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05/22/2020 Paul Kesselman, DPM
Medicare Therapeutic Shoe Program/ COVID-9 (Michael J Marcus, DPM
There is a short answer and a rather long explanation. First the short answer: Yes, you may use remote technology (Telehealth) to prescribe shoes and remote technology is also acceptable for the patient to be qualified by the MD/DO as needing shoes. However, fitting and dispensing must be done during an in-person exam.
Now for the long answer: There are two separate issues here. One is the issue of obtaining the required documentation and the other is the actual fitting and dispensing. Having recently (virtually) attended five DME conference calls of 3 hours or more, the topic space of therapeutic shoes was brought up by several other medical associations attending these meetings as well as myself representing APMA.
1) Thus, the examination by the MD/DO treating the DM and certifying the patient's qualification counts if conducted by Telehealth when performed under the PHE Telehealth provisions; 2) The Eligible Prescribers (MD/DO/DPM, PA, NP) prescription for shoes will qualify if conducted by Telehealth when performed under the PHE Telehealth provisions (subject also to state licensure) Since Federal Regulations at this time allow for DPM's to currently perform Telehealth services under the PHE, there is no issue w/DPM's prescribing shoes via a "virtual" Telehealth exam
As for the actual fitting and dispensing of shoes during the PHE using Telehealth the answer is no and I agree with this from numerous positions:
1) Even if it was allowed, I have gone on record and continue to do so that it is a very bad idea. We as a profession are claiming that diabetics are among the highest risk patients we see Patient who require shoes under the Therapeutic Shoe Provision, are the highest risk patient we see, in particular those requiring either custom milled or custom molded inserts and/shoes. To fit them "virtually" is simply asking for trouble from the liability perspective. It will be hard to defend yourself in a liability situation that the shoe fit was actually "good" if examined virtually. How can you feel the fit was good and are you really going to rely on the patient's subjective analysis if they are neuropathic? And how can you justify your objective fit to Medicare virtually?
2) The second "legal" challenge to overcome is the issue of regulatory policy vs. statutory policy. The Interim Final Rule (IFR) which addressed #1 and #2 is part of a regulatory policy which was aimed at addressing the provision of medical services and relaxation of requirements during the Public Health Emergency (PHE). However, the Quality Standards of 2018 is a statutory requirement. Within these standards is an Appendix C which requires in-person examination and fitting by the supplier of shoes and orthotics and prosthetics (for DPM's orthotics=AFO).
Regulatory policies cannot overturn statutory policies and thus the "legal" challenge to reversing this issue gets tossed over to requiring Federal legislation requiring Congressional passage and Presidential signature.
3) Last how are you going to heat mold inserts (custom milled, molded, or simply heat molded) without the patient in front of you to assure they are full contact?
I have gone on record at numerous meetings both within our profession and outside our profession not to ask for relief from this second issue. With many of our younger colleagues being "drafted" into providing acute care for Covid patients in hospitals during their residencies along with many of their senior staff members, this is not the time to be "trivial" and ask for relief. In particular other associations representing Orthotic Providers are also not asking for this type of relief, recognizing my previous point 1 just above regarding fitting and dispensing.
My concern continues to be access to care for our highest risk patients and thus if whether currently or post pandemic our patients can be "qualified" by the MD/DO remotely via Telehealth I personally am satisfied. These sentiments are shared by other associations representing shoe providers as well.
In summary, yes you can prescribe shoes virtually, you can obtain the required documentation from the MD/DO based on a virtual exam.But you cannot dispense shoes/inserts virtually.
Paul Kesselman, DPM, Woodside, NY
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