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01/26/2021
RESPONSES/COMMENTS (DME)
RE: Time for Podiatry to Say Something About DM Shoe Requirements
From: Michael J Marcus, DPM
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. Meeting 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...
Editor's note: Dr. Marcus' extended-length letter can be read here.
Other messages in this thread:
09/27/2023
RESPONSES/COMMENTS (DME) - PART 1 A
From: Elliot Udell, DPM
The problem with orthotics is not whether insurance covers them. The problem is if the patient's insurance does cover custom orthoses and pays you 120 dollars for a set, which is some cases, is less than the lab fees. The classic case in my practice was when a patient came in requesting custom sports orthotics. He was an avid tennis player. I called the insurance company and was told that he is covered and they would pay me twenty six dollars and fifty cents per foot. I called the patient and explained that I could not afford it. He begged me and told me that he would pay me out-of-pocket for the orthotics. I accepted his offer and even gave him a discount. He was happy with the orthotics. Six months later, I get a call from his wife and the rep from the insurance company. I was told that I was contractually obligated to reimburse him and take the 26 dollars per orthotic and eat the loss.
I've since learned that if the patient does have insurance that pays below lab costs, I either will dispense Powerstep orthotics or send the patient to a company such as Hangar orthotics and let them handle the finances. If the patient does not want to pay me for non-custom orthotics, I will simply refer them to Amazon and let them buy them but I do let the patient know that should it be necessary, I will not adjust an orthotic bought from Amazon or a sporting goods store.
Elliot Udell, DPM, Hicksville, NY
09/27/2023
RESPONSES/COMMENTS (DME) - PART 1 B
From: Donald R. Blum, DPM, JD
Because you have analyzed the cost of prescribing "custom" orthosis and are finding the cost to your practice as being prohibitive, you might consider an alternative. I think you missed other important costs to your practice - the time it takes to explain the purpose of orthosis, the time it takes to make an impression of the feet, the time it takes to fill in the order form, the time it takes to send the impression to the lab, the cost of postage for the lab to return the product to you when completed, and the cost if you need to return the appliance to the lab for any correction.
I suggest you are not making a $39 profit. Consideration could be made to charge the patient for the service just like you might when using a laser for treatment of nail fungus, or when using extra corporeal shockwave therapy, or selling the patient an OTC product or other services you might offer the patient that are not covered by health insurance. The alternatives are to let the patient go to a retail store for this service or continue taking the ownership for this service and lose money on a service for the benefit of your patient.
Donald R. Blum, DPM, JD, Dallas, TX
09/27/2023
RESPONSES/COMMENTS (DME) - PART 1C
From: Joel Morse, DPM, Robert Kornfeld, DPM
I recommend that you send out another letter and explain what the CPT code is that you use and show us a copy of the notes that you have so that we can see what is going on. I think that as long as you use the L 3000 code and you have all of the specifics of what type of an orthotic you dispense and the correct ICD-10 codes, you should be paid much more than $70 an orthotic.
Joel Morse, DPM, Washington, DC
I think what you charge depends on the value you deliver. I charge more than twice your $400 fee. And it is paid in full in cash. I do not accept insurance of any kind for the past 23 years. Here is why - patients are not just paying you for a product, they are paying you for the value they receive from the orthotic. This is what is missing from insurance-dependency. You are providing services that have lasting benefits for your patients in many ways, and there is way more value in that than just charging them for a piece of plastic. I'm sorry, but providing your patients with orthotics for $30 is downright insulting to you. But as I have stated many times, when you say yes to less, that is what you are going to get. As long as you are beholden to an insurance company to get paid, you will continue to be underpaid and exploited.
Robert Kornfeld, DPM, NY, NY
06/03/2023
RESPONSES/COMMENTS (DME)
From: Don R Blum, DPM, JD
I get frustrated every time I see a post regarding diabetic insoles with therapeutic footwear! APMA has been working on pushing a bill through Congress to ease the requirement of an MD/DO signing off for patients. Most patients never see a physician but only see the PA/NP. How many of the readers of PM News have contributed to APMA PAC?; how many have contributed to their state association, and finally how many of the readers are members of APMA/state association?
