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Keys for Success: Fall Risk Prevention … It’s a Best Practice!

The SafeStep Keys for Success that you’ll see here are based on real examples from podiatrists and can dramatically improve your practice.

October Key for Success: Set Up a Fall Risk Prevention Program

On an annual basis, it is important to ask every patient 65 years of age and older, if they have fallen in past year. This is a baseline for a fall-risk assessment and is a precautionary measure to help more patients.

If patients have not fallen or have fallen once without injury, consider them to be NOT at high risk for falls.

If patients have fallen once and been injured or two or more times without injury, consider them to BE at high risk for falls and use SafeStep’s “Functional Fall Risk Assessment Tool” to determine the basis for increased risk.

If fall risk assessment determines the increased risk to be orthopedic in origin, perform a “Biomechanical Evaluation” to determine the specific etiology and guide a plan of care. Such a plan might include:

  • Offering assistive devices including canes and walkers for those at risk.
  • Providing patients guidance about footwear options that will enhance stability.
  • Consideration of foot orthoses that can decrease foot pain and improve support.
  • Providing physical/occupational therapy options.
  • When appropriate, casting for bilateral Moore Balance Braces.
  • Its appropriate to bill an EM charge when fall risk is determined and a plan of care provided.

In order to learn more about how to get started:

1.     Read articles in library section of SafeStep website.

2.     Register at SafeStep.net for the training webinar: “Fall Risk Management with Moore Balance”.

3.     Call for SafeStep at 866.712.STEP for patient information brochures, order forms, free mailing labels and STS casting kit.

4.     Review the semi-weightbearing casting technique. Video located in AZ AFO section of SafeStep website, Library section.

5.     The SafeStep website features all Medicare required compliance documentation.

AFO Height Requirement Removed: Here’s the Latest on How to Appropriately Bill Prefabricated and Custom Fabricated Devices

The Medicare height requirement for AFOs that became effective January 1, 2013 has been removed.  Billing of prefabricated and custom gauntlets and AFOs remains, as it was, last year.

Some AFOs were unaffected by the January 1 change, some devices were affected but are now not impacted and other AFOs are still subject by earlier policy changes.

The following is a summary of where things stand in February 2013.  DPMs are reminded to include in their documentation the rationale for prescribing the specific device to be supplied/dispensed.  As always, the final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

 

L1902, “AFO ankle gauntlet, prefabricated”

Not required to have PDAC verification nor need extend as high as to near the fibular head.
The 2013 fee schedule ranges, depending on the state, from $69 to $92.

Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport

 

L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, are the only AFO required to have, active PDAC verification and are defined to have “a hinged ankle and a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation.”.

The 2013 fee schedule ranges, depending on the state, from $104 to $241.

Examples of such devices with active PDAC verification include:

Darco Body Armor Vario
Medspec EVO Hinge
Swede-O Arch Lok, Atom, Dorsi-Assist
United Surgical Trailblazer Hinged Ankle
Ossur Rebound

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that have design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change.  The above list is as of 2/7/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:

https://www.dmepdac.com/dmecsapp/do/productsearch

 

L1907, “AFO supramalleolar, with straps”

PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512 to $564.

 

L1930, “AFO plastic or other material, prefabricated”

No longer required to extend as high as the just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices, depending on the state, range from $170 to $326.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur
Ossur
FLA
AFO Light
AFO Leaf Spring
Foot Drop Splint

 

L1951, “AFO, spiral plastic or other material, prefabricated”

No longer required to extend to just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765 to $841.

Example recommended by the manufacturer and by SafeStep to be billed as such:

Eurointernational             Perosupport (formerly Peromax)

 

L1971, “AFO with ankle joint, prefabricated”

PDAC verification is not required. No longer required to extend to just below the fibular head.
The 2013 fee schedule ranges, depending on the state, ranges from $427 to $469.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Rebound
DJO Velocity
Swede-O SureStep
Bledsoe Axiom

 

L2340, “pre-tibial shell, molded to patient model”

According to the January 2013 Policy Article, “a pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.”

PDAC verification not required.
The 2013 fee schedule, depending on the state, ranges from $390 to $582.

 

L4350, “ankle control orthosis, stirrup style, rigid”

PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78 to $147.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Formfit, Airform Universal
Aircast Airlift PTTD, Airsport, Air Stirrup
SafeStep  DME Air Stirrup, Foam Stirrup
Swede-O Versi-Splint

 

L4361, “AFO walking boot type, varus / valgus correction (CROW)”

Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400 to $1931.

 

L4386, “Walking boot, non-pneumatic”

Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144 to $158.

