subchapter E relating to Medical Staff Membership & Privileges (§241.101 et al): Procedures to treat the foot/ankle by a Podiatrist at the hospital/surgical facility level are within the scope of practice for Podiatric Medicine in the State of Texas (by “any system or method”) as long as the Podiatrist is qualified and credentialed to do so and has hospital/surgical privileges for the same, for performance of the procedure at the hospital/surgical level as cleared by medical staff. Texas Health & Safety Code §241.101(g) "Hospital Authority Concerning Medical Staff" provides that a hospital's bylaw requirements for staff privileges may require a podiatrist to document the person's current clinical competency and professional training and experience in the medical procedures for which privileges are requested. A Podiatrist who is not trained in performance of the procedures being requested is not authorized to perform those procedures as unqualified practitioners are to refrain from attempting procedures that are not within the individual Podiatrist's capability. Texas Health & Safety Code §241.102(a) "Authorizations and Restrictions in Relation to Physicians and Podiatrists" provides that this chapter does not authorize a Podiatrist to perform podiatric acts that are beyond the scope of the respective license held.

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2. But what specific procedures can a Podiatrist perform?

   A list of approved techniques, procedures, etc. is not found in the Statute or Rules. For a specific inquiry, please submit your request in writing to the Board. All Podiatrists in Texas have graduated from a 4 year Podiatric Medical College and others have completed at least one (1) year of a residency up to three (3) years. (Note: Residency requirements became effective at 12:01 a.m. on July 1, 1995). Some Podiatrists have furthered their credentials by earning a certification or accreditation through various private “specialty/certifying” boards for surgery, etc. The State Board (i.e. TSBPME) does not maintain a list of credentialing. That information can be obtained through the Texas Podiatric Medical Association (TPMA) at 512-494-1123 or at http://www.txpma.org. The TPMA has a hospital manual for further assistance. In addition, the medical staff at any entity, hospital, surgi-center, etc. giving clinical privileges further determines a Podiatrist’s scope by their individual credentials/qualifications. They can NOT expand the scope determined by the Texas State Board of Podiatric Medical Examiners. Credentialing is a matter for local determination and community standards.

   Texas Statewide Strategic Planning Philosophy provides, in part, that: "...Decisions affecting individual Texans, in most instances, are best made by those individuals, their families, and the local government closest to their communities...Competition is the greatest incentive for achievement and excellence.  It inspires ingenuity and requires individuals to set their sights high.  And just as competition inspires excellence, a sense of personal responsibility drives individual citizens to do more for their future and the future of those they love..."

   Further Podiatric Medical Training information can be obtained at the Council on Podiatric Medical Education. (CPME: "The Council on Podiatric Medical Education is an autonomous accrediting agency for podiatric medical education. Deriving its authority from the House of Delegates of the American Podiatric Medical Association, the Council is empowered to develop and adopt standards and policies as necessary for the implementation of all aspects of its accreditation, approval, and recognition purview.")

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3. What is the penalty for practicing Podiatric Medicine without a license?

   Any persons suspected of treating any disease, disorder, physical injury, deformity, or ailment of the human foot by any system or method, other than a Podiatrist or Medical Doctor, will be viewed as practicing Podiatric Medicine without a license (criminal offense). Section 202.605. "General Criminal Penalty: Practicing Without a License" of the Texas Occupations Code, states:

   1. A person commits an offense if the person professes to be a podiatrist or practices or assumes the duties incident to the practice of podiatry without holding a license to practice podiatry.

   2. An offense under this section is punishable by:

      1. A fine of not less than $50 or more than $500 

      2. Confinement in the county jail for not less than 30 days or more than six months; or

      3. Both the fine and confinement.

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4. Can a Podiatrist write prescriptions?

   Yes, for a valid medical purpose & within the limits of "Podiatry" scope of practice, Podiatrists can write prescriptions to treat any disease, disorder, physical injury, deformity or ailment of the human foot.

   All "Controlled Substances" prescriptions are subject, in part, to related U.S. Drug Enforcement Administration, Texas Department of Public Safety and Texas Health & Safety Code provisions. For further information, please click on the following "License Verifications" page.

   Texas Health & Safety Code §481.071 "Medical Purpose Required Before Prescribing, Dispensing, Delivering, Or Administering Controlled Subsance" provides, in part, that:  "(a)  A practitioner defined by Section 481.002(39)(A) may not prescribe, dispense, deliver, or administer a controlled substance or cause a controlled substance to be administered under the practitioner's direction and supervision except for a valid medical purpose and in the course of medical practice."

   http://www.statutes.legis.state.tx.us/Docs/HS/pdf/HS.481.pdf

   United States Code of Federal Regulations; 21 CFR §1306.03 "Persons Entitled to Issue Prescriptions" provides that: "(a) A prescription for a controlled substance may be issued only by an individual practitioner who is: (1) Authorized to prescribe controlled substances by the jurisdiction in which he is licensed to practice his profession and (2) Either registered or exempted from registration pursuant to 1301.22(c) and 1301.23 of this chapter. (b) A prescription issued by an individual practitioner may be communicated to a pharmacist by an employee or agent of the individual practitioner. [36 FR 7799, Apr. 24, 1971, as amended at 36 FR 18732, Sept. 21, 1971. Redesignated at 38 FR 26609, Sept. 24, 1973, as amended at 62 FR 13966, Mar. 24, 1997]"

   With regard to "Dangerous Drugs," Texas Health & Safety Code §483.001(2) "Definitions" provides that: "In this chapter: 'Dangerous drug' means a device or a drug that is unsafe for self-medication and that is not included in Schedules I through V or Penalty Groups 1 through 4 of Chapter 481 (Texas Controlled Substances Act). The term includes a device or a drug that bears or is required to bear the legend: (A) 'Caution: federal law prohibits dispensing without prescription' or 'Rx only' or another legend that complies with federal law; or (B) 'Caution: federal law restricts this drug to use by or on the order of a licensed veterinarian.'"

