08/30/2013
RESPONSES / COMMENTS (DME)
RE: Diabetic Shoe Dispensing (Neil Hecht, DPM)
From: Paul Kesselman, DPM
I could not agree more with Neil. There are a few stronger Yiddish words my grandparents taught me, but I promised never to use them in public. Despite what the carrier medical directors (CMDs) have done in an attempt to destroy this program, it is enlightening to know that even the Medicare carriers can't agree on how many claims are audited and how many are either rejected on post-payment audit or are required to be refunded on post-payment audit. A difference from 93 to 97% is not that statistically different. But one from 93% (low side) on one study to 33% (high side) on another is certainly staggering. If the gov't wizards can't agree, what are we to think?
The original thread here suggested that keeping a...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
08/29/2013
RESPONSES / COMMENTS (DME)
RE: Diabetic Shoe Dispensing (Charles Baik, DPM)
From: Josh White, DPM, CPed
Dr. Hecht's frustration regarding compliance with the documentation requirements of Medicare's Therapeutic Shoe Program is understandable and common. It's unfortunate that a program created to save Medicare money by preventing ulceration and amputation while increasing podiatrist income has fallen into disfavor by many.
I've had the opportunity to poll how commonly podiatrists have been subject to pre-payment audits in the course of presentations and webinars I have given on the subject. Certain regions have been targeted more than others; I estimate a national prevalence of about...
Editor's note: Dr. White's extended-length letter can be read here.
08/02/2013
RESPONSES / COMMENTS (DME)
RE: Discontinuing Diabetic Shoe Program (Paul Kesselman, DPM)
From: Fred Huss, DPM
I appreciate Dr. Kesselman's comments. Part of the problem are the non-professional suppliers who come in to independent and assisted living facilities with an inventory of shoes after getting a list of diabetic residents from staff. They offer and dispense these items, same day, without the necessary paperwork, sometimes telling patients they're free. They rarely do follow-up evals; do not attach any documents to charts, if they're on site. I've been told by administrators that these non-professional suppliers explain that their residents will get their shoes without waiting. I've overheard a non-professional supplier tell a resident's family member that they use a physician, who has never seen the patient, to sign off on the certification because they know diabetics better than their own doctor.
It's hard to fight that kind of blatant fraud and abuse when there's so much complicit behavior at so many levels. I think Medicare put these obstacles in place to attempt to control the situation they know all too well exists, but only made things more difficult for those who practice compliance.
Fred Huss, DPM, Chicago, IL, fhussdpm@gmail.com
08/01/2013
RESPONSES / COMMENTS (DME)
RE: Discontinuing Diabetic Shoe Program (Neil H Hecht, DPM)
From: Paul Kesselman, DPM
Having returned recently from the APMA National Meeting, I had an opportunity to speak with many of my colleagues and the vendors who supply therapeutic shoes. Concurrently, there has been much written in PM News (and other forums, both podiatric and non-podiatric alike) about the discontinuation of providing and billing Medicare for therapeutic shoes.
I am not shocked nor can I criticize that many of my podiatric (and pedorthic) colleagues have discontinued providing their diabetic patients with therapeutic shoes under the Medicare Therapeutic Shoe Program for Patients with Diabetes. However, it is not because...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/27/2013
RESPONSES / COMMENTS (DME)
RE: Discontinuing Diabetic Shoe Program (Neil H Hecht, DPM)
From: Steven E. Black, DPM
I too have suspended my diabetic shoe program participation. Too many pairs are put into review and never seem to come out of review. I now have 10 pairs that are still outstanding since last year. I feel Medicare has made it impossible to be fully compliant with their requirements. How can I be sure my referring MD has a note on his chart regarding anything? I don't even know if he charts at all!!
This program was designed to encourage the use of appropriate shoes in a high-risk population. Then they made it so difficult to provide this service that probably there are fewer people in appropriate shoes than before. I know orthotists are having the same problem getting paid. This is just stupid.
Steven E. Black, DPM, Lancaster, CA, sblack152@aol.com
07/24/2013
RESPONSES / COMMENTS (DME)
RE: Discontinuing Diabetic Shoe Program
From: Neil H Hecht, DPM
After more than 15 years, I have suspended my optional involvement with the diabetic therapeutic shoe program. The inordinate paperwork and inappropriate need for PMD notes regarding pedal pathology has encouraged this decision. I am aware that APMA is working on a legislation to reverse this arbitrary requirement. My patients are not happy either. However, if I am unable to comply with the legal requirements of the government, I would be uncomfortable in the face of any potential audit.
