12/30/2025 Allen M. Jacobs, DPM
RE: -25 Modifier , RFC and Diabetes (Benjamin W. Weaver, 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 is responsible for up to 80% overall
amputations. The most significant manifestations
of neuropathy are the result of nonpainful
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 adjunctive
analgesics. This might include antiseizure
medications, or antidepressants. In addition,
there are many supplement therapies which have
been demonstrated as effective in the treatment of
symptomatic diabetic neuropathy.
Examples would include alpha lipoic acid,
correction of vitamin D deficiency,
supplementation with vitamin B complex, and a
variety of other therapies. Furthermore, a
substantial number of patients with symptomatic
diabetic neuropathy also suffer from "double crush
syndrome". And may in fact have moderate
peripheral neuropathy of metabolic etiology but
also may have a compression neuropathy such as
tarsal tunnel, spinal stenosis, soleal sling
syndrome, common peroneal compression syndrome,
anterior tarsal tunnel, piriformis syndrome, or
some combination of pathologies affecting the
peripheral nerves.
The presence of "double crush syndrome" may very
well explain the partial response to seemingly
appropriate pharmacologic therapies. The
evaluation of patients for these etiologies
requires time and effort including a proper
history and physical examination. This is
typically not performed by the primary care
physician, endocrinologist, or others caring for
the diabetic patient even though they may be
actively treating the Neuropathy. Furthermore,
there are many complementary therapy modalities
which may benefit some patients with painful
neuropathy either alone or in combination.
I suggest that the podiatric healthcare provider
is in the best position to evaluate and manage
these patients. This includes increased use of
diagnostic studies such as electrophysiologic
nerve testing.
Although the treatment of painful diabetic
neuropathy improves the quality of life of our
patients, it is nonpainful neuropathy that
frequently results in loss of limb from infected
ulceration or complications of Charcot's joint
disease. Not infrequently this is complicated by
the presence of peripheral arterial disease or
venous disorders.
While it is true that some patients present with a
concern that "I have numbness in my feet" many
people particularly in early-stage neuropathy are
unaware that they suffer from progressive sensory
deficit. Again, likely no to PM readers, multiple
studies have demonstrated that the neuropathy
associated with diabetes precedes the actual
diagnosis of diabetes for many years.
Furthermore, we know there is a neuropathy
associated with glucose intolerance/prediabetes.
The detection of early sensory and motor and
autonomic neuropathy requires time and effort and
a proper history and physical examination. This
includes Ipswich testing, 10 g filament testing,
vibratory perception, temperature perception
testing, provocative testing for the evaluation of
entrapment neuropathy.
Manifestations of autonomic neuropathy may include
edema, sudomotor deficit with dry skin, vascular
calcification, paresthesia or dysesthesia. Motor
neuropathy has been shown to be present in 50% of
patients with established diabetic neuropathy, and
is present in one of her patients at the time that
you are diagnosed with diabetes. This requires
observation, manual muscle testing, reflex
evaluation, evaluation of tone and power.
Sensory and motor neuropathy may be superimposed
on other problems which occur with aging such as
sarcopenia. This may predispose patients to the
risk of gait instability and falls. A get up and
go test as well as other gait evaluation may be
indicated in many patients. Again, this requires
time and effort and history and examination.
Many patients with asymptomatic early neuropathy
are shocked to find out that indeed they have
early manifestations of neuropathy. Again,
metabolic considerations, the presence of
entrapment neuropathies, or the presence of
"double crush syndrome" may contribute to the
progression of the neuropathy.
Under very limited circumstances, epidermal nerve
fiber density testing may be utilized. However,
it has been demonstrated that in almost 90% of
cases neuropathy may be diagnosed with a proper
history and physical examination without the need
for advanced neurologic testing. Furthermore,
electrodiagnostic testing is far more useful in
many patients as it would not be reflective of
sensory and motor findings and also in many
circumstances of work the podiatric healthcare
provider to the presence of multilevel disease
such as "double crush syndrome".
The utilization of epidermal nerve fiber density
testing is indicated only when there are signs and
symptoms of neuropathy, the patient is an "at risk
patient with a disorder known to be associated
with neuropathy", and patient has
electrodiagnostic studies which are negative
indicating that there is no evidence of large
fiber deficit. There is more to the diagnosis of
diabetic neuropathy than performing an epidermal
nerve fiber density testing which has been
largely, in my opinion, over-sold to the
profession by laboratory marketing.
All of these efforts are to provide the diabetic
patient with maximal care and lower the risk of
limb loss secondary to ulceration, or to provide
increased quality of life such as decreased
paresthesia or dysesthesia or the restoration of a
restful and restorative night sleep. All of these
efforts, when provided together with "at risk
footcare", should be recognized with appropriate
ICD–10 codes and an appropriate level of E/M with
the 25 modifier.
In many circumstances, combination therapies are
required for the treatment of asymptomatic or
symptomatic neuropathy. Many effective supplement
therapies, as mentioned earlier, may be utilized
and dispensed by the podiatric healthcare
provider. This has not only resulted in patient
benefit but provides increased office income.
Nutraceutical and topical therapies are available
which are effective. They may be effective as
isolated therapies or combined with more
traditional pharmacologic agents such as
antidepressants or antiseizure medications in
patients with symptomatic neuropathy.
Allen M. Jacobs, DPM, St. Louis, MO
