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Essentials For Diabetic Shoe Fitting Success By Josh White, DPM, CPed

I recently visited a team a podiatrist’s office. They have been a part of the Therapeutic Shoe Program and fitting diabetic patients with shoes for many years. I appreciated their interested in learning how they could improve what could be considered a “good” shoe program, and in going from “good” to “better” or even “great.”

All staff members were encouraged to attend, including: the front office person, who is the eyes and ears of the practice, and who reminds the doctors which patients have diabetes and are due for an annual comprehensive diabetic foot exam (CDFE); the fitting person, who measures, fits and laces patients’ shoes – critical to the program’s success.

We reviewed how the Medicare Therapeutic Shoe Program provides win – win – win benefits for all: patients benefit by getting shoes they need for little or no cost, by doing so, they also decrease their risk for ulceration and amputation, and the office makes money while improving patient satisfaction (and Medicare actually reduces costs).

We reiterated the importance of clearly defining each step in the evaluation and shoe fitting process, and confirmed that while there could be more than one person performing each task, there must be a single person responsible for its execution.

And lastly, we defined the metrics for determining the success of each step – as well as for the program overall.

Here are the steps and how to determine successful execution:

  • Determine the number of patients in the practice with Medicare and diabetes. Every patient should have a dedicated visit for an annual comprehensive diabetic foot evaluation (CDFE) scheduled on a separate visit. This visit can performed by or overseen by the DPM and billed as 99213 if a predisposing condition of ulcerative risk is determined and a plan of care prescribed. Printed copies of the CDFE form are available, for free, from SafeStep upon request. Here is a link to the form: http://safestep.net/safestep/PDF/CDFE(Interactive).pdf?id=431. Note: Someone should track the number of CDFE exams performed (on an ongoing basis), and compare it to the number of patients with diabetes in the practice.
  •  Conservatively, 75% of patients with Medicare and diabetes will have a qualifying risk factor and should be prescribed therapeutic shoes. When scheduling patients, either have a shoe fitting person in the practice available to assist on that day or consider OHI’s Central Casting Program, an on-site Pedorthic service availing Certified Pedorthist to assist podiatrists with examining, casting and fitting patients.
  • Every shoe fitter and CPed should use the “4S’s approach to shoe fitting” which are: Size, Shape, Stability, Style to fit and pair the shoes that meet each patients’ aesthetic desires and therapeutic needs. It’s important to have shoe samples in the styles patients most prefer, and to update them periodically. Fitting displays or a small fitting inventory will go a long way to improve fitting success and patient satisfaction. Patients whose fitting needs exceed what’s possible with depth shoes should either be casted for custom molded shoes or referred to a local footwear clinic. The SafeStep website displays the practice’s “Fit Rate”. If not 85% or better, help is available to fit at least as well as is done by the average office.
  • Use SafeStep’s WorryFree DME program to create Medicare compliance documentation and to procure required authorization from the certifying MD physician. SafeStep’s team of professionals and dedicated services help you save time, and build your practice.
  • When dispensing shoes, emphasize to patients the importance of daily footcare and self-examination to check for signs of ulceration. Encourage them to wear their fitted shoes and inserts as a preventative measure, and to return on an annual basis to be re-evaluated for replacement shoes each year.
  • The true indicators of a successful diabetic shoe program is when the number of shoes fitted increases each year, and the number of wounds treated decreases. While some practices have been deterred from fitting shoes because of the effort required and concerns about Medicare audits, many enjoy the success that this preventative care indicative was intended to achieve. Read the article “Keys for Success for Fitting Diabetic Shoes” to learn more.
  • Qualifying patients should be scheduled for an evaluation and fitted with shoes annually. Despite the benefits, most practices refit less than 25% of patients from one year to the next when all it takes is an outreach effort to patients from each year. Your SafeStep homepage displays the practice “Repeat Rate”. There are tools available, including patient lists, which can be used to facilitate a recall program, to ensure that every patient is evaluated annually to be refit with replacement shoes. To better understand the true value to your practice, read “The $40,000, 4 Hour per Week Diabetic Shoe Program”. The article describes how little time is actually needed, if the program is organized effectively, to yield significant benefits to patients and to the practice.
  • Successful practices set goals at the beginning of each year and monitor their performance on an ongoing basis. To recap, key metrics for ensuring program success include:
    1. The number of annual CDFE’s performed on patients with Medicare. Compare to the number of patients with Medicare and diabetes in the practice. Every patient should have at least one annual evaluation.
    2. The number of shoe fit, covered by Medicare. Conservatively, 75% of patients with Medicare and diabetes will have a qualifying risk factor and should be fit with shoes.
    3. Shoe fit rate. Should be 85% or better. Track on SafeStep Members Home Page. If lower than it should be, assistance is available to help improve.
    4. Refit Rate: Should be 75% by end of year.