   Furthermore, with regard to "Dangerous Drugs," the Texas Health & Safety Code provides for the following:

   "Texas Health & Safety Code §483.045. FORGING OR ALTERING PRESCRIPTION. (a) A person commits an offense if the person: (1) forges a prescription or increases the prescribed quantity of a dangerous drug in a prescription; (2) issues a prescription bearing a forged or fictitious signature; (3) obtains or attempts to obtain a dangerous drug by using a forged, fictitious, or altered prescription; (4) obtains or attempts to obtain a dangerous drug by means of a fictitious or fraudulent telephone call; or (5) possesses a dangerous drug obtained by a forged, fictitious, or altered prescription or by means of a fictitious or fraudulent telephone call. (b) An offense under this section is a Class B misdemeanor unless it is shown on the trial of the defendant that the defendant has previously been convicted of an offense under this chapter, in which event the offense is a Class A misdemeanor. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989."

   "Texas Health & Safety Code §483.046. FAILURE TO RETAIN PRESCRIPTION. (a) A pharmacist commits an offense if the pharmacist: (1) delivers a dangerous drug under a prescription; and (2) fails to retain the prescription as required by Section 483.023. (b) An offense under this section is a Class B misdemeanor unless it is shown on the trial of the defendant that the defendant has previously been convicted of an offense under this chapter, in which event the offense is a Class A misdemeanor. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989."

   "Texas Health & Safety Code §483.047. REFILLING PRESCRIPTION WITHOUT AUTHORIZATION. (a) Except as authorized by Subsection (b), a pharmacist commits an offense if the pharmacist refills a prescription unless: (1) the prescription contains an authorization by the practitioner for the refilling of the prescription, and the pharmacist refills the prescription in the manner provided by the authorization; or (2) at the time of refilling the prescription, the pharmacist is authorized to do so by the practitioner who issued the prescription. (b) A pharmacist may exercise his professional judgment in refilling a prescription for a dangerous drug without the authorization of the prescribing practitioner provided: (1) failure to refill the prescription might result in an interruption of a therapeutic regimen or create patient suffering; (2) either: (A) a natural or manmade disaster has occurred which prohibits the pharmacist from being able to contact the practitioner; or (B) the pharmacist is unable to contact the practitioner after reasonable effort; (3) the quantity of drug dispensed does not exceed a 72-hour supply; (4) the pharmacist informs the patient or the patient's agent at the time of dispensing that the refill is being provided without such authorization and that authorization of the practitioner is required for future refills; and (5) the pharmacist informs the practitioner of the emergency refill at the earliest reasonable time. (c) An offense under this section is a Class B misdemeanor unless it is shown on the trial of the defendant that the defendant has previously been convicted under this chapter, in which event the offense is a Class A misdemeanor. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989. Amended by Acts 1993, 73rd Leg., ch. 789, Sec. 22, eff. Sept. 1, 1993."

   "Texas Health & Safety Code §483.048. UNAUTHORIZED COMMUNICATION OF PRESCRIPTION. (a) An agent of a practitioner commits an offense if the agent communicates by telephone a prescription unless the agent is designated in writing under Section 483.022 as authorized by the practitioner to communicate prescriptions by telephone. (b) An offense under this section is a Class B misdemeanor unless it is shown on the trial of the defendant that the defendant has previously been convicted of an offense under this chapter, in which event the offense is a Class A misdemeanor. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989."

   "Texas Health & Safety Code §483.022. PRACTITIONER'S DESIGNATED AGENT; PRACTITIONER'S RESPONSIBILITIES. (a) A practitioner shall provide in writing the name of each designated agent as defined by Section 483.001(4)(A) and (C), and the name of each healthcare facility which employs persons defined by Section 483.001(4)(B). (b) The practitioner shall maintain at the practitioner's usual place of business a list of the designated agents or healthcare facilities as defined by Section 483.001(4). (c) The practitioner shall provide a pharmacist with a copy of the practitioner's written authorization for a designated agent as defined by Section 483.001(4) on the pharmacist's request. (d) This section does not relieve a practitioner or the practitioner's designated agent from the requirements of Subchapter A, Chapter 562, Occupations Code. (e) A practitioner remains personally responsible for the actions of a designated agent who communicates a prescription to a pharmacist. (f) A practitioner may designate a person who is a licensed vocational nurse or has an education equivalent to or greater than that required for a licensed vocational nurse to communicate prescriptions of an advanced practice nurse or physician assistant authorized by the practitioner to sign prescription drug orders under Subchapter B, Chapter 157, Occupations Code. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989. Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 201, eff. Sept. 1, 1991; Acts 1991, 72nd Leg., ch. 237, Sec. 11, eff. Sept. 1, 1991; Acts 1993, 73rd Leg., ch. 789, Sec. 19, eff. Sept. 1, 1993; Acts 1999, 76th Leg., ch. 428, Sec. 4, eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 1420, Sec. 14.797, eff. Sept. 1, 2001."

   "Texas Health & Safety Code §483.049. FAILURE TO MAINTAIN RECORDS. (a) A person commits an offense if the person is required to maintain a record under Section 483.023 or 483.024 and the person fails to maintain the record in the manner required by those sections. (b) An offense under this section is a Class B misdemeanor unless it is shown on the trial of the defendant that the defendant has previously been convicted of an offense under this chapter, in which event the offense is a Class A misdemeanor. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989."

   http://www.statutes.legis.state.tx.us/Docs/HS/pdf/HS.483.pdf

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5. Can Podiatrist’s conduct “History & Physicals”?

