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

Other messages in this thread:

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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