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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
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