07/31/2023    Allen Jacobs, DPM

Comprehensive Evaluation of Diabetic Patients

Podiatrists have long understood that diabetic foot
pathology is typically multifactorial in etiology.
I strongly believe that a substantial number of
diabetic alterations, infections, and amputations
could be prevented by the recognition of these
factors and early proactive care. This involves
dermatologic evaluation, vascular evaluation,
neurologic evaluation, gait analysis, and
biomechanical examination, evaluation for
underlying osseous and articular abnormalities, and
integrating and understanding of these factors,
into proactive efforts to reduce the incidence of
alterations, infection, and amputation.

All too often, I believe that the “treatment” of
the diabetic patient for so-called at risk care is
simply reducing nails for onychomycosis or
calluses, and prescribing diabetic footwear. In in
my experience, the evaluation of the diabetic
patient, particularly at the time of the initial
visit, requires a detailed multi system,
evaluation, and then education of the patient
regarding therapies to prevent ulceration.
interdictive strategies range from actual
aggressive and active treatment of onychomycosis to
the treatment of deformities that predisposed to
ulceration.

The problem? Unless there is identified pathology,
we are not paid for the substantial amount of time
and effort required to truly risk, assess, and
educate a diabetic patient. The closest that we can
come is adding a -24 modifier for an office visit
together with Neil or callus care. I believe the
current system importantly, Medicare, causes the
podiatrist to shuttle patients through the office
in large numbers, depriving the diabetic patient of
true evaluation and management. For example, in my
office, it is not uncommon for me to be treating
some skin condition in a diabetic patient, actively
treating their neuropathy, providing offloading
therapy for areas of pre-ulcerative change, and so
forth.

Yes, we can charge for Doppler studies typically
one level. Yes, you can dispense diabetic shoes,
orthotics, therapeutic creams, and lotions, and so
forth. However, this begs the essential question
which in my mind is why are we not reimbursed a
fixed fee for a comprehensive diabetic risk
assessment?

I am continually hearing from the “coding experts“
that combining a surgical service, such as nail
care together with an office visit with the -24 or
-25 modifier, is an invitation to a Medicare audit.
Therefore, many podiatrists practice, avoidance
behavior, and do not treat comprehensively. We do
not comprehensively evaluate the diabetic patient
until they present to the office with what was in
hindsight a preventable condition.

We have established leaders in our profession with
regard to evaluation and management of the diabetic
foot. We have the APMA, ACFAS, ACPM, and other
influential organizations. I am not an expert on
coding, but I think this time that we initiate a
unified push to have some type of coverage for the
comprehensive assessment of patients for diabetic
foot pathology. We all know that it is difficult to
obtain coverage for preventive care, but we also
know that this is critical to prevent, ulceration,
infection and amputation in the diabetic patient. I
do not have the personal insight or knowledge as to
how to accomplish this, but I’m certain we have the
expertise in the profession.

Supposedly, we have a podiatry supporter in
Congress. It is time to establish a reasonable
payment schedule to reward podiatric physicians for
the required time to perform a comprehensive risk
assessment, and for initiating and monitoring the
care required to prevent limb loss.

Allen Jacobs, DPM, St. Louis, MO

Other messages in this thread:

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08/09/2023    Paul Kesselman, DPM

Comprehensive Evaluation of Diabetic Patients (Allen Jacobs, DPM)

Of course, I acknowledge and agree with Dr. Jacobs
regarding the significant limits of the LOPS exam.
From my initial response to his LTE, I had stated
that the LOPS program is a flop simply because it
was ineffectual because most diabetic patients
would not qualify and the reimbursement is pitiful.
What it includes is I also agreed that an E/M code
was far more appropriate. The description I am
advocating is to use an appropriate E/M. After all,
is this exam not an evaluation and management
examination?

As I discussed and Dr. Jacobs and the IWGDF have
provided, a clear message that all patients with
diabetes should be seen by a healthcare
professional based on a tiered structure. It is
inconceivable that third-party payers and MCR don't
see the effectiveness in this message given the
significant amount of money paid out for treatments
related to diabetic foot pathologies, which eclipse
those of many cancers.