 

L4396, “static or dynamic AFO including soft interface, adjustable for fit, for positioning, minimal ambulation, prefabricated”

(Plantar fascia night splints)
Must as of 1/1/10 have adjustability. Many dorsal night splints commonly billed using this code lack “adjustably for fit” and so do not qualify for Medicare reimbursement. This item is an exception in that while others AFOs need be for ambulation, L4396 needs not when used for treatment of plantar fasciitis (728.71) or as part of a treatment plan for plantar flexion contracture of 10 degrees or greater (718.47).

The 2013 fee schedule ranges, depending on the state, from $150 to $183.

 

Arizona-type AFO / Moore Balance Brace

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets. According to PDAC, Arizona Short and Arizona Tall, or similar custom fabricated braces (including the Moore Balance Brace), only the following codes should be used:

  • L1940 Ankle foot orthosis, plastic or other material, custom fabricated
  • L2330 Addition to lower extremity, lacer or Velcro closure, molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
  • The 2013 fee schedule ranges, depending on the state, from $850 to $1389.
  • For the Arizona Extended and the Arizona Unweighting or similar custom fabricated braces, only the following codes should be used:
  • L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
  • L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section

The 2013 fee schedule ranges, depending on the state, from $902 to $1484.

 

Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are no longer required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.

The 2013 fee schedule for such devices ranges, depending on the state, from $621 to $929.

 

SafeStep presents a free live webinar on DME Treatment Protocols that includes all the latest coding and compliance issues.  To see the schedule and to register, CLICK HERE.

Your comments are welcome and appreciated. Updates relating to this and other coding, billing and compliance issues will be posted on the SafeStep blog, www.safestepblog.net.

 

Josh White, DPM, CPed

Joshwhite@safestep.net

 

A Case for Integrating Pedorthists into Podiatric Practices

Podiatrists have traditionally provided referrals to their patients who need therapeutic footwear. However, the opportunity to increase practice revenue, patient desire for “one-stop shopping,” and growing awareness of the Medicare Therapeutic Shoe Program have resulted in podiatrists increasingly making shoe fitting a part of their practices. As podiatrists become more efficient and skilled at fitting shoes and recognize how much they can benefit their patients while improving their bottom line, this trend is expected to continue.

Podiatrists can work most efficiently by creating “practice protocols” whereby commonly seen conditions are directed to and addressed in a routine way by trained office staff. Such an approach lends itself well to fitting patients who have diabetes and are at risk for ulceration with therapeutic footwear. Even before these patients meet with the podiatrist, offices can identify them and provide them with a brochure or information packet that details the role footwear can play in reducing their risk.

Continue Reading…

How To Integrate DME Into Treatment Protocols – Part 7

Secrets To Effective Inventory Management Of DME

Busy podiatry practices must make efficient use of the office space available in order to manage DME inventory.

Select products that offer an opportunity to be used for multiple conditions. Depending on the frequency of need and space allowance, consider products that one can use on the left and right foot, and that require fewer sizes. For less common conditions, establish a protocol for items to be used and the vendor that will provide the products.

The goal of maintaining inventory is to have on hand those items that are part of the treatment protocols, in sufficient quantity and sizes, given the physical confines of the available space. The practice should maintain a certain minimum quantity of products on hand, taking into consideration the rate at which they are used and the time for delivery. If the practice consistently runs out of products before the designated reorder time, increase the minimum quantity.

The medical assistants and physician should periodically review how well the devices are working, how much patients like them and what they can do to improve application. Consider new products, different products as recommended by others and products presented at conferences.

It is essential to designate a person in the practice who is responsible for organizing storage areas and determining maximum and minimum quantities for all products in all sizes.

Create a designated frequency and day when the ordering person checks inventory and orders as appropriate. The practice manager should periodically review quantities of products in stock and prices paid. Ordering can be easier via the use of customized screens on the given distributor’s website. Distributors can also help practitioners to order in a timely fashion by sending customized order forms that indicate the quantity of products to keep on hand and the price paid.

How To Integrate DME Into Treatment Protocols – Part 6

Pertinent Tips On Conservative Care For Tarsal Tunnel Syndrome

Tarsal tunnel syndrome. Possible diagnosis codes for this condition are 726.79 for tarsal tunnel syndrome or 719.47 for pain in the joint, ankle or foot.

At the initial visit, DME options are the GameDay (Ossur) or Exoform (Ossur), both of which have the possible HCPCS code of L1906.

At the follow-up visit, consider a non-pneumatic walker (with a possible HCPCS code of L4386) for severe cases. One can also cast custom orthoses.

In Conclusion

Increasingly, solo DPMs and small groups of practioners are collaborating with large group practices. Increased size offers greater negotiating power with third-party payers as well as cost efficiencies that come with size. Such an approach also offers greater opportunity to streamline treatments to deliver optimal care in the most cost-effective manner.