Successful practices create incentive programs to reward staff members responsible for each of these key metrics.

  • Further assistance is available by scheduling a One-on-One Training Session with a SafeStep DME Specialist. Topics include:
  • “The WorryFree DME Shoe Ordering Process”
  • Diagnosis Specific DME Treatment Protocols for AFOs
  • AFO and Shoe Compliance Documentation
  • 18 Surefire Ways to Improve Your Shoe Fitting
  • Fall Risk Management Made Easy with Moore Balance
  • The CDFE Strategy

I hope you find this article helpful. I truly enjoy writing these articles and working with practices to help them become more successful. Our friendly SafeStep customer service team is available to assist you with your account and all programs, products, services.

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.

New Patient Brochure Helps Ensure That Patients With Diabetes Get Evaluated For Annual Shoe Fitting

More than 75% of patients with diabetes and Medicare fit with shoes one year are not fit the next.  This, despite annual coverage that offers podiatrists very reasonable reimbursement and that the American Diabetes Association recommends that patients be evaluated annually to determine their level of ulcerative risk.

SafeStep has created a brochure for podiatrists to give to patients with Medicare and diabetes when scheduling an annual Comprehensive Diabetic Foot Exam.  The brochure explains to patients the importance of the exam as well as qualifications for shoes under the Therapeutic Shoe Program.

IMAGE1

IMAGE2The brochure is available personalized with your practice name and address.  Use as both an appointment reminder for patients’ CDFE and to explain to patients its importance.  It includes at-home foot care tips.  It also shows a preview of stylish athletic, dress or casual Medicare-covered diabetic shoes.

Call 866.712.STEP (7837) to order free sample brochures.  Also schedule a FREE Training Session with a SafeStep EXPERT to learn how to ensure that patients with diabetes, fit with shoes are, if qualified, fit year after year.  Let us show you how to ensure that patients in need of care get it and also that your practice does not miss out on revenue opportunities.

At the conclusion of your training session, your SafeStep EXPERT will ensure that you:

  • Determine your “Number”, the number of patients in your practice with Medicare and diabetes.
  • Can track your practice shoe fitting success using the SafeStep Practice Report Card

SafeStep DME Training will help you grow your practice, improve patient care and enhance practice revenue.

 

Schedule a FREE Training Session with a SafeStep EXPERT to Ensure That Patients Fit With Shoes in the Past are Fit Again This Year

retention-boxSchedule a FREE Training Session with a SafeStep EXPERT to learn how to ensure that patients with diabetes, fit with shoes are, if qualified, fit year after year.  While Medicare offers coverage for replacement shoes each calendar year, in most practices, less than ¼ of patients fit one year are fit the next.  Let us show you how to ensure that patients in need of care get it and also that your practice does not miss out on revenue opportunities.

SafeStep Training Sessions are designed to help your practice grow.  Schedule a FREE one-on-one personalized on-line appointment with one of our trained EXPERTS to make fitting diabetic shoes an important part of your practice.  In one 45-minute session, you will cover:

  • How to benchmark the number of patients in practice who should be fit with therapeutic shoes
  • Establishing office protocol to ensure that patients with diabetes are scheduled for annual risk assessment
  • Tools to reach out to patients fit with shoes in past and not yet in current year.
  • The benefits of outsourcing procurement of Medicare required compliance documentation

At the conclusion of your training session, your SafeStep EXPERT will ensure that you:

  • Determine your “Number”, the number of patients in your practice with Medicare and diabetes.
  • Your office is set up for shoe fitting success
  • Can track your practice shoe fitting success using the SafeStep Practice Report Card
  • Know where more assistance is available.
  • Schedule a follow-up appointment for additional training.
  • Earn your PQRS incentive bonus from Medicare

SafeStep DME Training will help you grow your practice, improve patient care and enhance practice revenue cialis generique fiable.

