07/13/2023    Lawrence Rubin, DPM

Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Jack Ressler, DPM) From:

I want to thank Dr. Ressler for his, “Killing the
Chicken Who Lays the Golden Eggs” story. He
witnessed the flagrant abuse and outright fraud in
the early 1980's that occurred when all too many
podiatrists abused the billing of CPT code 11730 -
nail avulsion.

It is so sad that even now, because of this long
ago situation, it is no longer a question of
whether or not a podiatrist will be subjected to a
random or targeted audit of 11730 coding and
billing. It is more a question of when this audit
will occur. But this is not the end of the Golden
Egg story. Things got worse.

In the early 1980s, the abuse Dr. Ressler describes
tarnished the reputation of podiatry in the minds
of HCFA administrators. Congress was aware of that
reputation, probably from information obtained from
HCFA. So, reportedly to prevent the same podiatry
abuse that was occurring via 11730 false billing,
in the late 1980s, Congress reacted by putting into
law restrictive medical necessity and utilization
control requirements. These requirements had to be
met before a diabetic patient could receive a pair
of soon to be available therapeutic shoes
prescribed and supplied by a podiatrist. The law
went into effect in 1993, and remains in effect
today.

Then as now, in order for a diabetic patient to
receive therapeutic shoes supplied directly from
their prescribing podiatrist, a primary care
physician must confirm the medical necessity
documentation the prescribing podiatrist submits –
even when that licensed and qualified prescribing
and supplying podiatrist adheres to required
documentation that adequately supports the medical
necessity of the shoes.

And if you research this on the Internet, you will
find references to the fact that HCFA wanted this
“second opinion,” because administrators believed
many podiatrists would, “just offer patients a pair
of free shoes every year, and they would bill
Medicare for those shoes without following medical
necessity guidelines.”

There is no question about it. Compliance matters
matter more than we may think.

Lawrence Rubin, DPM, Las Vegas, NV

There are no more messages in this thread.