   Yes, it falls within a Podiatrist's scope of practice and licensure to conduct “History and Physicals,” limited only by the position of the hospital/surgery center/entity/facility where privileges are granted (See Q&A #1 - Scope of Practice). Please click on the following to view the "November 27, 2006 Federal Register; Section 482.22(c)(5) Condition of Participation: Medical Staff" which provides, in part, that a physician (as defined in section 1861(r) of the Act), oromaxillofacial surgeon, or other qualified individual could complete the H&P in accordance with State law and hospital policy. These updated federal regulations become effective on January 26, 2007.

   Furthermore, Texas Health & Safety Code §241.102 "Authorizations and Restrictions In Relation To Physicians and Podiatrists" provides that: "(a) This chapter does not authorize a physician or podiatrist to perform medical or podiatric acts that are beyond the scope of the respective license held. (b) This chapter does not prevent the governing body of a hospital from providing that: (1) a podiatric patient be coadmitted to the hospital by a podiatrist and a physician; (2) a physician be responsible for the care of any medical problem or condition of a podiatric patient that may exist at the time of admission or that may arise during hospitalization and that is beyond the scope of the podiatrist's license; or (3) a physician determine the risk and effect of a proposed podiatric surgical procedure on the total health status of the patient. (c) An applicant for medical staff membership may not be denied membership solely on the ground that the applicant is a podiatrist rather than a physician. (d) This chapter does not automatically entitle a physician or a podiatrist to membership or privileges on a medical staff. (e) The governing body of a hospital may not require a member of the medical staff to involuntarily: (1) coadmit patients with a podiatrist; (2) be responsible for the care of any medical problem or condition of a podiatric patient; or (3) determine the risk and effect of any proposed podiatric procedure on the total health status of the patient."

   Ultimately, privileging is a local matter between the applicant and medical staff. Nevertheless, within licensure/scope, a Podiatrist MAY perform a full H&P (i.e. head-toe) for podiatric admission, but only if credentialed to do so by medical staff (local control) and of course, if prudent to do so understanding that most facilities take a multi-disciplinary admission approach for patient safety. This "full H&P" would include addressing "other elements in a full H&P such as cardiac, medical and/or other non podiatric related elements." But, the Podiatrist would have to demonstrate his/her competency to medical staff to perform full H&P's (i.e. head-toe).

   The limitation here is that a Podiatrist could NOT perform a full H&P for a patient NOT undergoing podiatric medical (foot/ankle) treatment. For example, a facility could not authorize a Podiatrist to do a full H&P on a patient for "medical" conditions such as knee, hip, back, heart, brain surgery, etc. Meaning, while a Podiatrist can do a full H&P for foot/ankle surgery, that is not a waiver for a Podiatrist to do full H&P's for non-foot/ankle conditions.

   Credentialing is a matter for local determination and community standards.

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6. For regulatory and compliance purposes, what portions of the Board Statute and Rules should Podiatrists make sure they know?

   Although the entire Podiatric Medical Practice Act (Texas Occupations Code, Chapter 202), the Board Rules (Texas Administrative Code; Title 22, Part 18)  and related other State/Federal Laws/Rules are quite extensive, from a "complaint" prevention perspective, it would be in a licensee’s best interest to be aware of the following BOARD STATUTE & RULES. Please click here for a PDF document. NOTE: Formal “Disciplinary Actions” (Board Orders) are reported to the National Practitioner Databank-Healthcare Integrity Protection Databank (NPDB-HIPDB) and on the Board's website.

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7. What does it mean if a Podiatrist’s license is in a “Delinquent” or "Cancelled" status; can they still practice?

   • If your license is EXPIRED ("DELINQUENT") or CANCELLED please read the following carefully.
   • Licensees who have submitted late renewals or have yet to submit a renewal have been placed in a “Delinquent” status. Please call the Board (512-305-7000) to determine if the renewal was received and if the license is “Active.” PENALTY FEES ACCRUE AFTER November 1^st.
   • Until September 9, 2007, a licensee in a “Delinquent” status is not fully prohibited from practicing. A licensee can be in a “Delinquent” status for one year from the time of the renewal period (deadline is November 1^st of each year) expiration, accruing penalty fees. If any entity providing the licensee clinical privileges wishes to restrict a licensee in a “Delinquent” status, for liability reasons, they may do so.
   • Effective September 10, 2007, all "Delinquent" licenses are subject to all administrative and criminal penalties of "Practicing Without A License." Any licensee in a "Delinquent" status shall not practice Podiatric Medicine; criminal act pursuant to Texas Occupations Code §202.605. There will no longer be a one year grace period. However, "Delinquent" license holders will have one year to renew their license with PENALTY FEES from November 1st before their license is "Cancelled."
   • Any licensee in a "Cancelled" status shall not practice Podiatric Medicine; criminal act pursuant to Texas Occupations Code §202.605. "Cancelled" licensees are required to fully re-apply for licensure. That includes re-taking the TSBPME jurisprudence examination and having completed a one-year residency program accredited by CPME.

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8. Can Podiatrists sign the written statement that accompanies the application for disabled person placards and license plates?

   Yes. Effective September 1, 2001, the 77th Texas Legislature, 2001, Regular Session passed Senate Bill 777 (Texas Transportation Code Chapter 681) which states that the required notarized written statement or written prescription that accompanies the initial application for a disabled person identification placard or license plate can be issued by a person licensed to practice podiatry in this state or a state adjacent to this state. The application must be made by on or behalf of a person with a mobility problem caused by a disorder of the foot. For more information, you may contact the Board or the Texas Department of Transportation at (512)-465-7719; (512)-465-7923.