How To Integrate DME Into Treatment Protocols – Part 5

Recommendations On Prefabricated Products For Ankle Sprains

Ankle sprain (grade 1). Possible diagnosis codes include 729.5 for ankle pain; 719.07 for effusion of the joint, ankle or foot; and 845.02 for sprain and strain of ankle and foot, specifically the calcaneofibular ligament.

At the initial visit, one can use an Air Stirrup (Aircast) with a possible HCPCS code of L4350. Other options include a GameDay (Ossur) or Exoform (Ossur), both of which have the possible HCPCS code L1906.

Ankle sprain (grade 2). As with grade 1 sprains, possible diagnosis codes include 729.5 for ankle pain; 719.07 for effusion of the joint, ankle or foot; and 845.02 for sprain and strain of ankle and foot, specifically the calcaneofibular ligament.

At the initial visit for grade 2 ankle sprains, one may prescribe a pneumatic walker with a possible HCPCS code of L4360. The DME products in this category include the SP Walker (Aircast), the XP Walker (Aircast) and the Air Walker (Ossur).

For a follow-up visit, patients may benefit from a semi-rigid shell with compression, such as the AirSport (Aircast), with a possible HCPCS code of L1906.

For subsequent visits, patients with grade 2 ankle sprains may use a wobble board or A60 (Aircast), which has a possible HCPCS code of L1902. Other DME products are a GameDay (Ossur) or Exoform (Ossur), which both have the possible HCPCS code of L1906.

Ankle sprain (grade 3). This is associated with fracture and there are number of possible diagnosis codes as follows:

  • 845.01 (sprain and strain of ankle and foot, deltoid ligament)
  • 719.07 (effusion of joint, ankle, foot)
  • 729.5 (ankle pain and support)
  • 824.2 (ankle fracture, lateral malleolus only)
  • 824.6 (ankle fracture, trimalleolar)
  • 845.02 (sprain, strain, calcaneofibular ligament)

At the initial visit, patients with grade 3 ankle sprains can use a pneumatic walker, with a possible HCPCS code of L4360 commander cialis pas cher. Durable medical equipment options in this category include the SP Walker (Aircast), the XP Walker (Aircast) and the Equalizer (Ossur).

At the follow-up visit, one can prescribe an AFO with multi-ligamentous ankle support with a possible HCPCS code of L1906. One such AFO is the AirSport (Aircast).

For subsequent visits, DME options for patients with grade 3 ankle sprains include a wobble board. Other options are the A60 (Aircast), with a possible HCPCS code of L1902, or the Exoform (Ossur), with a possible HCPCS code of L1906.

How To Integrate DME Into Treatment Protocols – Part 4

What About Conservative Modalities For Plantar Fasciitis?

For patients with commonly presenting foot and ankle conditions, there are a number of specific DME products that one can keep on hand.

Plantar fasciitis. One possible diagnosis code is 728.71 for plantar fascial fibromatosis.

At the initial visit for patients with plantar fasciitis, one may use an Airheel (Aircast), which has a possible HCPCS code of L2999. Patients may also benefit from a readymade insert such as Powerstep (Powerstep).

At the second visit, patients may use a posterior or dorsal night splint (possible HCPCS code L4396) or custom orthoses. Consider a low top pneumatic walker for severe cases (with a possible HCPCS code of L4360).

At the third visit for patients with plantar fasciitis, consider shockwave therapy if patients are not achieving adequate pain relief.

How To Integrate DME Into Treatment Protocols – Part 3

Maximizing Efficiency With DME Protocols

For every patient, the front office should determine, in advance of the doctor seeing the patient, if the insurance plan covers DME and whether the podiatrist is allowed to provide the specific DME product. If the plan includes coverage and the podiatrist can dispense it, determine whether the plan has an annual deductible or lifetime coverage amount. If the patient has coverage and the podiatrist is not allowed to dispense the product, the patient needs a referral.

The medical assistant can do the initial intake. Based on an understanding of treatment protocols, the assistant can then make the DME products readily available for the physician to recommend. The physician should review the initial intake and perform an evaluation. The physician describes the plan of treatment and therapeutic objectives of DME. The medical assistant reviews the application of DME with the patient.

When a patient’s therapeutic needs are beyond the ability of the provider, make a referral for consultation or further treatment. Consider pedorthists, orthotists and other podiatrists for possible referral. If appropriate, the medical assistant issues instructions on referral.

How To Integrate DME Into Treatment Protocols – Part 2

Incorporating DME Into Treatment Protocols: Can This Transform Your Practice?

While streamlining care is designed to improve patient outcomes and reduce overall health care costs, there is also an opportunity to increase practice revenue. Incorporating durable medical equipment (DME) into our treatment protocols for conditions of biomechanical etiology requiring stabilization may be beneficial in several respects.

Durable medical equipment provides readily available modalities when the patient presents. Utilizing DME enables you to get immediate patient feedback on the comfort and benefits of the given modality. Additionally, the availability and demonstration of DME products in the office can help facilitate both patient adherence and patient satisfaction.

