Making an Appointment
1. How do I make an appointment with Dr. Wittig?
All appointments are made through the NYC office by calling 212-241-1807.
2. What should I bring with me to my first appointment?
Under the Office Information section of this website, you will find all the information you need as a new patient. Click here for a copy of the Initial Consultation Checklist.
3. What is the best way to contact Dr. Wittig for non-urgent matters?
Either e-mail him through the "contact us" page of this website or call his NY office at 212-241-1807.
Types of Patient Forms/Medical Insurance Info
1. What does 'usual, customary and reasonable' mean?
Each insurance carrier has an established payment rate for each test, procedure, or other medical service depending on the provider's geographical area. The insurer arbitrarily decides what is appropriate, approved or allowed. Unfortunately, the insurer's determination may not reflect our current costs to provide a quality service to you. This rate can be called either usual, customary, and reasonable (UCR), or reasonable and customary. Each insurance company differs from each other in what they consider customary and reasonable. Dr. Wittig's charges may be different from what an insurance carrier decides is customary and reasonable. Patients are responsible for paying any difference between our charges and the carrier's payments. This is referred to as balance billing. In many instances, Dr. Wittig's office is capable of negotiating an acceptable rate of reimbursement to minimize and sometimes negate the amount that is balance-billed to the patient.
2. What is a Pre-authorization?
Most insurance companies require Pre-Authorization for a patient to undergo radiological studies, biopsies and/or surgical procedures. In addition, your insurance plan (usually an HMO) may require a Referral from your primary care physician (PCP) to undergo the study, test, biopsy and/or surgery. This referral is in addition to the Pre-Authorization. With most insurance providers, the authorization process can take up to 72 hours, and in some cases up to one week. Because of the uncertain turn-around time to obtain a Pre-Authorization, it is not possible to schedule radiological studies or surgeries until the Pre-Authorization has been obtained. If a Pre-Authorization is denied, additional time will be needed to appeal the denial. Our office appreciates your patience during this process, and will submit all the required paperwork for an authorization within one day of your visit. Our staff will work diligently to obtain the Pre-Authorization from your insurance provider as quickly as possible. It is the patient's responsibility, however to obtain the referral.
In instances where Pre-Authorization is delayed by the insurance company, it is often beneficial if the patient ( who is also the Consumer ) calls the insurance company directly to discuss the Pre-Authorization with the insurance company's representative. From our considerable experience with insurance providers, we have found that when the patient/insurance company client is involved, the process is expedited significantly.
We request that all patients contact their insurance provider in advance to determine if a Referral in addition to a Pre-Authorization is required. If so, you will need to obtain the Referral from your primary care physician and bring this Referral with you at the time you undergo the test, appointment, biopsy, procedure and/or surgery.
3. What is a Referral?
A Referral is a document usually obtained from your primary care physician (PCP) which gives permission for you to undergo a specific procedure, radiological test or be seen in another physician's office (usually a specialist) for a consultation. It is the Patient's responsibility to obtain all necessary Referrals from their primary care physician (PCP) and/or insurance companies for any office appointments, radiological tests, biopsies, surgeries and/or other procedures.
Office Appointments: All Referrals for office appointments and consultations should specify that the appointment include X-rays. If this is your first appointment, the Referral should include a biopsy, as well as an X-ray.
Failure to obtain/provide appropriate Referrals: All bills or insurance claims incurred by a Patient that are not paid by their insurance carrier due to the Patient's failure to provide an appropriate Referral Form will become the financial responsibility of the Patient. After payment is received by the office, a receipt will be provided to the Patient, which may be submitted to the insurance carrier to attempt reimbursement.
4. Additional forms - click here.
Types of Cancer
1. What are the differences between Sarcomas and Carcinomas?
Sarcomas and carcinomas are types of malignant tumors that can affect bones. They are derived from different types of cells. Sarcomas are derived from mesodermal (mesenchymal cells) and carcinomas are derived from epithelial types of cells. Sarcomas and carcinomas grow and spread differently. Sarcomas grow like "ball-like" masses and tend to push adjacent structures like arteries, nerves, veins away. The compress adjacent muscles into a pseudocapsule that contains microscopic projections of the tumor referred to as satellite nodules. The local growth of sarcomas like a ball enables resection in most instances. Sarcomas tend to arise primarily (directly) from bone as opposed to spreading to bone from another site. Sarcomas spread most commonly to the lungs. They can also spread to other bones (ie. arise from a bone and spread to other bones) and to the liver. These are the most common sites of spread. Sarcomas rarely spread to lymph nodes. Carcinomas grow in an infiltrative manner and grow through infiltration or invasion of adjacent structures. They more easily invade adjacent nerves, blood vessels and muscles. They do not form a pseudocapsular layer and therefore it is difficult to determine its exact anatomic extent during surgery. This makes it more difficult to remove entirely with surgery. Carcinomas spread to lymph nodes, lungs, bones and many other organs depending on the type of carcinoma. Carcinomas involve bone secondarily, that is by spreading from another site such as the breast to the bone. A patient can have the primary site removed and treated (ie. the breast cancer removed) and years later develop a bone tumor/metastasis from the old breast cancer.
2. Is there a difference between "Bone Cancer" and a "Bone Tumor"?
These two terms are very general terms. A bone tumor refers to any abnormal growth from the bone or in the bone, benign or malignant. Bone cancer refers to a malignant bone tumor. It can be a primary malignant tumor like an osteosarcoma, Ewing's sarcoma or chondrosarcoma. It can also be a metastatic carcinoma such as a breast cancer, lung cancer, prostate cancer, kidney cancer and thyroid cancer. It is important to differentiate between the various types of cancers that affect the bone because each has its own type of treatment and prognosis.
