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Falls are a BIG Problem; Become a Prevention Expert and Watch Your Practice Soar

Josh White, DPM, CPed

One out of three adults age 65 and older fall each year.  Falls are a silent killer that most podiatrists simply don’t think much about addressing.   Given the scale of the problem and the prevalence of risk factors, developing a specialty in fall prevention presents podiatrists with an opportunity that can significantly benefit their patients and their practice.

Conditions commonly seen by podiatrists and associated with increased risk for falling include:

  • Foot pain
  • Ankle weakness
  • Limited ankle motion
  • Postural instability
  • Loss of proprioception
  • Inappropriate shoe gear

Other risk factors podiatrists should be cognizant of include: dizziness, history of falls or near falls, peripheral neuropathy, impaired balance and drug interactions.  If any of these conditions are determined, a more comprehensive fall risk assessment is indicated.  See the sample podiatric fall risk evaluation form.

Balance and walking speed gradually decline with age.  This is attributable to decreased muscle mass and is exacerbated by reduced activity level. Weakening of the anterior tibialis muscle decreases the body’s ability to maintain balance and may affect the timing of toe clearance during the swing phase of gait.  Tripping can result from the toe catching on the floor.  Postural sway relates to the constant displacement and correction of the body’s center of gravity over it’s base of support.  Decreased muscle strength, particularly with decreased sensation can lead to increased postural sway and increase one’s risk for falling.

No assistive device is as effective at decreasing the likelihood of falls as a walker.  Patients though are often resistant to accepting such a device or a cane.  Unfortunately, the impetus to use a canes or walker often comes only after a fall occurs.   Ankle foot orthoses improve stability by reducing postural sway, increasing sensorimotor feedback and thus improving proprioception.   AFOs are only effective when worn and pose patient compliance issues relative to ease of use, impact on shoes that can be worn, comfort and appearance.  Fortunately, improved AFO designs fit more easily into shoes, are lightweight, offer ease of closure and still address risk factors that can contribute to increased risk for falling.

Medicare policy makes clear that patients documented to have orthopedic risk factors for falls are covered for custom AFO’s.  The Medicare LCD states that to be covered, an item must “be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”.  The Medicare Benefit Policy Manual states that appliances are covered when “used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”  If biomechanical examination determines any of the following diagnoses to be present, clinical indications demonstrating medical necessity are met:

  • Muscle weakness (728.87)
  • Ataxia, muscular incoordination (781.3)
  • Gait abnormality/ staggering, ataxic (781.2)
  • Osteoarthritis, localized primary ankle & foot (715.17)
  • Arthropathy, unspecified, ankle and foot (716.97)
  • Pain in joint, ankle, foot (719.47)
  • Instability of joint, ankle & foot (718.87)
  • Dropfoot (736.79)
  • Hemiplegia (438.20)

Fall prevention requires a comprehensive approach to care of which custom AFOs may be one component.  Based on podiatric fall risk assessment, the podiatrist should consider prescription of primary and ancillary services.  Such services and conditions that each may address include:

Physical / Occupational Therapy :

  • history of falls
  • sensory deficits
  • muscle weakness
  • poor balance

Primary Care:

  • vestibular abnormalities
  • medication interactions
  • history of seizures
  • history of hypotension

Home Health Care

  • difficulty leaving the home
  • Muscle weakness
  • hearing loss
  • vision loss

By providing appropriate intervention, podiatrists can assume a leading role in a multidisciplinary approach to care.

Summary

There are some basic steps that podiatrists can take to develop a fall prevention program:

  1. Create awareness within ones’s practice regarding the risk of falls and that the office is committed to offering appropriate preventative care.  Consider informational brochures and office posters.
  2. Speak to community groups about the role of intervention to reduce patient risk.
  3. Network with other physicians and specialists including physical therapists, occupational therapists and home healthcare workers to promote a team approach to care.
  4. Perform fall risk assessment and consider use of balance AFO if appropriate risk factors are determined.

There is no simple fall prevention strategy that will work for all patients.  As falls result from of a complex interaction of intrinsic and extrinsic risk factors, interventions require a multi-faceted approach. A strong fall prevention strategy that encompasses a number of interventions and targets multiple risk factors is more likely to be successful.

The Times of Our Lives

Being a supplier of Medicare Durable Medical Equipment entails a long list of ever changing deadlines and timeframes.  While it may seem difficult to keep track of them all, failure to keep abreast can easily result in claims denials and even exclusion from the program.  In order to help suppliers keep fitting and getting paid, the following are dates and timeframes that all should be familiar with.