One of the fundamental concepts for integration of DME into practice is to identify the frequency of the most common podiatric biomechanical diagnoses you see in practice. These are the conditions that offer the greatest benefit of integrating a streamlined approach to care. If you recommend a prefabricated ankle-foot orthotic (AFO) as a part of the treatment protocol, there should be a direct correlation between the incidence of the condition and the number of DME items dispensed.

After identifying the most common diagnoses you see, determine the DME items to use with each. Create treatment protocols for each visit and vary these by severity. Create protocols for follow-up visits depending on how well the condition is improving.

The DME recommendations should be based on the concept of providing items that are therapeutically appropriate and the least expensive. Recognize that some conditions are best treated by an orthotist who has more experience in the range of customized orthoses and related products.

There are a number of factors to consider when selecting DME products. For ease of ordering, seek out products from as few distributors as possible in order to obtain the best pricing and streamline ordering and bill paying. Look for distributors to match manufacturer direct pricing.

Favor products from companies that support podiatry through the American Podiatric Medical Association (APMA), American Academy of Podiatric Practice Management (AAPPM), American Academy of Podiatric Sports Medicine (AAPSM) and young practitioners associations. Work with distributors that offer ready technical assistance.

How To Integrate DME Into Treatment Protocols – Part 1

Having established treatment protocols for common conditions one sees in practice can go a long way toward reining in costs and maximizing efficiency. In this 7 part series, I will offer insights on the benefits of these protocols and how to incorporate durable medical equipment (DME) into the equation.

A key impetus for reining in health care costs is based on the understanding that 50 percent of these costs go toward unnecessary administrative costs, excessive or unnecessary tests and other waste.

Increasingly, large healthcare delivery systems are racing to reorganize their approaches to care as part of their ongoing efforts to rein in costs. Change can be difficult even when the benefits are obvious and the required actions are not complicated. For example, a tremendous amount of infection is still the result of health care professionals not employing well-documented hand washing procedures.

Integral to this reform effort is the creation of practice protocols. An example of integrating practice protocols on a large scale comes from Intermountain Healthcare, which serves patients in Idaho and Utah.1 It determined that 90 percent of its caseload involves the treatment of 70 different conditions. For the majority of these conditions, Intermountain settled on established treatment approaches supported by robust scientific evidence.

Intermountain officials understood that the recommended standardized approach is usually appropriate when patients present with one of the 70 conditions though the standardized approach does not apply in every instance.1 Such an approach allows for more consistent delivery of care, more predictable outcomes, better defense in the event of medical malpractice accusation, more consistent billing practices and more accurate documentation.

Four Pertinent Principles In Streamlining Health Care Delivery

Podiatrists can learn from Intermountain’s efforts to streamline its approach to care by adopting four key principles.

1. Manage the care. Select the most common conditions and settle on a treatment approach. The successful adaptation of treatment protocols requires acceptance by all members of the service chain. Applying evidence to practice requires standardization not just of operational routines but of the rules for making clinical decisions. The more detailed the descriptions in a series of tasks, the less decision making along the path and the more predicable the actions and the outcome. One must identify and address every symptom, observations and lab result.

2. Corral variability. Create mechanisms for addressing instances when the standardized approach is not appropriate or not successful. There are instances in which the presenting conditions are complicated, poorly understood and do not fit into expected protocols.

It is essential that practitioners have a way of addressing such instances and not continue in a way that is not predictable. Such an approach may entail alternative protocols, further testing or referral to an expert in the field. It is important to examine the incidence and reasons for conditions that fall outside of established protocols.

3. Reorganize resources. When practices redesign clinical protocols, they must also reconfigure the supporting infrastructure and routines. There must be a match of the staff, incentive systems, information technology (IT) systems, physical layout of the clinic and educational materials, all with the redesigned process in mind. When a practice does not adopt such a unified approach, podiatrists continue to perform work that they could delegate to medical assistants. Performance measures then remain focused on factors not critical to achieving desired outcomes.

It is essential that medical staff members receive training and stay up to date with educational materials and tools for each protocol. As the saying goes, “If you cannot measure it, you cannot manage it.” There must be mechanisms in place to determine if the staff is performing the desired procedures and mechanisms should be in place to ensure that this is the case. Determine the time, personnel and materials necessary for each approach.

4. Learn from everyday care. Continually monitor the results of the practice’s approach and integrate the lessons learned from cases when the standardized approach is not successful.

The structure and processes of the clinic must allow learning from the everyday work. The people designing the practice protocols must learn from every member performing the various tasks. The people designing the protocols must understand the demands for every service as well as how one performs the task. Such an approach will enable allocation of resources to best meet expected demand. Office managers should do ongoing reviews of charts to ensure that the practice is following treatment protocols and documentation is in order.