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9. Can Podiatrists use the word "Ankle" in an advertisement?

   "Yes," effective April 1, 2001 the restrictions on using the word "Ankle" in advertisements were lifted, pursuant to Section 375.1(2) of the Texas Administrative Code. However, any such advertisements or trade names must be approved by the Board. Any advertisements or trade names NOT approved by the Board are subject to investigation and administrative penalties.

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10. Where can I find information regarding the Diabetic Shoe Bill?

    You may visit the following CMS website which explains coverage and legal requirements:

    http://www.cms.hhs.gov/DiabetesSelfManagement/02_ProvResources.asp

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11. I'm "Retiring"! What do I need to do in order to properly close my practice?

    Board Rule §375.3(b) states: “A licensed podiatric physician shall conduct his practice on the highest plane of honesty, integrity, and fair dealing and shall not mislead his patients as to the gravity of such patient's podiatric medical needs. A podiatric physician shall not abandon a patient he has undertaken to treat. He may discontinue treatment after reasonable notice has been given to the patient by the podiatric physician of his intention to discontinue treatment and the patient has had a reasonable time to secure the services of another podiatric physician or all podiatric medical services actually begun have been completed and there is no contract or agreement to provide further treatment.”

    The Board does NOT intervene in civil/business/contractual/employment disputes; those are (peer-to-peer) civil or labor matters outside the Board's jurisdiction.

    Medical Records. Be advised, common complaints received by the Board include the release of Medical Records (inability to obtain) or fees charged for the same. Be advised, Board Rule §375.21 relate to "Records;" the following is noted. The records of the identity, diagnosis, evaluation, or treatment of a patient by a podiatric physician that are created or maintained by a podiatric physician are the property of the podiatric physician. A podiatric physician shall furnish copies of medical records or a summary or narrative of the medical records pursuant to a written request. The podiatric physician providing copies of requested medical records or a summary or a narrative of such medical records shall be entitled to payment of a reasonable fee prior to release of the information unless the information is requested by a health care provider licensed in Texas or licensed by any state, territory, or insular possession of the United States or any State or Province of Canada if requested for purposes of emergency or acute medical care. Complaints which involve the inability to obtain medical records must evidence proof that a proper written request and payment was made in accordance with these rules. Verbal requests by patients to obtain records and refusal to pay do not meet proper release standards; such complaints will not be pursued.

    Regarding the actual cessation/leaving of one's practice, please be advised of the following General Considerations. This also applies to scenarios involving any discontinuance of practice, retirement and termination of employment.

    a) Although the Podiatric Medical Practice Act of Texas and the Board’s Rules do not contain specific language addressing the closing/transferring of one’s practice, the Podiatrist should have an attorney draw up the contract for the practice transfer. He/she should be sure to include, in the contract, specific, common sense language to ensure that his/her current patients are provided with an opportunity for continuity of care.

    b) Board Rule §375.21(a) "Records" provides that: “All podiatric physicians shall make, maintain, and keep accurate records of the diagnosis made and the treatment performed for and upon each of his or her patients for reference and for protection of the patient for at least five years following the completion of treatment.”

    c) Normally, when closing a practice, the Podiatrist advises his/her patients of the closure by sending them a postcard. That postcard would advise the patient: 1) of the closure; 2) where their medical records will be maintained and where the patients can access them and 3) where the patient can secure continuity of Podiatric care by contacting the appropriate healthcare practitioner/Podiatrist. Each patient should at least receive a letter or post card. A postcard may be the least expensive form of written notification. The Podiatrist can contact a local publisher for any bulk productions.

    d) However, if the items in "C" are not feasible, visible signage in and around the closing practice is standard, to alert active patients of the change. A voice message on the office answering machine/service giving information on the office status, who will be taking over the practice, and information on patient records, etc. is also recommended.

    e) Newspaper/radio/television/internet-website/etc. advertising would be optional and covered by the “reasonableness” of the time selected for the advertisement to run. A time period of  “one week” would be considered reasonable for a small municipality. A time period of several days a week, for several weeks to a month should be considered for larger/major municipalities. However, given the circumstances, if this is not feasible, then "D" suffices.

    f) Podiatrists MUST also notify the Board of any change of address via signed letter (Facsimile: 512-305-7003, ATTN: "Change of Address") or via our website at: http://www.dir.state.tx.us/txoa/addresschange.html

    g) Board Rule §375.27 "Report Change of Practice Address and/or Phone Number to the Board" provides that: "It shall be the responsibility of each licensee to ensure that any change of address or phone number(s) for each licensees location(s) are reported in writing, via e-mail, facsimile or mail to the Board no later than 10 business days after the change is made. Failure to give written notification to the Board of these changes writing the required 10 business days shall result in an automatic administrative penalty of $10, for each business day that the information is not reported to the Board. The maximum penalty shall not exceed $300."

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12. I am a prospective patient, what can I do to research the background of a podiatrist or healthcare provider?

    As a patient, you are also responsible for the quality of your healthcare. One way of ensuring you receive medical care commensurate to your needs is to research your doctor or healthcare provider. There are several ways of doing this:

    1. You may verify basic Podiatry licensure information at: http://www.foot.state.tx.us/verification.online.htm.

    2. You may verify and print Podiatry Board Actions in the form of Agreed/Board Orders at: http://www.foot.state.tx.us/verification.disciplinary.htm.