Please join your state association/APMA. Please keep up with APMA news. Please support your PAC. Many of the diabetic insole questions are answered regularly by APMA.
Don R Blum, DPM, JD, Dallas, TX
06/01/2023
RESPONSES/COMMENTS (DME) - PART 1A
From: Terry Reed, C Ped
Currently, CMS is doing massive audits on diabetic shoes and are very picky about what they allow. An NP may conduct the exam but it has to be signed by the MD or DO overseeing the patient's diabetic plan of service, and not just signed. There must be a statement such as, "I agree with the above findings" or CMS will reject it.
Also, the auditors will claim that the MD or DO is not truly overseeing the patient if they have not personally seen the patient in the past six months. In other words, people in rural areas who go to a clinic manned by an NP who has their practice overseen by an MD or DO are flat out of luck because they never actually see that doctor.
Terry Reed, CPed, Wynne, AR
06/01/2023
RESPONSES/COMMENTS (DME) - PART 1B
From: Paul Kesselman, DPM
It was important to provide an additional response to the letter I provided in a recent issue of PM News. I purposely did not expand on the issue of when the NP/PA does the foot exam and prescribes the shoes (as they have the legal right to) and thus is the prescribing entity. This circumstance was purposefully omitted out of an abundance of creating more confusion. But since Dr. White brought this up, I feel compelled now to clear that issue up as well.
Dr. White is correct in that PAs and NPs under Medicare are eligible prescribers for therapeutic shoes and inserts, as well as ordering many other tests and DMEPOS. That is NPs/PAs can both prescribe shoes and inserts working incident to (under direct supervision with the MD/DO in the office) or under general supervision (when the MD/DO is not in the office but...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/31/2023
RESPONSES/COMMENTS (DME) - PART 1A
From: Paul Kesselman, DPM
CMS attempts to facilitate access for therapeutic shoes to patients who only see PAs or an NPs has been a flop. It also has confused the auditors at every level, created a larger paperwork trail. Even my fellow DME council members continue to flood my phone and email box just having reviewed this issue during a council meeting. So to try to give a straight answer covering every scenario in this format would be nearly impossible. This is what a PA can do:
If you are the supplier and prescriber: They (the PA) can perform a systems exam, sign the supervising physician statement, and attest agreement with your notes. However, every single one of those documents must be co-signed and dated by the...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/31/2023
RESPONSES/COMMENTS (DME) - PART 1B
From: Josh White DPM, C.Ped
PAs and NPs are permitted to do foot exams, documenting qualifying risk factors for therapeutic shoes and to complete a Statement of Therapeutic Necessity. Medicare still requires an MD/DO to be the Certifying Physician. It is okay if they provide "general supervision (versus direct)" of the NP/PA.
It is still necessary for the certifying physician to co-sign the certifying statement and foot exam. Often, this is a challenge to execute. It is NOT okay to get the NP/PA signatures without a MD/DO co-signing it.
Josh White DPM, C.Ped
12/17/2021
RESPONSES/COMMENTS (DME)
RE: CMS Releases DME 2022 Fee Schedule
From: Paul Kesselman, DPM
CMS released the DME 2022 fee schedule on time on December 15 2022. On average, there is a 5.1% increase after deflationary (yes, that is the correct term) factors are taken into consideration. The fee schedule is in Zip format and may be found on the CMS website.
Certainly, it will be more widely available in a more user-friendly format in the next few days on both the DME MAC contractors and the PDAC website.
Paul Kesselman, DPM, Oceanside, NY
10/06/2021
RESPONSES/COMMENTS (DME)
From: Keith L. Gurnick, DPM
This is a challenging question to address but it all comes down to educating your patient in advance and knowing in advance what their insurance situation is. Patients do not want to pay more money for something than they could have, and often in situations like this, they feel like "they got ripped off" by the doctor, but this simply is not true.