I am all for this, but quite frankly in over 35
years of practice, I have rarely if ever seen a
diabetic of Medicare age 65 or more where I did not
find some pathology related to their diabetes.
Xerosis, mycosis, mild neuropathy, mild
glycosylated tendons resulting even in mild equinus
can all have devastating effects on patients if not
managed and all can be tied to diabetes, whether
newly diagnosed, or even (and I shun to even utter
these words "pre-diabetes" The reasoning here is we
all know that many pedal manifestations may pre-
date by years the clinical diagnosis of diabetes
mellitus.
As for Dr. Rubin, another mentor and former teacher
from ICPM, he too advocates for preventative
examinations:

What is essential is that these examinations should
never be called screening, this is especially true
if the patients' MD/DO/NP/PA is referring the
patient to the DPM for an examination. In those
instances, the patient has already been screened
and now you the DPM are being asked for an opinion
as to how the patient is to be managed. Thus the
need for a "screening" CPT by the DPM has already
been skipped over and you are actually being asked
for a management workflow. Thus, an E/M. From the
words of a former Medicare official, well versed in
diabetes management, if you were performing a
"screening" exam, which may be initiated by the
patient, and you found something, requiring
management, then screening, by the coding
definition, it no longer is.

Case in point, screening colonoscopies are no
longer screening once the physician finds
something, diverticulosis, diverticulitis,
hemorrhoids, colon cancer, etc. So just because
something may have been initiated by the patient as
screening, it now no longer translates to that
point from a management perspective. Last point, is
I have never in 35+ years in practice received a
referral from an MD/DO/PA/NP which used the words
screen for diabetic foot screening. Most said,
evaluate and treat diabetic foot or simply evaluate
and treat and may or may not have even had a
diagnosis.

In the interim, kudos to both Drs. Jacobs and Rubin
for bringing their opinions to the forefront on
this issue. To me, the more important issue here
is that your chart notes, no matter what you do,
should be supportive of the use of any modifier and
everything else you document!

Paul Kesselman, DPM, Oceanside, NY

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08/07/2023    Allen Jacobs, DPM

RE: Comprehensive Evaluation of Diabetic Patients (John V. Guiliana, DPM, MS)

Personally, I feel the term LEAP (lower extremity
amputation prevention) might better summarize our
examination and treatment of the diabetic patient
than does the term “at-risk “. Ironically, the
older diabetic patient frequently takes the
greatest effort and time to care for, and is the
patient for which we receive the poorest
reimbursement. Given the ageing population and
diabetes pandemic, there will continue to be a
need for LEAP services. PAs, NPs, and physicians
cannot and do not provide the detailed services
required. They have neither the time nor interest
or knowledge. I have been fortunate to present at
many non- podiatry health care provider meetings
for many years. LEAP lectures are always
enthusiastically received once the participants
learn what they did not know.

Sadly, our involvement in this arena has become
more reactive than proactive. Market forces and
resultant seminar and educational efforts
emphasize ulcer care, grafts, surgical management
of Charcot’s joint disease and infection.
Interventive strategies for established pathology
is of course critical. Prevention of such
pathology is more important.

I always explain to patients or family that limb
loss is a potential reality in the patient with
DM, and that not infrequently the pathway to limb
loss begins with seemingly trivial and non-
threatening clinical problems. I use the Benjamin
Franklin warning
“ for want of nail a shoe was lost. For want of a
shoe the horse was lost. For want of a horse the
rider was lost. For want of the rider the battle
was lost.”

This means active management of onychomycosis,
tinea pedis, xerosis, pre- ulcerative callus
formation, biomechanical abnormalities, detection
of asymptomatic PAD, asymptomatic autonomic,
motor, sensory neuropathy. It means improving
quality of life issues such as fall risk
evaluation, treatment of symptomatic neuropathy,
entrapment neuropathies. It means selective
surgical management of pre-ulcerative deformities.
It involves continuing patient education.

