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

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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