08/03/2023    Eddie Davis, DPM

Increased Scope of Practice for Podiatrists

Podiatric medicine scope of practice relates to
the specific area of the body we treat akin to
dentists. We achieve some latitude with respect to
use of terms like "foot and related structures."

I understand the frustration of those who see too
few podiatrists supporting state and national
organizations but one must ask why that is so.
Members need perceive that such organizations are
acting in their best interest in order to be
motivated to belong. I have been an APMA and state
member since 1982 but often ask myself why.
Answers like, "that is the only organization we
have" just aren’t sufficiently compelling.

If I have an issue of concern, I can get more and
better answers from colleagues than calling our
official organizations most of the time. Major
issues such as those with respect to reimbursement,
reimbursement parity just are not adequately
addressed by our organizations in my opinion. Our
organizations need survey members to see what their
main concerns are. Our organizations need to speak
to non-members to see what their concerns are and
why they are not members - most importantly. I
often encounter anger from organization leaders
when I mention the latter. The non-members are not
slackers nor ingrates and need to be listened to.

Years ago, a bill was introduced into the
Washington State legislature, at the request of a
podiatrist who was a non-member of the state
organization. The bill granted DPMs the licensure
to act as physicians assistants. It was met by
opposition from the state association and did not
become law. The basis of the opposition was a
perceived "lowering" of our status as independent
practitioners. It was not brought up for
discussion among members. Certainly, our training
far exceeds that of mid-level practitioners so why
not be comprehensive doctors of the foot and ankle
while being able to treat the rest of the body
under MD supervision? It could have been a
stepping stone to better employment opportunities
and further scope advancement. Sometimes the best
strategy is not a full frontal assault but a
flanking maneuver.

Eddie Davis, DPM, San Antonio, TX

Other messages in this thread:

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08/18/2023    Ed Prikaszczikow, DPM

Increased Scope of Practice for Podiatrists (Paul Kesselman, DPM)

Thank you to Dr. Kesselman for his explanation of
the many ways APMA is fighting for equitable
reimbursement for its members in response to Dr.
Davis’ concerns. As a final clarification, I would
also like to point out that in 2018, APMA led a
national coalition to help avoid what would have
been a roughly 30-percent reduction in code values
solely for podiatrists. APMA met with employees at
the Department of Health and Human Services to
discuss the proposal to eliminate our ability to
bill for E/M services (which would have been
replaced with lower-paying G codes for
podiatrists). We were victorious in that effort,
and the result is that podiatrists nationwide have
earned hundreds of millions of dollars over the
past five years that otherwise would have been
lost. These earnings alone offset the cost of
member dues.

In response to Dr. Davis’ concerns about the
Medicare Orthotics and Prosthetics Patient-
Centered Care Act, APMA has been a supporter of
this bill and its predecessor. APMA originally
became aware of the bill in 2022 thanks to Dr.
Kesselman, chair of the APMA DME Work Group. The
APMA Legislative Committee reviewed the bill and
determined it would have a positive impact on
podiatry and our patients, so we would make it a
priority bill for APMA to support and push for
passage. Sadly, the congressional session ended
before the bill received a vote; however, the bill
sponsor just recently reintroduced the legislation
with some minor enhancements. APMA’s Legislative
Committee has reviewed the updated text of the
bill and again determined that it should receive
APMA’s support. APMA members can review the list
of bills supported by APMA by visiting
www.apma.org/FederalAdvocacy. This list is updated
monthly, so be sure to check for updates!

Ed Prikaszczikow, DPM, Chair, APMA Health Policy &
Practice Committee

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08/15/2023    Eddie Davis, DPM

Increased Scope of Practice for Podiatrists (Lawrence Rubin, DPM)

Dr. Rubin asked me to suggest means by which APMA
can improve it’s overall value. Dr. Rosenblatt
opined that APMA has done as well, if not better
than AMA and “their specialty Boards.”

AMA does not have a large membership base. AMA
financial support is largely derived from
publishing revenues and database sales:
https://www.citizen.org/wp-
content/uploads/hl_201211.pdf About 15 to 18
percent of MDs belong to the AMA:
https://www.physiciansweekly.com/is-the-ama-really-
the-voice-of-physicians-in-the-
us/#:':text=In%20fact%2C%20it%20is%20estimated,for%
20the%20views%20of%20doctors.