  • January 1: Every patient eligible for new shoes if documented need for replacement
  • 3 months: Time allowed from when certifying physician signs certifying statement to when shoes must be fit.
  • 3 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 3 (history of ulceration, amputation)
  • 6 months: Amount of time condition requiring stabilization could justify utilization of custom made AFO.
  • 6 months:  Time prior to fitting shoes that patient needs to have been seen by the physician managing their diabetes
  • 6 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 2 (neuropathy present)
  • 1 year: Interval when Medicare DME supplier number will become inactivated if no DME if billed to Medicare. Reactivation required resubmission of supplier application.
  • 1 year: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 0 (No neuropathy, protective sensation intact)
  • 3 years: Interval when Medicare DME suppliers must have supplier information revalidated. Registration every three years requires payment of $505 payment and may entail visit from inspector.
  • 3 -5 years: Amount of time custom made durable medical equipment is expected to last unless there is change in patient’s condition such that there is justified new reason of “medical necessity”
  • 2030: Time by which Medicare population is expected to double versus 2000 levels*

*MedPAC Report to Congress: Promoting Greater Efficiency in Medicare, June 2007. Washington DC: Medicare Payment Advisory Commission, June 2007.

Medicare Rules for Fitting Shoes are Clear. Use WorryFree DME to Conveniently Ensure Compliance

In 2011, many podiatrists were audited by Medicare and had to refund money because rules had changed and many were not aware of the documentation required to fit diabetic shoes.

As one famous retailer once said, “An educated consumer is our best customer”. In that spirit I have acquired one of the world’s largest collections of audit letters relating to the Medicare therapeutic shoe program. Examples are displayed in the “Library” section on the SafeStep website, accessible only after logging in.

When podiatrists have failed shoe audits, the vast majority of times it has been for :

  • Failure to demonstrate that the primary care physician has documented a qualifying foot condition and has had an in-person visit with the patient during which diabetes management is addressed within 6 months prior to the patient receiving shoes.

Even when podiatrists have figured out what they need to do to be complaint, the effort required to fill out the necessary forms and the time required to repeatedly fax these forms to the primary care physician and to be assured that the patient had a visit in the proceeding 6 months is so onerous that it might hardly seem worth the effort.

Guess what? There is a convenient way to assure Medicare compliance when fitting shoes and it’s called, “WorryFree DME”.

Here are the steps:

  1. Identify patients with Medicare and diabetes.
  2. Evaluate patients and determine qualifying conditions for therapeutic shoes.
  3. Select appropriate footwear.
  4. Fill out SafeStep information collection form.
  5. Enter required information into SafeStep website.

You are done! SafeStep takes over!

  • SafeStep creates the Statement of Certifying Physician for Therapeutic Shoes.
  • SafeStep creates the documentation required to be in the patient’s file of the primary care physician.
  • SafeStep assures that patient was seen by primary care physician not more than 6 months prior to being fit with shoes.
  • SafeStep faxes the forms, as though from the podiatrist for up to 3 weeks to get required signatures and dates.

Without any more work on your part:

  • SafeStep sends you the signed and dated documents.
  • SafeStep ships you the shoes.

Don’t let fear of Medicare audits nor the effort required to be compliant stop you from providing important care to your patients and creating revenue for your practice.

Use WorryFree DME to fit your patients conveniently and compliantly.

To learn more, go to SafeStep.net and register for a free 45 minute webinar on how to get started.

Early Testing For Foot Orthoses Could Prove Beneficial to the Elderly

Research studies carried out among the elderly through the years have shown significantly more falls resulting in serious injuries, due to problems with balance.  Implementing balance testing and providing foot orthoses’s for elderly patients could prove to potentially decrease the amount of falls and injuries associative with them.

With the inclusion of specific balance testing such as the ‘tandem stance test,’ and the ‘tandem gait test’ specialists in orthopedic care can provide a better means of assisting their elderly patients with improving balance, thus minimizing serious bodily injury from falls.   Dr. Michael T. Gross said that, “clinicians should consider asking older patients about their balance, and have them perform simple one leg balance tests.”  This alone will help in determining specific balance problems, and earlier evaluations for the possible need of foot otrhoses’s, which could prevent accidental falls before they happen.  The varied participant studies have proven that foot orthoses’s which are designed for each individual patient’s needs work to improve their own balance defects.

While the studies have been small thus far, and the results “preliminary,” Dr. Gross says that, “It’s important to note that we examined and addressed individual foot issues.”  Therefore, these basic tests are detrimental in patient care, because they allow for individual structural differences in gait and balance for each patient’s orthoses design.  Not every patient needs corrective features, or something like arch support, and these basic tests can help determine what will provide the most improvement for each and every patient orthopedic specialists have come in.

To read the full article you can access it here:  http://www.lowerextremityreview.com/news/in-the-moment-footcare/enhancing-balance