Many if not most patients require an E and M with
-25 or when indicated -24 modifier in addition to
so-called at risk foot care. Compensation for such
efforts might include dispensing of needed and
required products of pharmaceuticals, in addition
to billing for the time or complexity of such
encounters.

In my opinion, this is a major representation of
the “medicine” in podiatric medicine. Wound care
begins with wound prevention. As a profession, we
talk the talk but do not walk the walk. Why is it
that we hold the knowledge but do not employ this
power to its maximum? Ultimately, residents do not
see these principles employed by those whom they
observe. Detailed discussions on preventive care
strategies are not a typical portion of symposia
curriculum beyond very cursory acknowledgement.
Lack of adequate compensation, fear of Medicare
audit, increased documentation demands, poor
residency training, are some of the major
contributing factors to less than optimal LEAP
care. Even the recent IWGDF guidelines, which
included podiatry input, were to my estimate
superficial and narrow-focused. You can only
diagnose that which you know and evaluate for.
LEAP requires a comprehensive multi systemic
evasion for which adequate compensation must and
should rewarded.

Allen Jacobs, DPM, St. Louis, MO

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08/04/2023    Paul Kesselman, DPM

Comprehensive Evaluation of Diabetic Patients (Allen Jacobs, DPM)

Dr. Jacobs, as usual, makes many important
statements during his recent letter to the editor
regarding the need for podiatrists and other health
care providers to be afforded the opportunity to
provide an annual comprehensive diabetic foot
examination.

Unfortunately, the current system does not agree as
it is not only not affordable but inaccessible to
most. Let me explain. Screening examinations with
rare exceptions are unfortunately non-covered
services. In the case of diabetic foot screening,
the only two screening examinations are coded under
Loss of Protective Sensation, better known as LOPS
(Initial G0245)) or Subsequent (G0246).

These are widely under-utilized because the fees
associated with these are totally inadequate and
inconsistent with the real RVU and work effort it
takes to perform these examinations. More
importantly, if the patient has been seen by any
healthcare professional billing Medicare for any
foot related issue even if unrelated to diabetes,
within the previous six months, these codes are
non-reimbursable. The serious lack of CPT
utilization tables for LOPS coding is proof that
this program just does not work.

So where else can we look? PQRS also affords some
measures to evaluate patients at risk for DFU, but
again, this program doesn't directly reward or
increase the physicians' bottom line. And with all
the Covid exemptions as well as the difficulty
inherent with this program, it's hard to really get
a clear picture on how much performing any of the
diabetic foot related PQRS really affects the
bottom line.

The last place we can look is at Evaluation and
Management (E/M) Codes and this is where Dr. Jacobs
(while admitting he is not a coding guru) is really
telling us to look. The problem for most of our
profession, is that we are either afraid to use
these codes when also performing at risk foot care
or we simply don't document the E/M completely. Dr.
Jacobs hits a home run when he espouses all the
objective findings he can "see" while performing an
objective examination on the diabetic foot. But
where he hits a grand salami is where he starts
talking about how he is going to manage those
issues.

Most of the chart audits I see fail on billing E/M
codes, are when performing an E/M on the same DOS
as at risk foot care. Why? Because there are
minimal objective findings separate from those
needed to establish the eligibility for at risk
foot care. Even more so is the significant lack of
management of those findings. As one example, if
pulses are non-palpable, what is in your chart
documenting how you plan on managing that? Have you
referred the patient for vascular testing, or
appointed them for testing in your office, or
referred them to a vascular specialist, or are you
managing this with Plavix or some other agent? Are
you monitoring their cholesterol (along with their
cardiologist and PCP) to see what impact reducing
their lipid profile can have on their vascularity?
Are you encouraging patients to modify their diet
and exercise to see what impact that may have on
their PAD? Is tobacco use an issue here and what
are you doing about this? And are you documenting
any of this?

There are a myriad of other issues to address and
manage with respect to other diabetic foot
pathologies. What about the 3 types of neuropathy
and any MSK findings resulting in increased peak
plantar pressure, etc. off loading, etc.