    3. You may conduct a Public Criminal History Search via the Texas Department of Public Safety at: https://records.txdps.state.tx.us/DPS_WEB/Portal/index.aspx

    4. You may review your doctor's Physician Profile at: http://www.texasonline.state.tx.us/NASApp/txops/ProfilingSearchManager?AGENCY=tsbpme. This is a "Texas Online.com" service.

    5. You may obtain Federal Healthcare Exclusion information via the United States Department of Health and Human Services - Office of Inspector General at: http://exclusions.oig.hhs.gov.

    6. You may obtain Texas Medicaid Exclusion information via the Texas Health and Human Services Commission - Office of Inspector General at: http://www.hhsc.state.tx.us/.

    7. You may obtain Federal Student Loan Default information at: http://www.defaulteddocs.dhhs.gov/.

    8. You may visit your or your doctor's County Clerk's Office to Obtain Civil and/or Malpractice Litigation information. For most counties, you will have to physically appear at the Clerk's Office to conduct a query. Some larger counties have that same information available on-line. To determine if your county has an on-line service, you may click on the following link to obtain a list of county websites: http://www.state.tx.us/portal/tol/en/gov/11/3. This is a "Texas Online.com" service.

    9. You may view a list of State Agencies, who may also have jurisdiction over your doctor at: http://www.state.tx.us/portal/tol/en/gov/6/9. This is a "Texas Online.com" service.

    10. You may contact your Insurance Carrier to determine if they have any information on your doctor responsive to your request.

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13. I am a Podiatrist who would like to include Hyperbaric Oxygen (HBO) therapy as part of my Wound Care treatments. What are the requirements, scope and regulations for me to perform HBO? What else should I know?

    Hyperbaric Oxygen therapy involves placing (diving) a patient in a chamber filled with 100% oxygen, the atmospheric pressure of which has been increased. Be advised of the following concerning the scope of practice for Podiatric Medicine in the State of Texas regarding Hyperbaric Oxygen Therapy:

    • Section 202.001(4) of Texas Occupations Code (Statute) states: "Podiatry" means the treatment of or offer to treat any disease, disorder, physical injury, deformity, or ailment of the human foot by any system or method. The term includes podiatric medicine.

    • Section 375.1(2) of the Texas Administrative Code, Title 22, Part 18, (Rules) states: "Foot" -- The foot is the tibia and fibula in their articulation with the talus, and all bones to the toes, inclusive of all soft tissues (muscles, nerves, vascular structures, tendons, ligaments and any other anatomical structures) that insert into the tibia and fibula in their articulation with the talus and all bones to the toes.

    • Section 375.5 of the Texas Administrative Code, Title 22, Part 18, (Rules) states: A Podiatric physician shall be recognized and permitted to supervise and administer hyperbaric oxygen following the published recommendations of the Undersea and Hyperbaric Medical Society, Inc. (UHMS) and within the credentials and bylaws of the hospital that operates the hyperbaric unit with the following stipulations:

      1. A podiatric physician practicing hyperbaric oxygen must do so in a hospital setting.

      2. The Podiatric physician must, in addition, show evidence of attendance and successful completion of a course of hyperbaric training that is recognized by the Undersea and Hyperbaric Medical Society. That person may only utilize hyperbaric oxygen in the treatment of the foot as recognized by the Podiatric Medical Act, Texas Civil Statutes, Article 4567, et seq. A person shall be regarded as practicing podiatric medicine within the meaning of this law and shall be deemed and construed to be a podiatric physician, who shall treat or offer to treat any disease or disorder, physical injury, or deformity, or ailment of the human foot by any system or method

      3. Prior to administering hyperbaric oxygen, a podiatric physician must have on file with the Texas State Board of Podiatric Medical Examiners documentation certifying compliance with the above requirements.

      4. A copy of the published recommendations of the Undersea and Hyperbaric Medical Society, Inc., are available from the Texas State Board of Podiatric Medical Examiners, P.O. Box 12216; Austin, Texas 78711-2216.

    The utilization of HBO by a Podiatrist, pursuant to the aforementioned requisite Board certification, is an approved modality pursuant to Board Rule Chapter 375 and Attorney General Opinion DM-423 (11/06/1996). As long as the Podiatrist is performing dives on the "foot/ankle," he/she is authorized to utilize HBO.

    Due to the nature of HBO complications, it is required that the HBO facility be in a "hospital setting" to allow for other health professionals to be present in the event of a patient emergency. Location of the HBO facility within a "hospital campus" suffices the requirement that a "podiatric physician practicing HBO must do so in a hospital setting." Furthermore, in a large hospital (campus) setting, it is understood that the Podiatrist my have to leave the HBO facility to attend to matters at the main hospital building. Leaving the HBO facility would be allowable as long as appropriately trained staff could attend to the patient in a dive and that the Podiatrist be available when needed. Otherwise, the expectation is that the HBO facility be appropriately staffed at all times for the patient's well-being and the Podiatrist is responsible for his/her patients (at all times).

    In the past, it has been asked whether or not a Podiatrist can perform dives on conditions (hips, backs, torsos, etc.) beyond the scope of Podiatric Medicine. In response, the answer is "NO," unless he/she acting under the delegation or orders of a Medical Doctor or Doctor of Osteopathic Medicine (MD/DO) pursuant to Texas Occupations Code Section 157.001. Even if a Podiatrist is acting under the delegation/order of a MD/DO for non-scope treatments, a MD/DO needs to be on-site at the HBO facility in the event there is a complication of the non-podiatric wound and that the Podiatrist's medical records need to be sure to document their (co-)management of the patient with him/her and co-signatures. There is nothing in the law that precludes a Podiatrist from working together with Doctors of Medicine for the common goal of patient welfare; wound care can be well managed together, by both professionals. However, it is imperative that the patient medical records accurately record the totality of the provision of HBO therapy and by whom.

