01/26/2021    Michael J Marcus, DPM

Time for Podiatry to Say Something About DM Shoe Requirements

As a podiatrist, I have been dispensing diabetic
approved shoes to our patients since the
inception of this federally funded program. After
40 years of practice some of my patients have
received shoes from our office for the past 15 to
20 years. Each year, the requirements seem to
change by some degree. In the beginning of the
program, a confirmation form signed by the MD
treating physician, recognizing that patients fit
the criteria was all that was needed. Over time
the one form has now become a packet of forms
including copies of notes to hopefully confirm
the need and satisfy Medicare requirements.

As a profession we abide by these procedures.
Meetings after meeting we discuss the procedures
that are required. And even with good reporting
our claims are often denied or deemed not
complete. I do understand that in some
communities abuse may be a factor.
However, if I have a diabetic patient that has
lost a part of their foot and has required a DM
shoe in 2015. - Why would one need to question
the need for a DM shoe in the year 2021?. Have
you ever seen a patient with neuropathy improve
to such a degree that his neuropathy is no longer
present? Have you ever seen a patient with a loss
of a part regain full normal biomechanics? Have
you ever seen a DM patient who has suffered a
loss of a part not continue to be prone to
further loss?

I think we all know the answer.

So, for these diabetics why? Why in the heck to
we need to, yes, waste our valuable time with
ridiculous paperwork, as well as require our
referring physicians to sacrifice their time, and
lastly cause our patients such hurdles to ensure
the quality medical services for the prevention
of further loss.(shouldn’t an operative report
indicating that the diabetic had an amputation or
a photo of a foot missing a part be enough to
indicate need?)

Furthermore during this especially trying time of
the pandemic- wouldn't be a good time to modify
the procedure to enable these fragile patients a
more efficient way of securing proper shoes for
their diabetic foot condition. Data has already
shown an exponential increase in amputations with
covid. Just wait to see the post-covid syndromes
that will affect our diabetic population.

Our profession needs to address these concerns
ASAP. PLEASE

Michael J Marcus, DPM, Montebello, CA

Other messages in this thread:

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01/29/2021    Billy Dabdoub, DPM

Time for Podiatry to Say Something About DM Shoe Requirements (Michael J Marcus, DPM)

I want to thank my colleagues for raising this
important issue at the beginning of this
congressional session. I’ll start by recommending
that they can begin to educate themselves on this
and other issues impacting our profession by
becoming members of their state component and
members of APMA. Our professional associations
are our voice in our state and national capitals,
and they keep us informed about what’s happening
to our profession and the threats which we must
overcome.

APMA has been actively working to address the
problems with the Medicare Therapeutic Shoe
Program for patients with diabetes for more than
a decade. Several resolutions have been passed
over the years by the APMA House of Delegates to
address this issue and to reinforce the
importance and priority that the profession
places on finding a solution to this problem.
Attacking the issue from both a regulatory and
legislative standpoint, APMA staff and contract
lobbyists continue to meet with and educate
representatives from CMS and the members of
Congress who sit on the relevant committees.
Since 2013, APMA has included language to fix the
shoe problem in its bill to address Medicaid
recognition, which has garnered significant
attention in Congress. Over the last decade, APMA
and state component leaders have spent hundreds
of hours lobbying members of Congress to support
and pass our bill and have invited APMA members
and friends of the profession to participate and
to advocate to policymakers on this issue.

So that’s what APMA has been doing to address the
issue. Once more, if you have not had experience
participating in the legislative and regulatory
process, I urge you to get involved at the state
and national level. It is eye-opening. There are
inherent challenges to this process, most
significantly that it takes time and a combined
effort, so the more constituents who are
involved, the better our chances for effecting
real change in this situation.