Both you and your patient have a signed contract with the healthcare insurance company, and both the provider and the patient are bound by the contract. Irrespective of any deductibles or co-insurance you should be paid by either the insurance company or the...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
05/17/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Josh White, DPM
As the director of OrthoFeet’s medical division, I can share that we have not had a price increase on diabetic shoes nor pre-fabricated/custom inserts in over a year. While the cost of shipping containers from China has increased substantially, we have not passed this on. The cost of FedEx, UPS shipping has increased but these charges have also not been passed on as we negotiated better volume discounts.
OrthoFeet has NO backorder issues; we receive thousands of shoes a day from China. The biggest supply chain problem regarding diabetic shoes is the difficulty DPMs encounter in obtaining certification that the patient is under the care of an MD/DO for their diabetes and have been to this physician no more than 6 months prior to being fit with shoes. The APMA and the new LEAP Alliance have been working for years to remove this obstacle. With approximately 50% recurrence of foot wounds within a year of healing, the need for patients to be expertly fit with quality shoes has never been greater.
My suggestion is for practices to assign the task of documentation procurement to someone and incentivize them to do the necessary follow-up to obtain the required forms. Make sure your patients understand the importance of shoes in enabling their mobility and independence and that the MD/DO understands their responsibility in the team approach to care. Once patients are fit, the process should be repeated annually. With over $225 profit possible per pair of shoes and inserts, there is plenty of opportunity for everyone involved to benefit.
Josh White, DPM, CPed, VP, OrthoFeet
05/17/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Lawrence Rubin, DPM
I understand that optometrists are also having a supply chain issue getting timely delivery of custom eyeglass frames and lenses. It appears that the worldwide impact of COVID-19 is resulting in delays due to fewer employees on the production end in the factories, and also fewer workers on the job in the other links of the supply chain.
Lawrence Rubin, DPM, Las Vegas, NV
02/01/2021
RESPONSES/COMMENTS (DME)
From: Robert Creighton, DPM
I thought it interesting that Dr. Kass' recent comment regarding DM Shoe Requirements in which he used the word "profession" in quotes - as in podiatry "profession" - immediately followed Dr. Jones' comment on the same subject referring to Vision 2015's goal of podiatry parity with MDs and DOs. I have heard the word "profession" when referring to the medical specialty of podiatric medicine since I was a student at PCPM in the mid-1980s.
Just this month, it was much used in a lecture regarding the new E/M coding guidelines as they pertain to our "profession." Here's a suggestion: let's stop referring to our specialty-field of healthcare as a "profession" and call it what it is, a specialty-field within the domain of medicine and surgery; perhaps there's better terminology, but I think you understand the point. I do not believe nephrologists rheumatologists, and dermatologists refer to their fields of specialization as the nephrology-, rheumatology- or dermatology-profession, respectively.
Dr. Jones nicely listed some of the major accomplishments of our specialty field. Now it's time for us to communicate in a manner on par with those accomplishments. “He who wants to persuade should put his trust not in the right argument, but in the right word. The power of sound has always been greater than the power of sense.” – Joseph Conrad, writer.
Robert Creighton, DPM, Tampa, FL
01/29/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Billy Dabdoub, 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...
Editor's note: Dr. Dabdoub's extended-length letter can be read here.
01/29/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Jon Purdy, DPM
A few years back, after about 30 denials for payment on shoes and inserts, I gave up. I sent all to the ALJ level and waited three years to have the hearings. My documentation is in perfect order, and my patient criteria is without question. In the vast majority of cases, they were approved and a couple of judges apologized to me for the hassle. I did have one judge recently who seemed determined to deny my case. At the end, I was explaining the terms to her which she apparently did not understand. It was subsequently approved.
This is an obvious trend to keep a defined benefit in place while creating barriers to delivery of service in hopes it becomes too cumbersome for physicians to utilize and bill. They win, the patient loses. Physicians alone cannot win all battles without the public becoming involved in the fight over ever increasing deductibles and diminishing services. Medicare today resembles nothing of what the original legislation promised, which is no surprise.
