04/14/2018    Michael Forman, DPM

The Importance of Examining Legs

Recently, some of my colleagues have been
contacted by "Medicare" for the inappropriate use
of E/M codes during a routine foot care or an at-
risk foot care visit. I received notification from
Medicare that 33% of my visits submitted included
an E/M charge. I was told it was above the
average. I hope I am not thought of as a criminal
or law breaker. I would rather be thought of as a
doctor who cares for - and takes care of his
patients. As all of us are aware, our profession
has changed a great deal. We are responsible for
our patient's well-being and should be curious as
to their general medical health and in particular
their lower extremities.

If we are only interested in clipping someone’s
toenails and trimming a callus and whisking 30-40
people or more a day through our office while
ignoring important signs that are presented to us
- we are doing a disservice. I recently heard Dr.
Jeff Lehrman lecture at a meeting. He suggested
that we roll up our patients’ pant legs and take a
look at their legs. I've been doing that and I've
found a textbook of pathology of pathology up
there.

I have conflicting thoughts on the expression, "it
is what it is." It could mean that we accept
something without trying to alter it. On the
other hand, it could mean that if you see, feel,
smell (please do not taste) something " If it is
there, it's there." On some of my excursions up
people's pant legs, I found a trove of pathology.
Dr. Lehrman taught me the CEAP classification for
venous disease (Google it). In my opinion we
should properly memorialize what we see and make a
decision if any action need be taken. If your
examination includes the necessary components to
warrant an EM visit, of course you should note it
in your record and send your patient or their
insurance company a bill for the correct level of
service.

I have been an advocate of getting our noses out
of the nail groove. We are now turning out highly
trained three-year residents. They are real
physicians. Join them in taking a peek up a pant
leg and help your patient live longer.

Michael Forman, DPM, Cleveland, OH

Other messages in this thread:

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04/18/2018    Robert D. Phillips, DPM,

The Importance of Examining Legs:

I would like to commend the thoughtful letters
written by Dr. Forman (4/14/18), Dr. Silver
(4/18/18) and Dr. Jacobs (4/16/18). All bring to
the fore the important facts that diabetes not
only has a negative effect on all the systems in
the foot, but that decrease in the utilization of
the foot also accelerates the impact of the
disease on the other body systems.

Certainly, the main goal of any podiatrist
treating the diabetic patient is to increase the
activity level of the patient. Many years ago, I
heard Dr. Root talk about no longer thinking of
geriatric foot care as trimming calluses and nails
and moisturizing the skin. Instead he stated that
a major focus should be the prevention of falls.

This concept needs to be updated to include
diabetic foot care. A required journal read of all
medical students who rotate in our wound care
externship is “Cavanagh, Peter R., Guy G.
Simoneau, and Jan S. Ulbrecht. ‘Ulceration,
Unsteadiness, and Uncertainty: the Biomechanical
Consequences of Diabetes Mellitus.’ Journal of
Biomechanics 26 (1993): 23-40.” This now classic
article (cited now 254 times since) should create
no doubt in the physician’s mind that diabetes is
as much a biomechanical disease as an endocrine
disease.

The fact that any diabetic would have a callous
should point to a biomechanical issue that needs
to be addressed by the podiatric physician, and it
is unconscionable in my opinion that a significant
amount of E/M time isn’t spent in identifying the
etiologies of the callous.

I recently contributed to another podiatric
magazine, a brief overview on the biomechanical
issues that the diabetic faces, from changes in
the biomechanics of every body tissue, to the
changes in muscle mass(which changes start long
before any detection of deficit using a 10g
monofilament), to changes in proprioception and
changes in muscle firing patterns, all of which
markedly impairs normal walking and increases the
risk of falls.

I agree totally with Dr. Jacob’s statements that a
33% E/M use should be the norm for podiatry. Let
us hope that this time next year we will have a
consensus in the profession that less than 33% E/M
use is definitely below the norm.