I believe that Dr. Rosenblatt was thinking about
specialty organizations because that is where MD
membership is high. The MD specialty organizations
such as the American Orthopedic Association (AOA),
American Academy of Orthopedic Surgeons (AAOS),
American College of Radiology (ACR), American
Academy of Dermatology (AAD) as well as the other
specialty organizations are strong advocates for
the their members and generally enjoy excellent
membership.

I don’t need to remind our colleagues about the
role of the AOA with respect to podiatry hospital
privileges, reimbursement issues. The ACR noted
the advances in diagnostic ultrasound equipment
over the last two decades, initially bemoaned
inadequate reimbursement rates only to later
express concern that increased adoption of
ultrasound was a threat to MRI utilization. That
led to ACR seemingly opposing podiatric utilization
and a reduction of reimbursement. APMA failed to
“fight the good fight” on this issue. APMA also
failed to inform members about this issue, to the
best of my knowledge. Diagnostic ultrasound
reimbursements were cut significantly and, within
one year after that occurred, the exhibitors of
ultrasound equipment at our conventions and
meetings seemingly vanished.

Podiatrists discuss the issues of routine foot care
ad nauseum while the dermatologists use codes such
as the 113xx series, biopsies with seeming
alacrity, supported by their specialty
organization. I am not trying to open a discussion
on this issue, nor pass judgement on the veracity
of how they are billing, just making a point with
respect to how professional specialty organizations
support the ability of their members to be
reimbursed.

The ENT organization lobbied to obtain increased
reimbursement of office-based balloon sinuplasty.
Endovascular specialists lobbied to obtain
favorable reimbursement for office based
procedures, office based labs. The list of such
efforts is long. Podiatry has its roots in office
based treatment. What has APMA done to secure fair
reimbursement for procedures that we perform in the
office?

The ability to be paid fairly for one’s services is
fundamental to our success. We are generally paid
less than orthopedic surgeons for the same CPT
codes by private insurers. What has APMA done to
secure parity in reimbursement?

Beyond reimbursement rates, consider issues of
utilization of services. One example is the
provisioning of ankle foot orthotics by DPMs.
Doug Richie DPM educated our profession on AFOs and
provided AFO designs that were, in many cases,
superior to those which patients could obtain from
O&P shops.

Unfortunately, misinterpretation of the “same and
similar” rule by DMERC carriers has restricted our
ability to provide this essential service. I have
expressed my concerns about this issue to APMA and
our state organization to no beneficial effect.
Fortunately, the O&P industry has supported a bill
introduced to the House, the Medicare O&P Patient-
Centered Care Act (H.R. 4315) was introduced on
Friday, June 23.

The American Orthotic & Prosthetic Association has
a description of the bill on it’s Federal Advocacy
page: https://www.aopanet.org/legislative-
regulatory/aopa-advocacy-on-behalf-of-you/ I
became a bit frustrated with the lack of
information from APMA on it’s perspective and
perspective support of this legislation and emailed
Scott Haag at APMA Legislative Affairs on July 11.
I have not received a response from him to date.

Another area that affects podiatry with respect to
the ability to be reimbursed is the National
Correct Coding Initiative (NCCI). NCCI creates
policy that bundles charges that it maintains
should not be billed separately. Like all
organizations or entities, this entity is subject
to lobbying by provider groups. NCCI often bundles
services inappropriately and we need to know the
role of APMA with respect to addressing such
issues. A good example are total contact casts. A
patient with a diabetic ulcer requires wound care
and offloading simultaneously.

Failure to off-load a diabetic ulcer is a violation
of the standard of care yet NCCI disallows
application of the total contact cast when wound
debridement is performed at the same visit. So are
we to give the patient a set of crutches and tell
them to come back to the office on a subsequent
visit just to get reimbursed? We could provide a
CAM walking boot instead but that is noncovered for
treatment of off-loading a diabetic ulcer. What is
APMA doing to fix this and other NCCI issues? What
is it doing to allow podiatrists to be fairly
reimbursed for offloading diabetic ulcers?

Eddie Davis, DPM, San Antonio, TX