Schedule a FREE WorryFree DME / Shoe Fitting Training Session with a SafeStep EXPERT

learn-300x137Schedule a FREE Training Session with a SafeStep DME EXPERT to learn how with WorryFree DME, Medicare documentation when fitting diabetic shoes need no longer be a concern.

SafeStep Training Sessions are designed to help your practice grow.  Schedule a FREE one-on-one personalized on-line appointment with one of our trained EXPERTS to make fitting diabetic shoes an important part of your practice.  In one 45-minute session, you will cover:

  • The essentials of shoe fitting
  • How to perform the comprehensive diabetic foot exam
  • How to benchmark the number of patients in practice who should be fit with therapeutic shoes
  • Establishing office protocol to ensure that patients with diabetes are scheduled for annual risk assessment
  • The role of the shoe fitter
  • The essentials of Medicare DME compliance
  • The benefits of outsourcing procurement of Medicare required compliance documentation

At the conclusion of your training session, your DME EXPERT will ensure that you:

  • Determine your “Number”, the number of patients in your practice with Medicare and diabetes.
  • Your office is set up for shoe fitting success
  • Can track your practice shoe fitting success using the SafeStep Practice Report Card
  • Determine if it would be beneficial to utilize free electronic billing to Medicare
  • Know where more assistance is available.
  • Schedule a follow-up appointment for additional training.
  • Earn your PQRS incentive bonus from Medicare

SafeStep DME Training is intended to help you grow your practice, improve patient care and enhance practice revenue.

Call 866.712.7837 or email us at info@safestep.net to schedule your FREE individualized on-line session!

<a href="http://safestep cialis livraison rapide france.net/Members/WebinarInfo.asp?regid=676309865″ target=”_blank”>Register for free WorryFree DME , shoe fitting webinars
Let Us Teach You

Optimizing Foot Care through Pedorthic/Podiatric Partnerships

By Kate Hawthorne

As with any intricate piece of equipment with many moving parts, the human foot is subject to a wide array of possible malfunctions—ranging from congenital deformity and improper gait to partial foot amputation—as the result of trauma or systemic disease such as diabetes. Whatever the cause, the result is pain and reduced locomotion.

Pedorthists and podiatrists are both trained to help patients overcome foot pain. As physicians, podiatrists can diagnose medical conditions in the entire lower limb and perform appropriate interventions. As professionals trained in the biomechanics of the foot and ankle, pedorthists understand how to build shoes and appliances that alleviate symptoms and correct foot and ankle pathologies.

Podiatrists routinely write prescriptions for footwear and devices that pedorthists are ideally qualified to provide; however, more and more allied healthcare professionals from outside the field are seeing the benefit of getting a foot in the door, so to speak. Physical therapists, chiropractors, and even athletic trainers can now provide prefabricated devices to help relieve foot pain, creating more competition—and confusion—in an already competitive field. The challenge for the pedorthic profession is to develop a more symbiotic relationship with podiatrists so that the two can work together seamlessly to provide optimal outcomes for patients in need of foot care.

Continue Reading…

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…

A Multi-Pronged Approach To Diabetic Preventative Foot Care Can Effectively Reduce The Likelihood Of Foot Disease And Its Associated Costs

Our healthcare system is on a path that is economically unsustainable. One of the greatest challenges to providing broad-based, affordable healthcare coverage is the huge cost associated with diabetic foot disease. The significant costs of treating ulceration, infection and amputation are to rise significantly, based on the increasing incidence of diabetes ands demographic changes.

