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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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