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

There are no more messages in this thread.