Robert D. Phillips, DPM, Orlando, FL

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04/18/2018    Tom Silver, DPM

The Importance of Examining Legs Michael Forman, DPM)

I have tons of patients sent to me for "routine
care" from large managed care clinics in my area.
I often hear from these patients that they were
seen by the podiatrists in their clinic and told
by them, "I'm a surgeon. I don't trim toenails or
calluses!" and that they often don't even look at
their feet. They refer them out to the few clinics
in my area (population >1 million) that do
"routine care".

In most all cases, I do a full lower extremity
exam for these "routine care" patients. Many of
the elderly have had knee or hip replacements, so
I routinely measure for leg-length discrepancies,
excessive pronation, collapsing or collapsed
medial column, and I have them stand and walk. As
a result, we fit many with much needed Rx or pre-
fab orthotics, AFOs, and heel lifts.

I often perform a quick Doppler ultrasound exam to
evaluate arterial circulation, check for
varicosities, swelling, sores, etc., fitting many
with compression stockings, farrow wraps,
providing wound care, or a referral for a much
needed vascular consult. Many patients will need
surgical procedures to eliminate their calluses,
painful hammertoes, etc. as well as those needing
ingrown and total nail procedures.

We are also able to provide much needed additional
services such as: diabetic and special fit shoes
for swollen or arthritic feet, special creams, gel
toe protectors, etc. There are also skin and soft
tissue growths that need to be biopsied and
removed as well as dermatitis treated.

Yes, there are some that only need their toenails
and calluses trimmed, but most will need more than
just routine care! If you only look at the
toenails, you are not looking at the total
picture, doing a disservice for the patient and
leaving a lot of money on the table. The initial
post by Dr. Forman mentioned using the E/M code
33% of the time with routine care. The money
generated from this code is just a small portion
of the services we can provide and the income that
can be generated from "routine care" patients that
are often far from "routine".

Tom Silver, DPM, Minneapolis, MN

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04/16/2018    Allen Jacobs, DPM

The Importance of Examining Legs Michael Forman, DPM)

Dr. Forman raises the issue of a concurrent E/M
code with nail and/or callus care. In the case of
the diabetic patient, the question Dr. Forman
brings to the table is rather straightforward.
What is your job as a podiatric physician? Your
“job” is to improve quality of life, and reduce
the risk of limb loss. This requires the
identification of risk factors and the initiation
of appropriate interventions. Subsequently, the
effectiveness and safety of such therapies, and
appropriate adjustments must be conducted.

That requires evaluation and treatment of
dermatologic, neurologic, arterial, venous,
musculoskeletal, rheumatic pathologies, gait, and
fall risk evaluation, and assessment of footwear.
In my humble opinion, the problem is not that Dr.
Forman’s 33% concurrent E/M use is above the
norm. The problem is “the norm”. It is the
failure of our colleagues to actively diagnose
and treat risk factors for limb amputation. It is
the failure of our colleagues to treat
symptomatic neuropathy, edema, xerosis and
fissuring, to seek out PAD prior to overt
manifestations of such disease. It. is the
failure to actively treat onychomycosis and tinea
pedis.

A final problem is that of allowing third party
carriers such as Medicare to threaten caring and
legitimate podiatrists by attempting to enforce
their preconceived notions and definitions of
podiatry. The standard of Podiatric care should
be defined by podiatrists. Not third party
carriers interested in profit maximization.

Conversely, you may be held liable for the
failure to diagnose and treat or refer for
treatment pathology which results in limb loss or
even death.

Of course there is the necessity to document
separate and impactful pathology with appropriate
evaluation (that’s the E) and management (that’s
the M).

33%? The issue is not Dr. Forman. In my view 33%
is too low. The real question is whether
amputation prevention is a proactive or reactive
circumstance. If I were Medicare, I’d rather pay
3 or 4 level 2 or 3 EM visits per year than pay
for years of wound care, HBO, hospitalizations
and amputations.

Allen Jacobs, DPM, St. Louis, MO