To echo Dr. Jacobs' words which I've heard him say
many times at lectures, there are so many things
you can and should be documenting about your
objective findings and managing those findings, and
which in simple English our colleagues are not!
Getting back to Dr. Jacobs' question is, do we
really need a separate CPT code for a CDFE?
The answer is yes, but only if this will get
Medicare and the other payers get off our backs
when using the -25 modifier when we correctly
perform a CDFE at the same time as at risk foot
care.

But even if we have a separate code, Medicare (and
other third party payers) might still audit the
CDFE, no matter what the code is, to be sure it is
properly documented, even if simply for objective
findings, which are separate from the need to
qualify the patient for at risk foot care.

To prove that a new code is needed, one needs to be
able to establish that the current CPT coding
structure doesn't adequately provide such coding.
I'm not so sure that is true. What I am more sure
of is that as Dr. Jacobs seems to be hinting at is
that our colleagues are simply missing the boat on
properly performing these exams. My additional
comment is that our colleagues are also failing to
manage patients and instead settling for chipping
and clipping toenails and calluses and moving onto
the next patient.

If you want to be treated like an RD (real doctor)
then act like one! Stop simply clipping and
chipping. Perform and document a proper
examination, not only documenting findings but also
their management. If your patient truly has
findings, it no longer is a screening examination.
As for LOPS, perhaps it needs to be reformatted for
patients who truly are being screened and have no
real foot issues. And if so, then the payment still
needs to be made commensurate with its real value.
For the most part, LOPS just doesn't work for
patients who see the DPM on a regular basis. E/M
coding may work, but it requires you to work as
well.

Paul Kesselman, DPM, Oceanside, NY

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08/03/2023    John V. Guiliana, DPM, MS

Comprehensive Evaluation of Diabetic Patients ( Allen Jacobs, DPM

Kudos to Dr. Jacobs, who always seems to have his
finger on the pulse of professional challenges. He
has again accurately identified a problem that
translates into needless infections,
hospitalizations, amputations, and death in our
diabetic population, estimated to cost
approximately $80 billion annually.

As a profession, we have become so preoccupied with
the worry of audits that many forget to look beyond
just the nail and callus care in this “at risk”
population. Attacking the $80 billion annual price
tag involves comprehensive chronic care management,
and paramount to our role in this initiative
involves maintaining skin integrity. Without skin
integrity, the unfortunate and costly “chain of
consequences” (fissure, ulceration, infection,
amputation, death) ensues. The root cause of
compromised skin integrity is frequently because of
skin dryness from neuropathic sudomotor
deficiencies, as well as pressure from poorly
fitted shoe gear.

Dr. Jacobs accurately pointed out that without the
medical necessity needed for appropriately being
compensated for an evaluation and management
service, we are financially limited to attending to
only the nail and callus care and ignoring the real
“elephant in the room.” This not only serves as a
grave injustice for patients with diabetes, but it
also has created a great deal of professional
fungibility for podiatry, as other
paraprofessionals have begun taking over those nail
and callus care tasks.

We don’t have to succumb to this challenge,
however! If my colleagues would change their
approach to how they view the at-risk foot care
visit for patients with diabetes, many ethical and
financial challenges can be resolved, particularly
when we are facing a healthcare system shifting
towards value-based care. We need to expand our
current philosophy on what constitutes “podiatric
vital signs” specifically for the diabetic foot to
extend beyond the measurement of height, weight,
blood pressure, etc.,and quickly, efficiently, and
quantitatively assess the diabetic foot for its
skin moisture index (SMI) and “hot spots.”

Very inexpensive tools and innovations are now
available to identify the medical necessity needed
for the additional chronic care management for our
patients with diabetes, as well as compensation for
our role in this critical lower extremity
amputation prevention (LEAP) initiative to prevent
the “chain of consequences” for many patients. I
encourage my colleagues to explore using DermaStat®
and IRStat® as part of their “LEAP Vitals” to
measure skin moisture index and hot spots,
respectively, in our patients with diabetes. It can
ultimately change our role in the healthcare
system, as well as have a very positive impact on
our practice’s economy.

John V. Guiliana, DPM, MS, Little Egg Harbor, NJ