3. How can I find our more about my diagnosis?
You can go to the PATIENT EDUCATION section of the website to learn more.
Making a Diagnosis
1. What is a Biopsy?
A biopsy is the act of obtaining a piece of tissue from a tumor. It is then studied under a microscope by a pathologist (a physician who specializes in this area) to determine the type of tumor. Determining the type of tumor, and whether it is benign or malignant (cancerous) enables the doctors to determine the type of treatment. It is essential to have a biopsy before any surgery or treatment is administered. Biopsies can be performed in several ways. The safest and best way, in my opinion, is to have the biopsy performed in a minimally invasive manner (without having to cut the skin and make an incision) by means of a core-needle biopsy.
A core-needle biopsy uses a needle to get the tissue samples. It should be performed by the surgeon (orthopedic oncologist) who will treat the tumor or by a radiologist who is experienced with bone and muscle tumors and performing biopsies of them. The orthopedic oncologist and radiologist will discuss the tumor and approach prior to the biopsy and are in constant communication. The patient is given an injection of numbing medicine (usually lidocaine and marcaine) into the area of the tumor that will be biopsied. The patient is also administered medicines intravenously (into the vein) to relax the patient and prevent pain. During the procedure the patient is comfortable. The physician makes a single stab hole in the anesthetized area of the skin and aims the needle in multiple directions to sample different parts of the tumor. In most instances, the procedure will be performed under a CT (pronounced CAT) scan so the tumor can be seen and biopsied accurately. Ultrasound or other imaging modality may also be utilized. Once the specimen is obtained it takes about 3-4 days for the specimen to be processed and interpreted by the pathologist. Minimally Invasive Biopsies are also performed in the operating room by the surgeon often under fluoroscopic guidance.
An Open Biopsy requires that the patient be brought to the operating room and the skin is cut (incision is made) over the tumor. A piece of tumor is cut out and sent to the pathologist to be studied under the microscope. An open biopsy requires the skin to heal postoperatively before starting any treatment. This is different from a core needle biopsy in which there is no healing time. There are also more complications such as infection, hematoma and fracture associated with an open biopsy. The risk of a local recurrence (the tumor coming back after it is surgically removed) is also higher following an open biopsy than with a core needle-biopsy.
The diagnostic accuracy rate of a core needle biopsy is the same or better than an open biopsy when performed at a center experienced with the treatment of these tumors (experienced orthopedic oncologist, musculoskeletal radiologist and surgical pathologist). About 90% of tumors are diagnosed accurately with this method. I therefore prefer core needle biopsy over an open biopsy for bone and muscle tumors (sarcomas of bone and soft tissues) because of its greater diagnostic accuracy and because it is associated with fewer complications. Open biopsies are usually reserved for unusual circumstances or when a diagnosis can not be rendered by a core needle biopsy (if more biopsy material will help make a diagnosis).
FNA refers to Fine Needle Aspiration and should not be confused with a core needle biopsy. An FNA uses a very fine needle and does not obtain sufficient material for the diagnosis of bone and soft tissue tumors, bone sarcomas / soft tissue sarcomas. It is not used to biopsy tumors of the musculoskeletal system.
2. What does Staging mean?
Staging is a way of assessing specific characteristics about a sarcoma and correlating it with a prognosis. It is a way of estimating a prognosis for patients. There are separate staging systems for bone and soft tissue sarcomas. There are also a few different types of staging systems. In general, staging systems assess tumor size, grade, superficial or deep location, intracompartmental or extracompartmental involvement, and whether it has spread to any other area of the body. Most high grade sarcomas of bone or soft tissue present as stage 2 tumors. Stage 4 tumors refer to those tumors of any size that have spread to OR metastasized to other body parts at the time the tumor is discovered. Stage 1 tumors have the best prognosis and stage 4 tumors have the worst prognosis.
Types of Treatment Available
For additional information, go to the patient education section of the website or click here.
1. What is a Percutaneous Radiofrequency Ablation aka RFA?
The latest, "State of the Art Treatment" for Osteoid Osteoma is PERCUTANEOUS RADIOFREQUENCY ABLATION (also known as RFA). This is a minimally invasive procedure that is performed under a CAT Scan, usually by a highly specialized musculoskeletal radiologist, in which a needle or probe is inserted into the lesion and the lesion is heated and destroyed. The CAT scan is utilized to localize the Osteoid Osteoma so the needle can be guided directly into the tumor. It is an outpatient procedure. The patient goes home the same day. It is minimally invasive and therefore only a small stab incision or poke hole is made for the needle. The procedure does require that the patient be put to sleep with general anesthesia because insertion of the needle into the Osteoid Osteoma is very painful. The patient must also lie motionless during the procedure. The procedure is greater than 90% effective. This is the same success rate as with actual surgical removal. The pain from the osteoid osteoma is usually relieved within 1 day. Often in the recovery room after the procedure, the patient will say that the pain from the tumor is gone. There is full use of the leg or arm and return to normal activities the following day. There is virtually no blood loss and very little risk (less than 1% risk) of developing an infection after the procedure. Less than 10% of the time the procedure needs to be repeated or the patient requires a surgical procedure to remove the tumor.
You can view the procedure by clicking here.
Questions About Surgery
1. How do I schedule surgery?
Surgeries are scheduled by the office's administrative staff, and you are asked to discuss your scheduling preferences with the Surgery Coordinator. Changes are made to the surgery calendar daily, and the administrative staff will do their best to accommodate your needs accordingly.