My questions for the readership are: how many other podiatrists have suspended their program, and if not, how are they adequately complying with the current requirements? My referring MDs refer their patients to me because they don’t evaluate and treat podiatric pathology, nor do they make specific notes regarding deformities or footwear needs. I believe, rightly, that the MD defers these evaluations to “us”. Therefore, my compliance with Medicare diabetic shoe paperwork requirements is impossible.
Neil H Hecht, DPM, Tarzana, CA, drhecht@drneilhecht.com
07/02/2013
RESPONSES / COMMENTS (DME) - PART 1A
RE: Effect of DME Competitive Bidding on Podiatrists (Olga Luepschens, DPM)
From: Paul Kesselman, DPM
At the present time, competitive bidding does not affect most items dispensed by podiatrists, including, but not limited to: shoes/inserts or any items covered under the Therapeutic Shoe Program for Patients with Diabetes, any O&P product normally dispensed by podiatrists (e.g. night braces, CAM boots, AFOs), crutches, canes, or surgical dressings. Walkers are subject to competitive bidding, however, when dispensed by physicians (MD/DO/DPM), they are exempt. The HCPCS codes (too lengthy to list here) must be amended by the "KV" modifier.
Other items typically not furnished but prescribed by podiatrists, which in Round 2 are subject to competitive bidding include but are not limited to: walkers (again exempt if the DPM furnishes them), wheelchairs, NPWT, mattresses, and oxygen. Diabetic testing supplies must be furnished by a contracted mail order supplier. This has just about eliminated all of the local mom and pop pharmacies and surgical suppliers.
The effect here is that for patients who live in a competitive bid region, all new orders must be sent to a contracted supplier (one who was awarded a competitive bid). CMS has an excellent resource on the competitive bidding process for physicians to reference.
Paul Kesselman, DPM, Woodside, NY, drkesselmandpm1@hotmail.com
07/02/2013
RESPONSES / COMMENTS (DME) - PART 1B
RE: Effect of DME Competitive Bidding on Podiatrists (Olga Luepschens, DPM)
From: Kevin A. Saluck, DPM
In a nutshell, the DMEPOS Competitive Bidding Program will have a dramatic effect on the DME/HME industry but, as of today, I see little to no effect on podiatry. July 1, 2013 starts Round 2 of this program. Round 1 consisted of 9 CBAs and Round 2 consists of 91 CBAs. There are 9 product categories that are affected-CPAP Devices, Respiratory Assist Devices; Enteral Nutrients, Equipment and Supplies; Hospital Beds and Related Accessories; Mail-Order Diabetic Supplies; Negative Pressure Wound Therapy Pumps and Supplies; Oxygen Equipment and Supplies; Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories; Support Surfaces (Group 2 mattresses and overlays); Walkers and Related Accessories.
In Dr. Luepschens’ query, she mentions diabetic shoes, braces, and wound products. L codes are not included in this program (at this point-CMS reserves the right to add or subtract product categories). She mentions wound products; the only wound care that is currently in this program is NPWT. The only other DME that podiatrists might order are wheelchairs, walkers, and maybe scooters.
More information on the DMEPOS Competitive Bidding program can be found at Medicare.gov. Stay tuned as the DME industry and Congress are actively trying to stop or fix this fatally flawed program.
Kevin A. Saluck, DPM, Mount Laurel, NJ, drsaluck@comcast.net
06/07/2013
RESPONSES / COMMENTS (DME)
RE: Diabetic Shoes for Medicare Patients
From: Ed Davis, DPM
The changes in Medicare documentation requirements for diabetic shoes have made the provision of this service challenging. APMA held a webinar on this topic in January and mentioned that it was working on a satisfactory resolution to ensure coverage/compliance. I have not heard anything further from APMA since then.
The most difficult requirement is obtaining information within the body of the PCP progress notes documenting the need for diabetic shoes. It is unclear as to what those notes must...
Editor's note: Dr. Davis' extended-length letter can be read here.
05/23/2013
RESPONSES / COMMENTS (DME)
RE: Diabetic Shoe/Inserts (DME) Wholesale Suppliers (Isa Schwarzberg, DPM)
From: Josh White, DPM, CPed
SafeStep features shoes from Apex, Orthofeet, New Balance, Brooks, Hush Puppies, SureFit, OrthaHeel, and Darco at manufacturer direct prices. SafeStep is the exclusive podiatric distributor of Arizona AFO and features the Moore Balance Brace.