    Medical Staff at hospitals can enact their own restrictions/controls (by-laws) with respect to HBO treatments by a Podiatrist but they can NOT expand the scope set forth by the Board's laws/rules. Meaning, Medical Staff cannot authorize a Podiatrist to perform non-podiatric HBO treatments in the absence of a MD/DO delegation/order. For podiatric HBO treatments, the Podiatrist would be well within the scope to perform such treatments, upon  Board certification/registration pursuant to Chapter 375. For those "medical" treatments delegated by an MD/DO to the Podiatrist, be advised of the potential liability involved to the Podiatrist if the MD's/DO's do not adequately delegate/order, co-sign, co-manage and co-document their care. Again, proper medical record keeping is imperative or the Podiatrist will be subject to Board disciplinary action.

    Lastly, pursuant to Medicare rules, another physician also trained in HBO must be readily available in case there is a problem in the chamber that is outside the scope of podiatric care. From Trailblazer LCD on Hyperbaric Oxygen therapy: "Limited license physicians performing Hyperbaric Medicine services must have an unlimited license physician who is also credentialed in Hyperbaric Medicine by the hospital entity readily available to render assistance if needed." Furthermore, per Trailblazer, the chamber must be a "full-body" chamber and not just an "oxygen tent" set-up.

    The health and safety of patients shall be the first consideration of the Podiatric Physician.
    

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14. I am a Podiatrist who is the subject of a complaint investigation filed by one of my patients. Is it o.k. for me to contact the patient to discuss his/her complaint while the Board investigates the matter?

    No. It is recommended that you do not contact the patient during an on-going investigation. If you contact the patient (complainant) a situation may be created where the complainant feels they are being harassed or intimidated by you (doctor/licensee); they may fear retaliation. Unnecessary contact only confounds & complicates the investigation for both parties. Once a case has been initiated by the Board, it is expected that the doctor/licensee cease all communications that are the subject of the complaint, with the complainant, unless necessary for the continuity of the patient's (complainant's) medical care or directed otherwise by your legal counsel.

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15. I am a Podiatrist who is having problems with an (private) Insurance Company. I have been denied payment, my payments are not timely and I am having other business problems with the carrier which is having a negative impact on my practice. Who can assist me in filing a complaint to resolve these matters?

    The Texas State Board of Podiatric Medical Examiners has NO authority to proceed against an insurance company. However, you can file a complaint with the Texas Department of Insurance; click on the following link for more information: http://www.tdi.state.tx.us/hprovider/index.html.

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16. Can a Podiatrist order and/or supervise the administering of anesthesia by a CRNA (Certified Registered Nurse Anesthetist)?

    The administration of anesthesia by a CRNA is under the regulation of the Texas Board of Nursing (TBON) and the Texas Medical Board (TMB). We recommend that requestors contact the TBON & TMB for further information. Podiatrists do request the provision of anesthesia services from the appropriate provider in consideration of the safety and well being of a patient.

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17. I am a patient who has been the victim of a sexual impropriety/act/crime and boundary violation by a physician. Where can I find assistance and information with victims rights beyond solely filing a complaint with the Board or Law Enforcement?

    The Texas State Board of Podiatric Medical Examiners in conjunction with Law Enforcement authorities investigates any allegations of sexual misconduct/crimes committed by a podiatric physician. While the Board focuses on the investigation, patients/victims can seek advocacy assistance/services or learn more information by contacting the following.

    Rehabilitation, continuing education (CME) and awareness information/services are also available for physicians through "Professional Boundaries Incorporated."

    In any instance involving victimization, "No Means NO!"

    CONTACTS FOR PATIENTS/VICTIMS:

    • Office of the Attorney General’s “Crime Victims Services” at http://www.oag.state.tx.us/victims/index.shtml.

    • Advocate Web at http://www.advocateweb.org/

    CONTACTS FOR PHYSICIANS (ONLY):

    • Professional Boundaries Incorporated at
      http://www.professionalboundaries.com/

    GENERAL CONTACTS / INFORMATION:

    • Additional searches can be conducted by searching “Victims Rights” at http://www.google.com.

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18. As a patient or podiatric physician, where can I find information related to "Informed Consent Forms"?

    The Texas Medical Disclosure Panel publishes rules and forms related to "Informed Consent" under Title 25; Part 7; Chapter 601 of the Texas Administrative Code. Please click on the link for more information.

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19. I suspect Child Abuse/Neglect/sexual exploitation. I also suspect Elder Abuse/Neglect. What do I do?

    Whether or not you are a Podiatric Physician, under Texas Family Code Chapter 261, ANYONE having cause to believe that a child's physical or mental health or welfare has been or may be adversely affected by abuse or neglect MUST REPORT the case IMMEDIATELY to a state or local law enforcement agency or the Texas Department of Family and Protective Services (TDFPS). Click here for a "General Guide" published by the Texas Office of the Attorney General. Also, TDFPS has a toll-free, 24-hour Family Violence Hotline: 1-800-252-5400 to report Child/Elder Abuse/Neglect. Click on the following link to read more about Elder Abuse/Neglect: "Elder Abuse is Everyone's Business"

    In addition, Texas Penal Code §38.17 "Failure to Stop or Report Aggravated Sexual Assault of Child" and Texas Penal Code §38.171 "Failure to Report Felony" provides criminal penalties for other failures to act.

