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12/29/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE)
From: Benjamin W. Weaver, DPM
Dr. Jacobs makes an important point that’s worth reinforcing from an E/M and compliance perspective. During at-risk foot care, when tools like Arche LEAP Vitals are used to evaluate sudomotor function and often elusive points of irritation (“hot spots”), a podiatrist is not simply performing routine nail or skin care. They are truly engaging in comprehensive care that leads to a significant reduction in diabetic wounds and amputations.
Using the Arche LEAP Vitals tools and identifying sudomotor neuropathy as the underlying cause of dry, xerotic skin represents a meaningful clinical assessment with direct implications for risk stratification, patient education, and management in patients with diabetes. Dry xerotic skin related to autonomic neuropathy significantly increases the risk of fissures, infection, and ulceration. Evaluating this condition, interpreting objective findings from LEAP Vitals, discussing risk, and initiating or adjusting a care plan constitutes a medically necessary, separately identifiable Evaluation and Management service. When properly documented, this clearly supports reporting an E/M service (with appropriate modifier use) in addition to at-risk foot care, reflecting the full scope of cognitive work performed during the visit.
I have been using the Arche LEAP Vitals protocol in my practice for quite some time, and it has demonstrated significant results for my patients. Disclosure: I have no financial relationship with Arche Healthcare.
Benjamin W. Weaver, DPM, Wichita, KS
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12/30/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE)
from: Allen M. Jacobs, DPM
A very common example of the pathology in the diabetic patient requiring evaluation and treatment of a podiatric healthcare provider is that of neuropathy. We are all aware of the fact that neuropathy and ulceration associated with neuropathy are responsible for up to 80% of overall amputations. The most significant manifestations of neuropathy are the result of non-painful neuropathy, such as Charcot's joint disease, ulceration, and infection. Painful neuropathy is associated with decreased quality of life.
With reference to non-painful neuropathy, it has been my experience that unless a patient has profound sensory deficit of which the patient is aware, or has a frank sensory ataxia, many patients are not aware that indeed neuropathy is affecting them. With reference to painful neuropathy, there are many standard protocols which can be followed utilizing various...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
12/18/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE) -PART 1B
From: Allen M. Jacobs, DPM
The "direct pay" or "concierge" practice models are certainly an option for a select number of podiatric healthcare providers whose patients have the capability of paying for healthcare directly. Unfortunately, the majority of Americans cannot afford the "direct pay" model of healthcare.
I would remind Dr. Roth and others who advocate the direct pay model that many of our patients struggle just to pay for their cardiac or diabetic or cancer or other needed medications or therapies. We have an increasingly large geriatric population (that is correct before you say it, people such as myself) who are on a fixed income and struggles to maintain a date to the existence for basic food and housing. Yes, there is a sub-population of well-heeled individuals who can afford to pay directly for medical care, and there is certainly nothing unethical or illegal to care for such patients and receive direct pay. However, what do we do for the majority of...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
12/18/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE) -PART 1A
From: Joseph Borreggine, DPM
This discussion centers on a single diagnosis that is significantly under-utilized within the field of podiatry. While there are other conditions that can be “evaluated, managed, and treated,” the LCD for routine foot care has unfortunately limited many podiatrists to believing that is the sole service they can bill for and utilize.
As Dr. Jacobs states, regrettably, many lecturers who are considered “experts” on this subject derive their income from this practice and speak from authority despite their limited practical experience or lack of clinical care. In their lectures, these experts assert that all routine foot care codes include the E/M component within their RVU for those specific codes. While this may be true, it does not imply that the diagnosis of an acute or chronic condition should be disregarded solely to avoid audits. This attitude is unfortunate and should be addressed at all costs.
As podiatric physicians, we encounter complex patients daily who require specialist evaluation, management, and treatment. Therefore, it is imperative to engage with the patient, conduct a thorough examination, and provide appropriate treatment based on our podiatric knowledge and experience. Minimizing this attitude by simply trimming nails and calluses, either through the typical foot doctor mentality or delegating it to medical assistants, is neither prudent nor efficient. The potential revenue lost due to clinician fear, ignorance, or the desire to see as many patients as possible on a daily basis is unfortunate. Furthermore, to avoid the need to use routine foot care codes entirely, some podiatrists may resort to billing the E/M code to encompass all the care they provide to a patient. This practice is also unfortunate, unwarranted, and constitutes a misrepresentation of the actual situation.
Joseph Borreggine, DPM, Fort Myers, FL
12/17/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE) -PART 1B
From: Ivar Roth, DPM, MPH
Dr. Jacobs makes some good points, but the answer is much simpler and is staring us in the face in my opinion. While we have obligations as a provider, if the insurance provider informs the patient properly, meaning presenting them with a well written explanation and informed consent for them to sign, we have done our job. In the end, it is up to the patient to work within their insurance and decide the path forward for them. The simple solution is that they will have to pay you out of their pocket for your services they require. The machinations discussed are very complex and this solution, I believe, solves and absolves the provider from this dilemma.
As a concierge direct pay provider, I no longer have to jump through any hoops and the patients leave happy and satisfied with paying a reasonable fee for the required services.
Ivar Roth, DPM, MPH, Newport Beach, CA
12/17/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE) -PART 1A
RE: -25 Modifier and RFC And Diabetes
From: Allen M. Jacobs, DPM
Regarding the use of the -25 modifier in order to allow maximal and to optimize care of the diabetic patient, particularly the older patient, we must recall that there is true fraud, "honest fraud", and creative billing or billing "gamesmanship". True fraud, in my opinion, is a conscious/willful effort to deceive a third-party such as Medicare in order to receive payment. I suspect that many of our colleagues are accused of fraud and abuse, when in fact they are guilty of "honest fraud", meaning that they provided needed and legitimate services but failed to meet documentation or other requirements.
Many of the billing and coding seminars, in my opinion, fail to provide the necessary detailed documentation required to satisfy the E/M office visit, together with the provision of so-called "surgical services", meaning needed skin and nail care. Speakers at these meetings emphasize the definition of the -25 modifier, but quite frankly are individuals who make their living lecturing, and some have never been in...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
12/16/2025
RESPONSES/COMMENTS (ROUTINE FOOT CARE)
From: John V. Guiliana, DPM, MS, Joseph Borreggine, DPM
Every podiatrist should read Dr. Jacobs' post SEVERAL times.
John V. Guiliana, DPM, MS, Fort Myers, FL
I wholeheartedly concur with Dr. Jacobs’ perspective on the appropriate course of action for podiatric physicians. His response has effectively defined our profession. If a podiatric physician solely bills for routine foot care without providing comprehensive evaluation and management, they should be regarded as mere nail technicians. The apprehension regarding the use of evaluation and management (E/M) codes with the -25 modifier due to potential OIG audits stems from inadequate documentation. Proper documentation is essential to qualify for these codes.
Recent changes were implemented a few years ago to establish new categories and guidelines for billing medical decision-making and time spent in the E/M code arena. If you have not reviewed the updated documentation requirements, I recommend consulting the relevant resources and utilizing them to your advantage. This will enable you to effectively practice as a podiatric physician.
The abuse of E/M codes has been identified through random audits that focused on poor or non-existent documentation. While this constitutes fraud, it is important to note that if you have thoroughly examined a patient, documented all necessary findings, and provided appropriate care, you are not engaging in fraudulent activity. Your actions benefit both the patient and the podiatric profession.
Joseph Borreggine, DPM, Ft. Myers, FL
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