Jon Purdy, DPM, New Iberia, LA
01/28/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Steven Finer, DPM
You are paying for the sins of others. When I was in practice, patients would come in with shoes from suspect private stores where the shoes were obviously not custom-molded. The inserts came right off the shelf with no corrections for lesions, etc. I repeatedly would tell the patient to go back and complain. One showed me a pair where some charlatan placed a one cent rubber pad inside and charged him $80.
I had a family of patients that would brag to me as to the number of shoes they could get. Read old OIG reports about the abuse with braces, scooters, TENS units, and power chairs. As an ethical practitioner, you are being inundated with paperwork for saving people's feet. Blame the system. The free lunch is never free.
Steven Finer, DPM, Philadelphia, PA
01/28/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Paul Kesselman, DPM
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 MACs on this issue.
At one point, a 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, NP/PAs have been given...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
01/27/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Daniel Jones, DPM
I remember when I was in school. There was 'Vision 2015'. It essentially stated that the goal of podiatry was to have parity with MDs and DOs by 2015. Yet here we are, some 6 years later, still seen as second class physicians, or "allied healthcare providers". Even with the excellent work of the APMA, a podiatrist serving in Congress, and mandatory 3-year residencies (the same as PCPs nationwide), we still have to have a 'real doctor' sign off on our patients. Who knows our patients’ feet better than us? Who sees our diabetic patients more than us?
The point is this: We should be able to sign for the shoes ourselves. My staff and I spend countless hours explaining to our patients that the NP and PA they see for their primary care doesn't 'count' in getting shoes signed for. This also creates a potential rift between podiatrists and NPs and PAs, who see us sending patients they referred to us to another provider for this visit. By signing for ourselves, it eliminates barriers to diabetic ulcer prevention and lets our patients see their PCPs without burdening the system with unnecessary MD/DO foot checks.
For better or worse, there will be political changes to the practice of medicine. Likely, one of these multi-thousand page bills will be signed into law. Can we have just one of those pages give parity to DPMs? Title XIX has hindered us long enough. It's time for DPMs to take their seat at the table with MDs and DOs.
Daniel Jones, DPM, Casper, WY
01/27/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Jeffrey Kass, DPM
I must compliment Barry Block, DPM, JD (editor of this forum) for allowing colleagues to express opinions here. It is becoming a little bothersome to continuously read problems the profession faces at this stage of the “profession”. Podiatry has evolved. Our colleagues have advanced this profession by leaps and bounds. Drs. Sokoloff and Marcus eloquently write about their frustrations with volunteering for administering Covid shots and the absurdity of the rules and regulations of the diabetic shoe program. I agree with them both as I’m sure the overwhelming majority of podiatrists do.
I’m curious what the APMA’s position is on these topics and why it is so difficult to straighten the BS out? Multiple drug companies figured out in “warp speed” how to create a vaccine in record time but podiatric leadership can’t figure out a way for a podiatrist to dispense a diabetic shoe to a patient missing multiple toes without writing an encyclopedia, asking an MD to sign off on it, and then having the money taken back anyway for not including an Rx even though he was the prescribing doctor.
I encourage those who have ideas how to change some of the dilemmas the profession faces to write in with them. Whether that means having every diabetic patient sign a petition or what not. I mean people - we really ought to put some of these issues to rest already.
Jeffrey Kass, DPM, Forest Hills, NY
11/25/2020
RESPONSES/COMMENTS (DME)
RE: Therapeutic Shoe Update
From: Paul Kesselman, DPM
As of November, there is an update to the Therapeutic Shoe Policy which some of you will be happy with and others may be troubled by. A summary is provided below. Both nurse practitioners (NP) and physicians assistants (PA), with certain limitations, are now afforded the ability to certify patients as diabetic with respect to their need for therapeutic shoes/inserts. There are two pathways, both of which have limitations which are summarized below.
