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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
Other messages in this thread:
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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