10/23/2024    Paul Kesselman, DPM

APMA Should Promote Annual Comprehensive Diabetes Prevention Foot Examination for At-risk Patient (Doran Edwards, MD)

APMA Should Promote Annual Comprehensive Diabetes
Prevention Foot Examination for At-risk Patient
(Doran Edwards, MD)

I must admit that those promoting this are either
a mentor and friend of the last twenty years
(Doran Edwards MD) or Lawrence Rubin DPM, a long
time mentor, friend and former teacher of mine at
ICPM in the late 70's and 80's. So it pains me to
have to offer some criticism of each of their
posts. And I will have attempted to speak with or
have already spoken with both of them prior to
this post being printed.

For one, Dr. Edwards and I have worked together
numerous times to improve the therapeutic shoe
bill, met with DME MAC medical directors and CMS
to improve the accessibility to beneficiaries by
removing some of the obstacles. Dr. Edwards, who
many consider one of the founding fathers of the
Therapeutic Shoe bill, with me addressed the
NYSPMA Clinical Conference many years ago during a
two hour session on this very subject.

However, Dr. Edwards, while 100% correct on the
use of E/M exams when a patient's diagnosis or
conditions changes, failed to address the essence
of what Dr Rubin and others advocate. That is the
screening exam, even when nothing is seemingly
untoward, should be a covered mandated service
under Medicare. As of now, that is not the
case.What many including Dr Rubin and myself
advocate for is for an annual foot exam, as
exists for annual ophthalmology, gyn exams and
screening mammograms and colonoscopies (although
the latter not annual).

Some might say that LOPS is the answer to the
screening exam. But LOPS does not go far enough
and it is only limited to those patients who have
not had a foot related issue in the past 6 months,
and further only to those with neurological
defects. This proves why its utilization is so
poor and it is so ineffectual. By the time a
patient qualifies for LOPS, the horse has has left
the barn with the barn on fire.

Let me also make this perfectly clear that despite
what some may think, a comprehensive diabetic foot
examination is a term which to this point in time
has not been copyrighted, just as there is no
copyright of a comprehensive diabetic eye
examination . My recent conversation with Dr.
Edwards confirms these thoughts.

I want to emphasize that there is not a 100%
consensus on what should be in a CDFE in terms or
the order or how it is documented. Some may want
to include a hand held doppler, some skin
perfusion testing. or a quick sensometer test.
Others may simply palpate pulses or use a tuning
fork or monofilament. Some may wish to incorporate
pressure mat type testing or thermography of one
sort or another.

All of course should include a musculoskeletal and
derm survey of some sort.
All of these are great suggestions, but to suggest
that there is only one way to do this exam is just
as wrong as stipulating that
there is only one way to document an E/M.

As for Dr. Rubin's comments, suggesting that PCM
is theoretically the answer around this, I would
suggest otherwise. From a practical perspective
that unfortunately is not the case. The Local MACs
have a code taxonomy edit not permitting
reimbursement for PCM when performed by DPMs.

The overall issue here is that patients should be
able to have the ability to receive an annual
screening exam for foot disease. This should not
be limited to diabetic patients, but for all
patients, as there are many undiagnosed diabetic
patients who deserve our attention.

We as a profession should be reporting on
patients' pulses and neuromuscular status on every
exam. Especially for those patients who are
"Simply" coming in for, and I hate this turn,
"routine"foot care. These are the very patients
who have many ingredients of the issues which
directly need to be addressed (some more urgently
than others).

There is no such thing as routine and I would
suggest that these are the very patients who
should have their pulses and neuro musc and derm
systems checked at every visit. I dare say that to
not to do would be malpractice. That is likely
what Dr Edwards was referring to, but this is not
an annual screening exam per se.

The recent PM News poll which he drew to my
attention, suggests this is rarely done on routine
foot care patients and I agreed with him that this
is a shocking revelation and I am very dismayed by
this.

If we as a profession want to represent the need
for at least an annual screening exam, then we
need to stand by what we say and document
everything as Dr/ Edwards says we see, feel and
smell during our exams.

By the time many of our patients are diabetic it
is too late to prevent the complications.
Screening exams are just that to screen patients
for a disease before it gets underway. Annual eye
exams are covered not based on the patient being
diabetic, but on being eligible based on age. Same
should be true for podiatric patients. It should
be a CFE (Comprehensive Foot Exam).

Paul Kesselman, DPM, Oceanside, NY

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