Billy Dabdoub, DPM, Slidell, LA

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01/28/2021    Paul Kesselman DPM

Time for Podiatry to Say Something About DM Shoe Requirements

I have read the postings regarding the time for
podiatry to do "something" about DM shoe
requirements. Unfortunately, the "something" has
been equated to actually succeeding. And while
unfair, that assumption is readily understandable
to me as both a provider of therapeutic shoes and
chair of APMA's DME Workgroup. APMA and other
organizations have had a litany of meetings with
the DME MAC contractors regarding this matter. I
actually attended my first meeting with the then
SADMERC (now PDAC) well over 15 years ago, and I
have attended many more since with other DME MAC
on this issue.

At one point, one former DME MAC Carrier Medical
Director joined me and APMA officials to speak to
the DME MAC Carrier Medical Directors, asking for
relief for suppliers. Unfortunately to no avail.
Recently the NP/PA has been given some authority
to actually provide the documentation to examine
the patient under certain limitations.

Despite the best efforts of many well versed
individuals, the biggest obstacle remains. That
is, the Eligible Prescriber's notes must be
cosigned by the MD/DO treating the DM. That to me
remains the one sticking point which the DME MAC
refuses to address without directives from CMS.
And meetings have been held with CMS on this
issue as well.

Apparently the DME MAC moved on the issue of
NP/PA being eligible to serve in some respects as
the supervising entity (with some limitations),
but that initiative came from CMS, not from the
DME MAC, due to pressure from medical associations
such as the American Academy of Family Physicians
and others. Interestingly enough, in the past,
the DME MAC claimed that NP/PA could not perform
the function of the supervising MD/DO because it
was codified in statute requiring congressional
action. Well, apparently that was not the case,
and to some degree it has now been modified.

My personal opinion at this point, is that our
specialty should continue to work with other
collaborative medical organizations, including
but not limited to AMA, the Society for Vascular
Surgery, AAOS, etc. This is NOT a podiatry
issue. It is an issue wherein the Eligible
Prescriber, be it a DPM or another medical
specialist not treating the DM, must have their
note signed by the MD/DO treating the DM. Why
would any non-specialist ever want to sign off
and "agree" with the findings of a specialist? As
one cardiologist who was treating a patient's DM
once said to me, "Why do I have to sign off on
your notes; you are the foot specialist not me."
And that to me makes perfect sense! Does the
MD/DO have to agree with the findings of an
ophthalmologist if the specialist's opinion is
that the patient requires eye surgery? Of course
not!

The requirements of a generalist or other
specialist signing off on another's
recommendation is purely and simply an archaic
requirement. It has never been proven to have any
influence as a fraud prevention tool. If the
MD/DO treating DM doesn't want to certify the
patient, they can simply choose not to do so.
That requirement needs to stay in place, and I
have no issue with that!

It is my understanding that the law requires any
health care provider to provide their medical
records to their patient. It may also be the same
for one health care provider treating the patient
when requested by the patient. So contrary to
what I have heard from others, obtaining the
medical records for a patient from the PCP,
endocrinologist, etc. who is treating the DM
should be a non-issue and was almost never one
for me while in practice.

The timelines are also fairly straightforward: 90
days for certification and six months for
Supervising MD/DO notes and that of the eligible
prescriber. Those by the way are not anywhere in
the congressional records, and the DME MAC can
certainly deal with this.

So what is left is for the medical associations
and those representing patients with DM (ADA),
along with AARP and others to work together to
pressure CMS to finally move the therapeutic shoe
policy regulations to the 21st Century. If that
were to occur, all eligible prescribers’ notes
would need to stand on their own, just as they do
for all other medical procedures.

In closing, I share the frustration of those
writing to PM News on this issue, but it is
unfair to say that it's time that Podiatry do
something about this. Podiatry has been doing
something about this for the last 15 years.
Certainly, if anyone has some novel constructive
ideas about how we can push the needed change(s)
forward, your input would be well received.

I will be addressing this issue as part of the
APMA Coding Workshop during NYSPMA Clinical
Conference this Friday morning.

Paul Kesselman, DPM, Oceanside, nY