We have very competitively priced private label ready-made inserts, walkers, night splints, ankle gauntlets, canes, crutches and walkers. SafeStep also features Ossur, Aircast, Swede-O, EuroInternational, Darco Donjoy, PowerStep, Bledsoe, and others.
Most significantly, SafeStep guarantees Medicare shoe compliance when using our exclusive "WorryFree DME" documentation service. It creates all 6 required documents and even obtains signed and dated forms from the certifying MD, REGARDLESS OF WHETHER SHOES ARE ORDERED FROM SAFESTEP OR NOT. Customers are invoiced twice per month.
Josh White, DPM, CPed, President, Founder, SafeStep, joshwhite@safestep.net
02/12/2013
RESPONSES / COMMENTS (DME)
RE: DME and Diabetic Shoe Payment Problems
From: Michael M. Rosenblatt, DPM
A number of years ago, our Washington State Podiatric Medical Association had some payment issues concerning diabetics. At the time, I was Chair of the Insurance Committee (which has since been renamed). I contacted the president of the Washington State Diabetes Association, who was so alarmed by our predicament that she gave me her home phone number. These people are active politically to defend the rights of diabetic patients. I was astonished at how hard she worked with us to "correct" our problems.
If podiatrists are having a hard time getting paid for DME for diabetics, no matter what you prescribe, your local diabetes association is definitely an asset. I would go further and say they WANT to be informed of the problems you are having. Naturally, they are concerned about over-use or downright fraud, but they are more concerned that diabetic patients get the treatment they need. They already know that you are a very important part of that equation.
You will not have to convince them. All I said was, "I was chair of the Washington State Podiatric Medical Association Insurance Committee." That was all I needed to get them on our side. It should probably be done on the State Association Level. In our case, the president of their association volunteered to testify before a State Legislative Committee in our behalf.
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net
02/09/2013
RESPONSES / COMMENTS (DME) - PART 1B
RE: Diabetic Therapeutic Shoe Bill (Josh White, DPM, CPed)
From: Dale Feinberg, DPM, CPed
While at the recent Professional Footware Association meeting in Little Rock, Arkansas, I had the opportunity to discuss my difficulties of Medicare audits with Dr. White. I reviewed his documentation. Just getting the primary care doctor to agree with your extensive note doesn't cut it in Fargo, North Dakota.
I am not disagreeing that other podiatrists in other regions have less difficulty with the program, but unfortunately these are my experiences as a full-time practitioner who is in the trenches everyday, and not a middleman who is not fiscally responsible for Medicare audits.
Dale Feinberg, DPM, CPed Yuma, AZ, hd5bl@aol.com
02/09/2013
RESPONSES / COMMENTS (DME) - PART 1A
RE: Diabetic Therapeutic Shoe Bill (Michael Hames, DPM)
From: Paul Kesselman, DPM)
With all the DME fraud and abuse, who can blame the Feds for kicking back with more audits? However, they have kicked the ball way too far to the other side of the court.
It appears to many of my colleagues (and I would agree) that there are far too many ill-trained auditors who seem to be ignoring the materials put in front of them. One can't blame those providers who don't dot every "i" or crossing every "t" from being frustrated.
This problem is not unique to podiatry and it has been...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
02/08/2013
RESPONSES / COMMENTS (DME) - PART 2
RE: Diabetic Therapeutic Shoe Bill (Dale Feinberg, DPM)
From: Josh White, DPM, CPed
I resent the implication by Dr. Feinberg that he follows SafeStep protocols. He has never used our WorryFree DME service to process a single Medicare order, and so I am not surprised at his difficulty complying with Medicare documentation requirements.
Since the recent posting by Dr. Johnson, it has been very satisfying to hear from other DPMs who have shared with me stories of their successfully passing scores of Medicare shoe audits by utilizing our WorryFree DME compliance service.
Josh White, DPM, CPed, President, SafeStep, joshwhite@safestep.net
02/08/2013
RESPONSES / COMMENTS (DME) - PART 1
RE: Medicare Rescinds AFO Height Requirement
From: Paul Kesselman, DPM
Medicare has announced that the height restrictions on AFOs have been rescinded. The policy article stipulating that AFOs come to somewhere near the fibular head has been revised to remove this requirement.
