08/01/2013 Paul Kesselman, DPM
Discontinuing Diabetic Shoe Program (Neil H Hecht, 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 there is a slim profit
margin, as was suggested by one previous letter
to the editor. The mathematics suggests this
program is profitable to the supplier, the
vendor, and most importantly the patient, so long
as there is a minimal amount of paper work and
labor. This does not even take into account the
reduced economic hit the local Medicare Part Bs
take with reduced costs associated with fewer
DFUs, infections, and amputations.
In other words, in an ideal world, if CMS were to
look at this program, it would suggest that
dispensing shoes to even 30% of the Medicare
patients would save the system millions of
dollars in other health-related costs, and thus
save the Medicare trust fund hundreds of millions
of dollars over time. The BMAD data does not even
suggest that number of patients are receiving
shoes.
In addition, Medicare is not a single system, and
the DME MACs and their Medical Director are only
interested in illustrating they are paying less
this year than last for any one category of DME.
The same is true for the local MACs who wish to
pay less for DFU care and those items they
cover.
Unfortunately, this leaves the DPM suppliers and
physicians stuck squarely in the middle between
both carriers, both of whom wish to pay out less,
and the providers, who wish to provide the best
care to patients.
I have to agree with the thoughts of many DPMs,
orthotists, and pedorthists who have communicated
that the paperwork has become too burdensome. The
costs (financial and labor) associated with
collecting the required data from other providers
and submitting appeal after appeal far outweighs
the reimbursement. Many have also felt that the
threat of multiple agencies auditing the same
claim(s) year after year is just not worth
dealing with.
Many have commented that even if they did obtain
all the required paperwork prior to dispensing
shoes, there is a continued and purposeful denial
of claims by ill-trained auditors, who routinely
deny claims when the appropriate evidence (they
cite is lacking), is right before their eyes.
This latter statement appears to be backed up by
countless colleagues (DPM, CPed, and CO) who have
successfully appealed their claims at levels
beyond the carrier. Those claims overturned on
appeal are done so and supported by the presence
of the supposed lack of the same evidence noted
by the carriers' auditors.
Providers involved in this process almost
unanimously also cite the difficulty in having
one physician (PCP, endocrinologist) countersign
and attest to the findings of the specialty
physician (DPM, or other MD/DO specialist)
treating the foot. This is the number one reason
why claims which undergo pre-payment review are
denied. This is not only counter-intuitive (I'm
being polite here), but is counter to the current
standards of medicine. What court would ever cite
and place precedent over the findings of the non-
specialist over and above those of the
specialist? What other LCD currently requires a
generalist to countersign the orders of a
specialist? If anything, it is just the opposite.
Despite many meetings with Carrier Medical
Directors (CMDs) to resolve this at the carrier
level, there appears to be no current regulatory
relief given their current interpretation of the
LCD by the DME MACs.
This leaves several places to seek relief. One is
through the courts (as is being considered by the
American Orthotics and Prosthetics Association
(AOPA) which represents orthotists and
orthotists/prosthetists; and the other is
legislative (as is being considered by APMA and
others). The original Medicare Therapeutic Shoe
Program for Patients with Diabetes must be
modified and re-written into the Social Security
Act so as to bring it into reality and take away
one of the major obstacles each specialty
physician faces with the DME Medicare auditors.
The goals HR1761 and Senate Resolution 1318 are
to allow each physician's records to be treated
with full weight, not requiring one physician to
attest, countersign, or document the findings of
another. In simple language, it makes the
requirements consistent with what goes on daily
in all healthcare providers’ offices, hospitals,
and nursing homes. Each provider is solely
responsible for his/her own body of work.
For therapeutic shoes, the MD/DO would simply be
required to sign off on the certification
statement that the patient has diabetes and is
being treated by another physician for one of the
six other foot findings. Their (MD/DO treating
the DM) medical records would be required to
support the certification statement. That is, it
would suffice for the MD/DO treating the DM to
document the patient's treatment of DM, and
that a podiatrist was treating a foot problem.
Obtaining these records would be a simple act of
having your patients sign a medical release form
(which is what I currently recommend) for the
medical record and a signature on the
certification statement.
The specialty physicians records (e.g. DPM) would
simply be required to cite that another physician
(MD/DO) is treating the diabetes; and of course
there would need to be documentation in the
specialty physician’s records (e.g. DPM) of one
(or more) of the six local foot findings.
If we are to leave this as is, what other
procedures DPMs (or other physicians) perform
will next require the countersignature or
attestation of another physician? The current
TSPD LCD sets a very bad precedent and that is
why the legislative relief sought by HR1761 is
also backed by the AMA and other physician
groups. While R1761 and SR 1318 was initially
drafted to redefine podiatrists as physicians so
as to make podiatric services mandatory for state
Medicaid programs, it is much more than that.
his is an appeal for all DPMs, MDs, DOs, CPOs,
COs, and CPeds to speak with their U.S. senators
and congressmen; speak with them about your
frustrations in treating and preventing
amputations in diabetic patients. The more
bipartisan support and sponsors to support this
bill, the more likely it is to be enacted. If the
current LCD is left standing, many diabetic
patients will suffer.
Paul Kesselman, DPM, Woodside, NY,
drkesselmandpm1@hotmail.com