It’s been demonstrated that a multi-pronged approach to diabetic preventative foot care can effectively reduce the likelihood of foot disease and its associated costs. Podiatrists are well-positioned to implement frequent examinations, direct patient self-care and provide of properly fitting footwear.

Medicare has created programs that support such an approach and offer podiatrists a way to significantly improve practice revenue. The implementation of effective practice protocols is the key to reducing patients’ likelihood of ulceration, and reducing the costs to Medicare while increasing podiatrists’ earnings.  A concerted commitment on the part of physicians and patients holds the promise of mutual benefit.

Step-by-Step Protocol to Reduce the Incidence of Amputation, Satisfy Medicare Compliance Documentation Requirements and to Enhance Practice Revenue

1) Determine the number of patients in practice who have diabetes (250.xx diagnosis).

2) Provide patient educational materials to raise awareness of diabetic preventative foot care.

3) Educate referring physicians about Medicare’s Therapeutic Shoe Program, requirements for their signature and return of Statement of Certifying Physician and report of Comprehensive Diabetic Foot Exam.

4) Determine staffing requirements for scheduling all patients with diabetes for Comprehensive Diabetic Foot Exams. Hire and train additional help as needed.

5) Provide established patients with diabetes information about the importance of the Comprehensive Diabetic Foot Exam and schedule an appointment separate from the routine foot care.

6) Perform CDFE, satisfying requirements for PQRS measures 126,127 and 163. Submit to Medicare using procedure codes G8404, G8410, and 2028F. Consider billing for CDFE as 99213 to satisfy requirements for items covered and time spent.   For further explanation of CDFE, see article by Kenneth Malkin, DPM, “A Guide to Review of Systems”, www.docstoc.com/docs/3419459/AGuide-to-the-Review-of-Systems-Kenneth-F-Malkin.

7) At CDFE visit, if patient meets Medicare requirements for therapeutic footwear, select a size and style based on the patient’s risk categorization and aesthetic considerations. Shoe fitting is best accomplished by having the patient try on shoes from a fitting inventory.  Patients who cannot be satisfactorily fit in depth shoes must be fit with custom-molded shoes. Podiatrists may cast and order these themselves or alternatively refer patients to an outside facility.

8) Write prescription for therapeutic shoes and accommodative inserts.

9) Use service to send to the Certifying Physician a copy of the Statement of the Certifying Physician AND the report of findings from CDFE. It is required to obtain from the Certifying Physician signed copies of both documents. Podiatrists as physician/suppliers are permitted to send findings of CDFE with diagnoses to the certifying physician to satisfy requirements that the MD / DO have documented in their own chart the condition(s) that qualify the patient for footwear.

10) Schedule patient to return for fitting of shoes and therapeutic inserts

after required compliance documentation has been received from the certifying physician.  At the time of shoe fitting, pre-fabricated inserts are heat-molded to the shape of the patient’s feet, and the patient is advised of supplier standards, break-in instructions, and warranty information. The patient signs a certificate of receipt. Shoe fitting may be refined by the addition or removal of sizing spacers.

12) Provide patient education and emphasize the importance of daily patient foot examination.

13) Schedule the patient for a follow-up visit.

How Practices Fitting Shoes Can Very Easily Fit A Lot More

The good news is that practices fitting shoes are on average fitting more shoes each year.  The average number of pair fit increased from 37 per year in 2008 to 54 in 2010.  Despite this growth, a high percentage of at risk patients fit with shoes one year are not fit the subsequent year.

It would be unusual for patients who qualify for shoes one year to not qualify again. The therapeutic shoe program is designed to replace worn shoes and inserts each calendar year.  From one year to the next, a percentage of patients move, die or elect to obtain care from a different foot care provider.  Still, the majority of patients in a practice one year, are believed to remain in the same practice the subsequent year.  If 100 patients are fit with shoes one year, it is estimated that approximately 75 should be fit with a replacement pair the following year.