One should note that no changes have been made to medical necessity requirements or PDAC verification requirements for HCPCS 1906.
Congratulations is due the rest of the DME Subcommittee as well as Drs. Harry Goldsmith, Marc Block, Michael King, and Scott Haag (APMA staff) for a job well done. It is my hope that APMA will be invited by CMS to assist in the development of a new AFO policy sometime in the future.
Paul Kesselman, DPM, Woodside, NY, drkesselmandpm1@hotmail.com
02/07/2013
RESPONSES / COMMENTS (DME)
RE: Diabetic Therapeutic Shoe Bill (Michael Hames, DPM)
From: Dale Feinberg, DPM, CPed
My recent post concerning not getting involved with the diabetic shoe program was to give new practitioners a reality check on the business of podiatry. Please let me quote two letters I received from Noridian Medicare Region D. "This claim has been selected for complex medical review." This is followed by, "Due to the complexity of the issue, it is considered too complex to be completed as a reopening. Additional documentation previously submitted was reviewed and the denial upheld."
I too did over six figures annually in the diabetic shoe program. I feel that Noridian put me on their "no fly" list and every time they see my DME number, it automatically triggers the above stated chain of events. Worse yet, the suppliers will not wait months to get paid, so you will outlay your operating expenses while you play the game.
We have followed Dr. Comfort and Safe Step protocols but the non-medical reviewers don't have the clinical knowledge or experience to make a correct determination, so you lose. The IRS expects their quarterly payments on time, and you must submit employee payroll deductions on time monthly or face penalties. As a new practitioner, you must decide where you want to put your time and energies to grow your practice. You may be right, but as a long-term practicing podiatrist, I have already wall-papered one bathroom with insurance checks from one cent to thirteen cents.
Dale Feinberg, DPM, CPed, Yuma, Az. hd5bl@aol.com
02/05/2013
RESPONSES / COMMENTS (DME) - PART 1B
RE: Diabetic Therapeutic Shoe Bill (David S. Chung, DPM)
From: Mark K. Johnson, DPM
We have been doing the diabetic shoe program since 2000. While it is not an easy road, it does provide a valuable service to patients who comply with it. Our audits increased to 30% of DM shoe cases last year. Most passed the first round, but, some required resubmission of documents to the next level of redetermination, which has a 40-60 day delay in payment. Our documentation is ethical, extensive, and fully compliant but some reviewers obviously or purposely don't see that. We submit a letter with a timeline and copies of EVERYTHING REQUESTED.
We find Dr. Josh White's Worry Free DME procurement system for the MD/DO documents helpful. You must have a certifying physician office note copy including DM diagnosis and treatment within 6 months of the DME dispense date in documents. A few doctors are sluggish or, rarely, unable to sign the Medicare required forms. So be it. We feel that the program benefits our diabetics who choose to comply with it. We monitor and document that as well. Cautiously optimistic, we accept that certain aspects of podiatry will continue to be challenging, and difficult but not insurmountable in the future. We hope.
Mark K. Johnson, DPM, West Plains, MO. DDR004@centurytel.net
02/05/2013
RESPONSES / COMMENTS (DME) - PART 1A
RE: Diabetic Therapeutic Shoe Bill (David S. Chung, DPM)
From: Ed Davis, DPM
If my recollection is correct, coverage for diabetic shoes was instituted by an Act of Congress. It appears that current attempts to effectively deny that coverage via the application of unreasonable bureaucratic hurdles then violates that legislation. APMA really needs to show some resolve.
Ed Davis, DPM, San Antonio, TX, ed@sanantoniodoc.net
02/04/2013
RESPONSES / COMMENTS (DME)
RE: Diabetic Therapeutic Shoe Bill (David S. Chung, DPM)
From: Dale Feinberg, DPM
I've dispensed a lot of diabetic shoes over the past ten years. I can never get paid without a prepayment audit. After complying with all the required paperwork, I still get denied payment. We used to try to get the required MD certification over a fax, but now have the patients obtain this information themselves. The patients who are successful usually report that it takes 3-4 visits to get their family doctor to comply with written notes that conform to Medicare requirements. DME products, like retirement, are a thing of the past. My recommendation to young podiatrist is don't waste your time.