    Furthermore, with regards to Sexual Exploitation of Children, any person may contact the National Center for Missing and Exploited Children and report concerns as well to The Cyber TipLine. These public efforts are coordinated with the appropriate law enforcement agencies.

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20. What are the Medicare regulations relating to Podiatrist orders and debridement of mycotic/dystrophic nail tissue in a nursing home setting?

    [Medicare is a federal health insurance program established by Congress in 1965 to provide health care insurance for seniors and people with disabilities (added in 1972). The Medicare program has two components, Part A and Part B. Part A provides coverage for services from institutional providers such as hospitals and skilled nursing facilities. Part B provides coverage for services from physicians, non-physician practitioners, laboratories and suppliers.]

    For reference, requestors can visit Trailblazer Health Enterprises, LLC directly at http://www.trailblazerhealth.com for further information. TrailBlazer Health Enterprises, LLC is an independent licensee of the Blue Cross and Blue Shield Association and administers the Medicare program under contracting arrangements with the Centers for Medicare & Medicaid Services (CMS). On their website, one can access “Local Coverage Determinations” (LCD) under the “Policies” link for “Part B & J4” policies. “Routine Foot Care and Debridement of Mycotic Nail” provisions can be found under “R.” The following is provided:

    • ... Documentation of foot-care services to residents of nursing homes not performed solely at the request of the patient or patient’s family/conservator must include a current nursing facility order (dated and signed with date of signature) for routine foot care service issued by the patient’s supervising physician that describes the specific service necessary. Such orders must meet the following requirements:
      
      • The order must be dated and must have been issued by the supervising physician prior to foot-care services being rendered.
      • Telephone or verbal orders not written personally by the supervising physician must be authenticated by the dated physician’s signature within a reasonable period of time following issuance of the order.
      • The order must be consistent with the attending physician’s overall plan of care.
      • The order must be for medically necessary services to address a specific patient complaint or physical finding.
      • Routinely issued or “standing” facility orders for routine foot-care services and orders for non-specific foot-care services that do not meet the above requirements are insufficient.
    • Documentation of foot-care services to residents of nursing homes performed solely at the request of the patient or patient’s family/conservator should name the person who requested the services and should identify the requesting person’s relationship to the patient ...

    Medical necessity withstanding, when any orders are written (hospital or nursing home), those orders are addressed to a "specific" physician (i.e. by name). Therefore, the order cannot state “…Podiatrist to ... do something….” The order must also specify what the ordering physician expects the latter physician to treat or do.

    The aforementioned Medicare LCD provisions from Trailblazer Health Enterprises, LLC can be found HERE. For further inquiries, requestors will need to contact Trailblazer Health Enterprises, LLC or requestors may also contact the Texas Podiatric Medical Association (TPMA) at 512-494-1123 and ask for their “Medicare Liaison.” Nevertheless, since these are federal provisions and due to high exposure for “Healthcare Fraud” in the event Local Coverage Determinations are not met as stipulated, it is recommended that Trailblazer Health Enterprises, LLC be contacted for further education/information.

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21. I am a patient with a billing problem. I had seen my doctor who is an out of network provider for my insurance plan. I am now stuck with a large bill for "usual and customary" rates that are not covered and I can't afford this. What can be done?

    First, the Texas State Board of Podiatric Medical Examiners has NO authority to proceed against an insurance company. However, you can file a complaint with the Texas Department of Insurance.

    The following is from the Office of the New York State Attorney General: "...In February 2008, the Attorney General announced an industry-wide investigation into allegations that health insurers unfairly saddle consumers with too much of the cost of out-of-network health care. Seventy percent of insured working Americans pay higher premiums for insurance plans that allow them to use out-of-network doctors. In exchange, insurers often promise to cover up to eighty percent of the 'usual and customary' rate of the out-of-network expenses, and consumers are responsible for paying the balance of the bill..." Please CLICK HERE to view the related State of New York press release.

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22. Can a Podiatrist advertise and promote an off-label non-FDA approved use of lasers (& other drugs/devices) for toenail fungus treatment?

    With regard to laser devices, all lasers are regulated by the Texas Department of State Health Services - Radiation Control Program (DSHS). We suggest that they be contacted with regard to registration, use and safety standards for such a device. http://www.dshs.state.tx.us/radiation/laser.shtm

    Podiatrists in Texas can treat the "foot/ankle" by "any system or method" and this COULD include the use of laser devices so long as it is properly registered with DSHS, used safely & for its intended purpose and not prohibited by any other regulatory agency. The possibility exists that some “Laser” treatments may be the practice of "Medicine" (the field regulated by the Texas Medical Board), such as when it comes to laser treatments and possibly cosmetic surgery, depending on what actually will be occurring. There is also a Texas Spa Act (Texas Occupations Code Chapter 702) that could have an applicability of jurisdiction. Therefore, the use of “Lasers” are subject not only to Podiatry Regulations, but also to those of the Texas Cosmetology Commission (i.e. the Texas Department of Licensing & Regulation), the Texas Department of State Health Services, the Texas Medical Board, the Texas Spa Act and the U.S. Food & Drug Administration (FDA).

    With regard to podiatrists advertising and promoting an off-label use of lasers for toenail fungus treatment, the U.S. Food & Drug Administration has regulations (http://www.fda.gov/cdrh/devadvice/3315.html) that govern misbranding, mislabeling and false advertising by manufacturers. Medical providers are restricted from advertising or promoting an off-label indication to attract patients for an off-label procedure; such promotion and inducement of an off-label therapy is misleading/deceptive. Patients should be notified by the Podiatrist of any off-label use of (drugs &) devices and informed consent should be obtained for the safety of the patient.

