12/25/2015    Paul Kesselman, DPM

ICD-10 and the Diabetic Therapeutic Shoes

The recent postings regarding the audit and ICD-
10 problems associated with therapeutic shoe
claims are somewhat well-founded.

I too found that the Medicare representatives on
the recently conducted CERT call were
often callus, sarcastic and condescending. Last
week, I spoke with the lead CERT auditor for the
second time in recent weeks for over 30 minutes.
In a firm and polite manner, the outrage over the
manner in which the CERT auditors presented their
materials was discussed.

They are now keenly aware that many podiatrists
(and other suppliers) have had many claim
rejections overturned on appeal, by supervisory
personnel at the carrier level itself. This I
pointed out, suggests that the auditors are
either poorly trained or are purposefully
rejecting claims on absolutely no basis. Either
situation can not be tolerated and I asked for a
full accountability on Medicare to properly train
auditors.

This I should point out is far from the first
time, I as a consultant for a shoe manufacturer,
or as part of a delegation for APMA has had this
type of conversation, with supervisory Medicare
officials. Thus, the remarks from several of my
colleagues regarding a lack of effort by APMA
and others can not be substantiated. There have
been numerous well (and not so well) publicized
attempts by APMA, Pedorthic Foot Care and
American Orthotic and Prosthetic Associations and
several shoe distributors and manufacturers which
attempted to secure non-PHI containing
information from podiatrists and others, to
present to Carrier Medical Directors and CMS.

The hope was to present them with literally
thousands of claims documents showing them how
their auditors failed to follow the medical
policy. This too could also be presented to
congressional representatives, as examples of CMS
inadequacies. Unfortunately, most manufacturers
have reported that few of their clients have
provided this information. The same is true from
the APMA, PFA, and AOPA perspective.

During this most recent conversation with the
lead CERT auditor on Therapeutic Shoes agreed to
personally review all claims which were
incorrectly rejected, so that a pattern of abuse
or ignorance could be identified. He agreed that
if a pattern of ignorance or abuse on the part of
any auditor was shown to be true, that auditor
would be re educated and the rejections could be
overturned without having to go through to the
ALJ.

If we are to hold him (and other CMS officials)
to their word, we cannot continue with the same
pattern of yelling, kicking and screaming, yet
not provide overwhelming evidence to those who
agree (at least on the face of it) to assist. We
must continue to yell, kick and scream but we
must have the ammunition to back it up!

Scott L. Haag, Director Center for Professional
Advocacy & Health Policy & Practice
American Podiatric Medical Association, Inc.and
this writer agree that it does not matter whether
or not you are an APMA member with respect to
documentation submission to APMA. Shoe
manufacturers can also present these materials to
APMA (or me).

I am therefore asking as your New Years
resolution to assist yourself in resolving this
problem. If you have therapeutic shoe claims
which you believe have been incorrectly rejected,
now is the time to act. Collect the
information(with PHI redacted) and send any
information required by the auditor(s) to
healthpolicy.hpp@apma.org.

While this is holiday time for most, this is a
time sensitive matter and I would ask that all
materials be collected prior to Jan 15 2016.

As for the ICD-10 issues, this is no different
from the ICD-10 problems seen with routine foot
care or other LCDs since October 1, 2015. While
the diagnosis codes seem to be present in the
LCD, the claims processing seems to be
problematic. In Region A at least the NYC
representative has agreed to follow up on this,
but again, we require examples of claims (PHI
redacted). Medicare personnel can trace these
claim errors with the CCN# on the EOB, so no PHI
(or other materials for this) are required, for
claims rejected solely due to ICD coverage
issues. In similar fashion the policy writers at
the various DME MACs would then be contacted to
assist in resolving this problem.

Again, the sooner we can collect this
information, the faster we hope to be on the way
to resolving many of the well-founded issues
presented in these forums.

Paul Kesselman, DPM, Woodside, NY

There are no more messages in this thread.