Dale Feinberg, DPM, CPed, Yuma, AZ, hd5bl@aol.com
02/02/2013
RESPONSES / COMMENTS (DME) - PART 2
RE: Diabetic Therapeutic Shoe Bill (Josh White, DPM, CPed)
From: Paul Kesselman, DPM
It is a sad fact that many podiatrists and orthotists, as well as pedorthists, have discontinued providing shoes through Medicare. It has become more difficult to obtain the required documentation and even when it is obtained, the auditors often ignore or misinterpret the documentation that is sent. In most cases, if the provider bothers to take these claims up the appeal ladder, they are paid.
As Dr. White has pointed out, there are formulas for reducing the time expenditure required of you and/or your staff. One key point not to forget; it is essential to...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
01/14/2013
RESPONSES / COMMENTS (DME)
RE: Confusion Over New AFO Height Requirements (Josh White, DPM, CPed)
From: Paul Kesselman, DPM
I respectfully disagree with the recent letter by Josh White (owner of SafeStep). He and other advertisers are advising that everything is okay with the AFOs that their companies provide to the podiatry community. Whether that is true or false is subject to the answers to the questions I have outlined below.
Q: Is it mandatory that the PDAC verify custom (and pre-fabricated AFOs)?
A: In a previous letter, I advised that the answer to #1 is NO with the exception of devices which meet the criteria for...
Editor's note: Dr. Kesselman's extended-length letter appears here. Dr. White intended the following to be added to his previous note.
01/12/2013
RESPONSES / COMMENTS (DME)
RE: Confusion Over New AFO Height Requirements (Paul Kesselman, DPM)
From: Jason Kraus, Don Pierson
I read with interest Dr. Kesselman's post regarding the new height requirements for AFOs. We are in complete agreement with Dr. Kesselman's statement regarding the ultimate responsibility belonging to the party who bills Medicare. We also believe that the new policy article makes little clinical sense and should be reconsidered in light of a voluminous amount of scientific literature supporting the efficacy of the braces commonly used in podiatry, and orthotics and prosthetics today. We are being asked to operate in a bizarre environment where two different Medicare contractors are stating completely opposite positions about how to apply the new policies. If that weren’t confusing enough, there are two different policy articles which are currently valid which contain contradictory information.
Dr. Kesselman’s post might have given PM News readers the sense that...
Editor's note: Jason Kraus' and Don Pierson's extended-length letter can be read here.
01/11/2013
RESPONSES / COMMENTS (DME)
RE: Confusion Over New AFO Height Requirements (Paul Kesselman, DPM)
From: Josh White, DPM, CPed
The recent “Article for Ankle-Foot/Knee-Ankle Foot Orthoses – Policy Article – Effective January 2013” has created much confusion regarding how high AFOs need to extend to qualify for Medicare coverage. The article poorly describes two different “usually” required heights, one, “between the proximal border of the gastrocnemius and the apex of the head of the fibula (a region that is generally 2-4 cm distal to the apex of the head of the fibula)” and the other “within 1.5 inches distal to the apex of the head of the fibula.”
The full text of the section describing the required height reads as follows: ...
Editor's Note: Dr. White's extended-length letter can be read here.
01/09/2013
RESPONSES / COMMENTS (DME)
RE: Confusion Over New AFO Height Requirements
From: Paul Kesselman, DPM
Lately, there has been considerable confusion concerning the new AFO LCD. APMA and leaders of other professions have been working diligently to overturn the height requirements which have no scientific basis. Review of the source documents used by Medicare officials reveals they were published years ago and the height requirements, as stipulated by Medicare, were taken out of context. Despite strong objections by APMA and other stakeholder associations, the current height regulations as stipulated in the AFO LCD are required.
Questions abound concerning whether one style of AFO vs. another needs to meet these absurd height requirements. Advertisers may have seized on this apprehension to...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
11/03/2012
RESPONSES / COMMENTS (DME)
RE: L1970 and PDAC (Joe DeRose, DPM)
From: Josh White, DPM, CPed
Medicare did indeed revise the LCD for AFOs to require custom plastic hinged devices to extend at least as high as an inch and one half beneath the fibular head.
Podiatrists have a long history of dispensing devices that extend only as high as 5 inches above the malleoli and have proven the success of such devices treating adult-acquired flatfoot and other orthopedic conditions. The APMA and the American Orthotics and Prosthetics Association have submitted strong requests to recognize the permissibility of hinged devices that extend mid-leg.
DPMs are reminded that custom AFOs are not required to have PDAC verification, though some do.
Josh White, DPM, CPed, Owner Safestep, joshwhite@safestep.net