    Board Rule §373.13 “Advertising” provides, in part, that: “(a) A podiatric physician may advertise. A podiatric physician shall not, however, use or participate in the use of any publication, including advertisements, news stories, press releases, and periodical articles, that contains a false, fraudulent, misleading, deceptive, scientifically unsupported or generally unaccepted, or unfair statement or claim, or that are exaggerations or are untrue. (b) A false, fraudulent, misleading, deceptive, scientifically unsupported or generally unaccepted, or unfair statement or claim includes but is not limited to, a statement or claim that: (1) contains a misrepresentation of fact, or claims as fact something that has not been generally accepted among the podiatric community or by the Board as having been proven or established as fact; (2) is likely to mislead or deceive or entice or persuade a reasonable person because it fails to make full disclosure of relevant facts whether regarding fees, modes of treatment, conditions or techniques of surgery, post-operative conditions such as degree of pain, length of time of recovery, mobility and strength during recovery, and the like; (3) is intended or likely to create in an ordinary reasonable person false or unjustified expectations of favorable results; (4) states or implies educational or professional attainments or licensing recognition not supported in fact; (5) states or implies that the podiatric physician has received formal recognition as a specialist, or has any specialized expertise if this is not the case; (6) contains any laudatory statement, or other statement or implication that the podiatric physician's services are of exceptional quality; (7) contains statistical data or information that reflects or is intended to reflect quality or degree of success of past performance, or prediction of future success; (8) represents that podiatric services can or will be completely performed for a stated fee amount when this is not the case, or makes representations with respect to fees that do not disclose all variables affecting the fees, or makes representations that might reasonable cause an ordinary prudent person to misunderstand or be deceived about the fee amount; (9) contains a testimonial; (10) represents that health care insurance deductibles or co-payments may be waived or are not applicable to health care services to be provided if the deductibles or co-payments are required; (11) represents that the benefits of a health benefit plan will be accepted as full payment when deductibles or co-payments are required. (f) If a publication by or for a podiatric physician includes mention of a particular surgical technique or device, such as laser surgery, minimal incision surgery, laser bunion surgery or similar particular techniques or devices, the publication must also include a specific and true statement that reveals to an ordinary reasonable person the limits and scope and specific purpose of the technique so as not to mislead an ordinary reasonable person regarding the difficulty, pain or discomfort, length of time for surgery or recuperation, or possibility of complications.”

    Board Rule §373.15 “Violations” provides that: “(a) Any person who violates this chapter et seq., or a determination of the Board hereunder is subject to a administrative penalty of up to $500 for each day of violation. (b) In addition, failure of a podiatric physician licensed by the Board to identify his practice consistent with this chapter is subject to the penalties provided by Chapter 376 of this title (relating to Violations and Penalties). (c) At the request of the board, the attorney general shall institute and conduct the action in the name of the state.”

    Board Rule §375.19 "Fees and Informed Consent" provides that: "The podiatric physician has special knowledge which his patient does not have; therefore, to avoid misunderstanding he should advise his patient in advance of beginning treatment of the nature and extent of the treatment needed; the approximate time required to perform the recommended treatment and services; and any further or additional services or return by the patient for treatment, adjustments, or consultation and the time in which this shall occur. A podiatric physician should inform his patients as to the fees to be charged for services before the services are performed, regardless of whether the fees are charged on a case basis, on the basis of a separate charge for each service, or a combination of these two methods, or some other basis. If an exact fee for a particular service, as in extended care cases, cannot be quoted to a patient, a fair and reasonable estimate of what the fee will be and the basis on which it will be determined should be given the patient. (b) A podiatric physician shall not tender or receive a commission for a referral."

    Engaging in grossly unprofessional or dishonorable conduct of a character that in the Board's opinion is likely to deceive or defraud the public and using any advertising statement of a character tending to mislead or deceive the public is prohibited in accordance with Texas Occupations Code §202.253(a)(4)(6).

    The American Podiatric Medical Association (APMA) provides the following:

    “Refresher on "Off-Label" Use of Marketed Drugs and Medical Devices Sound medical practice and the best interests of the patient require that podiatrists use legally available drugs and devices according to their best knowledge and judgment. However, podiatrists may routinely utilize a Food and Drug Administration (FDA)-approved drug or medical device to treat a condition or perform a surgical procedure for which the product has not yet been approved. Podiatrists may receive information about the success of such off-label use from colleagues, seminars, medical literature, and, in some cases, from the manufacturer itself. In these cases, the podiatrist has the responsibility to be well-informed about the product; to base its use on firm, scientific rationale and on sound medical evidence; and to maintain records of the product's use and effects. When using a drug or device for an off-label use, DPMs should inform the patient of this use, advise the patient of possible complications, and document this conversation in the patient's medical record.

    While off-label use of a prescription drug or device by medical practitioners can contribute to a manufacturer's success, FDA regulations allow manufacturers to promote only approved indications for drugs and devices. FDA permits a manufacturer to disseminate only educational, "non-promotional" materials about non-approved indications or uses, such as peer-reviewed medical journal articles and reports of clinical studies. FDA also requires that if a manufacturer wants to disseminate information about the new use, it must have a pending application to FDA for approval of the new use, provide the FDA-approved labeling for the current indications, or use and make it clear that the off-label use of the product described in materials is not yet FDA-approved. Similarly, podiatrists cannot promote or advertise the off-label use of a drug or device. The podiatrist can, however, advise a patient seeking treatment of the off-label medication or device when the patient presents with a condition for which the podiatrist determines that the off-label medication or device is in the patient's best interest.

    If you have questions about the appropriateness of devices used in your practice, visit www.fda.gov for more information."

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