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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
Other messages in this thread:
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.
05/17/2021
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
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 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 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
07/28/2020
RESPONSES/COMMENTS (DME) - PART 1B
From: John Chisholm, DPM
I highly recommend Rybo Medical in Lake Forest, CA. Great devices great prices, great service. I have no relationship with Rybo Medical except as a loyal customer for many years.
John Chisholm, DPM, Chula Vista, CA
04/03/2018
RESPONSES/COMMENTS (DME) - PART 1B
From: Joseph Borreggine, DPM
It comes directly from CMS and fully explains the fee amount and reasons why it needs to be paid.
Joseph Borreggine, DPM, Chalreston, IL
10/27/2016
RESPONSES/COMMENTS (DME) - PART 1B
From: Martin V. Sloan, MS, DPM
With my prior billing company, I dispensed and billed for the boot at the time of surgery, place of service "hospital or surgery center". With my current billing company, eClinical Works, I dispense the boot from the office prior to surgery and bill for it separately. EClinicalworks argues that we cannot bill for DME at the "hospital place of service" because that is not our registered locale for dispensing of DME. I include a letter of medical necessity within the EMR.
Martin V. Sloan, MS, DPM, Abilene, TX
03/02/2016
RESPONSES/COMMENTS (DME) - PART 1B
From: Daniel Chaskin, DPM
If a DPM practices in an area considered by CMS as a "Health Manpower Shortage Area", then that podiatrist may be defined as the "certifying physician" and perform the required DCE.
What about a homebound patient who can only find a NP to perform house calls, and what if MDs refuse to come to the home? Why can't CMS expand its definition of "Health Manpower Shortage Area" to include any homebound patient's address where it is difficult to find an MD willing to perform a house call? Why can't the podiatrist then be defined as the certifying physician?
Daniel Chaskin, DPM, Ridgewood, NY
12/26/2015
RESPONSES/COMMENTS (DME) - PART 1B
From: George Jacobson, DPM
Thank you, Dr. Kesselman. We quit the program a year ago after knocking our head against the wall. I have been sending patients to Hanger as they are close my office. As of two months ago this Hanger office is no long er accepting patients for Diabetic shoes.
George Jacobson, DPM, Hollywood, FL
01/22/2015
RESPONSES/COMMENTS (DME) - PART 1B
From: Stanton C. Southward, DPM
I solved this little problem many years ago. Buy your own office building; then you make the rules.
Stanton C. Southward, DPM Colorado Springs, CO
08/12/2014
RESPONSES/COMMENTS (DME) - PART 1B
From: Mark K. Johnson, DPM
I recently discussed the L3000 custom orthotics issue with a colleague of mine from Pennsylvania. We stopped accepting orthotic payment from all insurance companies years ago. We collect 50% down at casting visit and the balance when dispensed. The office does not pre-authorize or write letters to insurances - we have been burned in the past with separate DME deductibles and "loopholes." We do bill the orthotics to private insurance companies as a courtesy if requested and reimburse the patient if any payment is made.
08/05/2014
RESPONSES/COMMENTS (DME) - PART 1B
I work in an area where DME reimbursement is substantial and contributes largely to my income. I am in a similar situation as an RVU podiatrist. I get reimbursed for orthotics, CAM boots, braces, etc. The diabetic shoes are a little "iffy". The staff usually distributes them and then I give a quick instruction about the break-in period and how to wear them. Therefore, I don't see return on the diabetic shoes. I am curious as to where this reimbursement is going in your practice - overhead? Someone else's pockets? Bottom line, if you are casting, you are explaining, you are instructing and measuring, then you should be reimbursed just as with a nail avulsion or any other procedure.
Name Withheld
08/04/2014
RESPONSES/COMMENTS (DME) - PART 1B
From: Al Musella, DPM
OFFICE HOURS:
MON 7-12 PM
TUE 7-12 PM
WED 8-12 PM
THUR 7-12 PM
FRI 7-12 PM
This sign will get you thrown out quickly. 7-12 PM means 7 PM (night) until noon the second day. They can inspect at midnight.
06/02/2014
RESPONSES/COMMENTS (DME) - PART 1B
From: Greg Mangum, DPM
In Texas, there is a "mandate in force" to cover orthotics(shoes) for at-risk diabetics for Blue Shield. I have been denied as well as non-covered, but on review I have been successful.
Ask for a "Right of Review"- cite that there may a "Violation of Title 29 of the United States Code of Federal Regulations-section 2560.503-1(f)(2)(iii)" , which mandates the coverage for diabetics at risk. Ask for the documentation or articles used in the denial and the credentials of the person denying the claim. I assume the Fed Regs are the same for Ohio.
04/25/2014
RESPONSES/COMMENTS (DME) - PART 1B
From: Dave Mullens, DPM, Esq
Paul Kesselman has asked great questions. First, let me give you the most important piece of information regarding the express agreement included here.
I sent CMS a copy of the agreement and asked CMS to cite any Medicare rules or regulations preventing use of the agreement. If the folks at CMS could have cited a rule prohibiting use of the agreement, CMS would have. That didn’t happen. Instead, CMS sent me a long list of citations to the Social Security Act (SSA) and the Code of Federal Regulations (CFR). I did the attorney thing and very carefully read every one of the referenced sections. My legal opinion: There isn’t..
Editor's note: Dr. Mullen's extended-length letter can be read here.
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