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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.

Be an AFO Expert – It’s Easy if You Use DME Protocols

Time and time again I am asked the same four questions about AFOs:

  1. When should they be used
  2. What’s the correct diagnosis code
  3. What HCPCS code should be used for the AFO
  4. How much does it pay?

While Medicare does not offer definite answers to any of these questions, it does offer guidance in the form of LCDs, Letter of Common Determination and fee schedules.

SafeStep features free webinars on DME Treatment Protocols and another on Compliance.  To register, simply click here, http://www commande  Recorded versions of presentations can also be found in “Library” section of SafeStep website. Even if you have seen this presentation in the past, it’s worth attending again as codes and requirement continue to change.

In collaboration with leaders of the American Academy of Podiatric Management and other knowledgeable practioners, SafeStep created the DME Treatment Protocols booklet.  This guide offers a step by step approach to devices that will effectively work for the most commonly seen biomechanical conditions and offers guidance of how to bill and how much to charge.  While not intended to be followed explicated, it offers practioners an effective starting point and way to developer’s ones own approach to care.  To get your copy of this valuable guide, cont

Once protocols are established, they should be combined with an effective inventory management routine so that the office is certain to always have in stock products for the most commonly seen condition but not so much inventory as to take up valuable office space.  When effectively implemented into office routines, staff should put possible devices out for the doctor to consider so that easily available to discuss with the patient.  If indicated for a Medicare patient, the device can be dispensed on the spot, no prior authorization is necessary.

Medicare Rules and Coding for Diabetic Patient with Amputation

For Diabetic patient with amputation, if requirements are met documentation-wise, are patients entitled to ONE pair of shoes, and diabetic orthotics with met/toe fillers per ONE  year? And what codes would be billed?

According to NHIC DME MAC A Listserve of June 8, 2012 featured below, Medicare clarified eligibility for L5000, “Partial foot with longitudinal arch, toe filler”.

If foot missing hallux or forefoot, arch support with filler understood to require additional rigidity than foot insert without filler and can be billed as L5000. Medicare allows coverage for a single L5000. If patient has diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts.

If foot missing lesser digit, arch support with filler NOT assumed to require additional rigidity than foot insert without filler and CANOT be billed as L5000. If patient HAS diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts. If patient DOES NOT have diabetes, “partial foot, shoe insert with longitudinal arch, toe filler” can be billed as L5000 only if beneficiary missing hallux or forefoot. It is not appropriate to billing either L5000, A5512 or A5513 is patient does not have diabetes and is missing lesser digit only.

Toe Fillers and Diabetic Shoe Inserts – Coding Clarification

Questions have arisen about the correct coding for shoe inserts used to accommodate missing digits (toes) on feet for beneficiaries with and without diabetes. These items fall under two separate benefit categories and use two distinct Healthcare Common Procedure Coding System (HCPCS) codes, L5000 and A5513.

Beneficiaries without Diabetes
Shoe inserts for beneficiaries with missing toes or partial foot amputations who are not diabetic are considered for coverage under the prosthetic benefit. Code L5000 is described by:


As noted in the descriptor, code L5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe), or the forefoot, L5000 inserts are designed to provide standing balance and toe off support for improved gait. The biomechanical control required of L5000 differs from the foot-protective function provided by inserts used as part of diabetes management.

For beneficiaries who are non-diabetic and require accommodation of missing foot digit(s) or forefoot, suppliers must only bill code L5000. Codes A5512 and A5513 describe inserts used with therapeutic shoes provided to persons with diabetes (see below) and must not be billed for non-diabetic beneficiaries.

A separate benefit category allows Medicare coverage of therapeutic shoes and inserts for persons with diabetes. Shoe inserts for persons with diabetes are described by the codes below:



For a beneficiary with diabetes missing digit(s) or a forefoot, suppliers have two options for billing inserts:

Option 1: For diabetic beneficiaries who do not require the rigidity and support afforded by code L5000 (e.g., beneficiaries missing digits excluding the hallux), suppliers must bill code A5513 for an insert appropriately custom-fabricated to accommodate the missing digit(s). Codes L5000 or A5512 may not be billed in addition to code A5513.

Option 2: For beneficiaries missing the hallux or a forefoot that require rigidity and support for effective gait, suppliers must bill L5000 for an insert appropriately custom-fabricated to accommodate the missing digit(s) or forefoot as well as providing the foot-protective functions required for a person with diabetes. Codes A5512 or A5513 may not be billed in addition to code L5000.

Suppliers are encouraged to review both the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination and related Policy Article and the Lower Limb Prostheses Local Coverage Determination and related Policy Article for additional information on the coverage, coding and documentation of these items.

The Medicare LCD for therapeutic shoes states that patients with diabetes and ulcerative risk factors may be eligible for a replacement pair of shoes each calendar year.

According to the LCD for lower limb prostheses, Policy Article, Effect January 2011, Replacement of a prosthesis or prosthetic component is covered if the treating physician orders a replacement device or part because of any of the following:

A change in the physiological condition of the patient; or
Irreparable wear of the device or a part of the device; or
The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of the part being replaced.

Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be reimbursed without a physician’s order when it is determined that the prosthesis as originally ordered still fills the patient’s medical needs.