Pathway #1: NP/PA Working Incident to an MD/DO Effective November 5, 2020 If an NP or PA is working both under the direct supervision of an MD/DO and billing under the NPI of the MD/DO who was/is supervising the DM care, then the NP/PA can perform the examination to demonstrate that the patient is diabetic and needs therapeutic shoes. They may also sign the certification form that the patient requires therapeutic shoes. The exam records of the NP or PA, however, must be...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
11/12/2020
RESPONSES/COMMENTS (DME)
RE: Therapeutic Shoe Breaking News
From Paul Kesselman DPM
CGS, the JB and JC DMEPOS Contractor, announced on November 5, 2020 a long-awaited update to the Therapeutic Shoe Policy. This update, would for the first time, permit the documentation of a nurse practitioner or physicians assistant (NP/PA) working under the “incidence to” rule. But this is subject to some restrictions. It is not clear how soon the LCD itself will be updated. Auditors at various CMS agencies are currently being educated on this matter now and that expects to be completed in about six weeks. How this new update will affect claims submitted with a DOS prior to November 5, 2020 is unclear at this time. Noridian (DME MAC A and D) has not yet posted this on their website, but since the policies are equally enforced, there is no doubt the posting from Noridian will be forthcoming soon.
I cannot stress enough that for now in states where NP and PA can work independently and bill under their own NPI, this ruling may have little effect and, in fact, create more confusion. This update precludes the inclusion of documentation of an NP or PA working independently. In states where NP or PA can work independently, it is advisable to check with the NP or PA to ensure that their documentation fits the incident to guidelines.
Paul Kesselman, DPM, Oceanside, NY
10/02/2020
RESPONSES/COMMENTS (DME)
RE: Telemedicine and DME
From: Paul Kesselman, DPM
A recent bust by the OIG charged physicians who prescribed DME via telemedicine. Please be careful about companies which promise you big bucks to do telemedicine. While I have not been contacted, I know other DPMs who have, and when contacted regarding this matter, my suggestions are the same. Be careful. Inquire what you may be asked to do, and set parameters and that you will insist that patients go to an actual provider for prescriptions, orders, etc. Inquire about the telemedicine company's relationship with DME companies. Perhaps it might be best to only engage in telemedicine with your own patients when they can't get to your office.
Paul Kesselman, DPM, Oceanside, NY
08/28/2020
RESPONSES/COMMENTS (DME)
From: Paul Kesselman, DPM
Each DME MAC has a provider portal where Same or Similar can be researched. My CGS is the portal for DME MAC Region B and C. Go to either of those DME MAC homepages and look for the MYCGS link. There are several hurdles in signing up. I’ve been working with their portal managers to make signing up and maintaining one’s subscription less frustrating.
Once on the MY CGS Portal, the claims history button provides a way to input previous “L“ codes and to a search history. There continue to be nuances with the portal which need updating and ...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/30/2020
RESPONSES/COMMENTS (DME)
From: Paul Kesselman, DPM
Last week, CMS announced that audits would resume on August 3, 2020, in spite of the ongoing pandemic and cases of COVID-19 actually worsening in large parts of the country. Due to a significant backlash from providers and representative organizations last week, CMS has provided some further clarification on audits.
1) Targeted Probe and Educate (TPE): No time frame for resumption
2) Recovery Audit Contractor (RAC) and Supplemental Medical Review Contractor (SMRC) audits: No time frame for resumption
3) Post-payment reviews by the DME carriers will be restarted and that includes those that were previously in the cue. However, providers who respond by providing documentation of their inability to complete the audit will be reviewed by the DME MAC and likely will be dismissed.
To those who are not DME providers, similar audit resolution will likely follow on the physician side. This could not have been accomplished without the hard work of the Medicare Jurisdiction Councils of which I am the APMA representative. So to the recent question of why it pays to be an APMA member, well there you have it.
Paul Kesselman, DPM, Oceanside, NY
07/28/2020
RESPONSES/COMMENTS (DME) - PART 1A
From: Doug Richie, DPM, Brad Katzman, DPM
The Richie Brace family of lab distributors offer a gauntlet AFO with the patented Arch Suspender: Also, the Richie Brace labs offer the California AFO which is a unique gauntlet brace incorporating the Arch Suspender without any laces.
Doug Richie, DPM, Seal Beach, CA
Check out Biostep. They are located in Panorama City, California. They make excellent orthotics and custom braces at extremely reasonable pricing with excellent products and service.
Brad Katzman, DPM, Chino Hills, CA
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