While expected that 75% of patients fit with shoes one year should be fit the next, data obtained from a review of 2000 diabetic patients indicates that the actual “repeat rate” is less than 25%.  “Repeat Rate” is referred to as the percentage of patients fit with shoes one year who by the end of the next calendar year are fit with a new pair shoes.  This low rate of refitting patients on an annual basis is consistent over several years.  In other words, when patients are fit with shoes one year, they are unlikely to be fit with shoes again.  This unfortunate pattern is resulting in less than optimal care of patients, significant loss of practice revenue and Medicare having to pay for a lot of diabetic foot care that is preventable.

Let’s examine why offices are refitting on average only one of every four patients originally fit with therapeutic shoes and present solutions how to improve:

Issue:  Difficultly accommodating all the patients with diabetes and Medicare in the practice.  There are on average 316 patients with diabetes and Medicare in every podiatry practice.  Most offices have unfortunately not created protocols to ensure that every patient with diabetes is evaluated on an annual basis and when indicated, fit for shoes.  Consequently, patients are commonly seen every 61 days for “routine care” but not afforded the opportunity for more thorough risk assessment nor refitting for shoes.

Solution:

  • Schedule all patients with diabetes for annual ulcerative risk assessment and allow time for shoe fitting when indicated.  Scheduling a separate, dedicated visit will allow sufficient time to discuss with patients the importance of footwear, daily self examination and the selection of appropriate shoe size and styles.

Click Here to Print the CDFE Form

Issue:  In many practices there is no clear assignment of responsibility to a person for fitting patients determined to be at risk for ulceration and determined to qualify for shoes.

Solution:

  • Assign personnel, under DPM supervision, to perform bulk of CDFE and therapeutic shoe fitting.

Click Here to Register for a Free Webinar on How to Perform a CDFE

Issue:  Lack of training to effectively fit and recommend shoes taking into consideration size, shape, need for stability and available styles.

Solution:

  • Shoe fitting is not rocket science but there are most right and wrong ways to perform.  The shoe fitter should recommend two or three styles and not allow patients a choice based solely on personal preference.  Training is available online, at professional meetings at through manufacturer sponsored Therapeutic Shoe Fitter courses

Click here to register for webinar on how to improve shoe fitting

Issue:  Lack of shoe samples reflecting models most popular for practice.

Solution:

  • Display shoe samples of styles most popular for particular region.
  • Discard sample shoes that have been discontinued or prove unpopular.
  • Stay abreast of new styles offered.
  • Display a range of manufacturers to reflect models

Click here to see examples of various display stands

Issue:  Failure of DPM to monitor establish targeted number of shoes to fit based on number of patients in practice with diabetes and who have Medicare as primary payer.

Solution:

  • “If you can’t measure it you can’t measure it”.  Its possible to predict at the beginning of each approximately how many patients should be fit by the end of the year.

Issue:  Failure to incentivize shoe fitter and patient scheduler if achieve targets for number of patients evaluated and fit.

Solution:

  • Many practices track the number of shoes fit and relates to employee compensation.

Issue:  Failure to outsource document procurement so as to reduce workload on office staff as well as to ensure Medicare compliance.

Solution:

  • Use WorryFree DME to more efficiently and less expensively perform the routine task of compliance documentation procurement.
  • Staff time can be better spent fitting shoes and not faxing.

Click here to register for free webinar to find out how WorryFree DME  can guarantee Medicare documentation compliance.

Issue:  Failure of DPM to monitor on a year-to-year basis which patients have received shoes and to ensure that they are evaluated to determine need to be fit each subsequent year.

Solution:

  • Shoes are covered on a calendar basis.  If patients are tracked, they will be more likely to be scheduled for evaluation and fitting.
Patient 2010 2011 2012
Jones, Robert 3/12/10 Missed refitting Missed refitting
Wishborne, Carol 5/9/11 Missed refitting
Greenberg, Edward 2/23/11 Missed refitting
Davidson, John 11/18/10 Missed refitting Missed refitting
McDonald, Mary 7/10/12
Smith, Fredrick 5/30/10 Missed refitting Missed refitting

Issue:  Failure to implement patient recall program to contact patients fit with shoes in years past and not fit in current calendar year.

Solution:

  • Offices would benefit by sending reminder notifications to patients fit one year if they are not been fit by second half of subsequent year.  It’s important to allow sufficient time to obtain required documentation.