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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”,

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.


  • 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.


  • 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.


  • 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.


  • 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.


  • “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.


  • 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.


  • 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.


  • 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.


  • 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.

The Financial Benefit Of Particpating In The Medicare Therapeutic Shoe Program Can Be Significiant

The opportunity exists for podiatrists to significantly increase practice revenue by fitting at risk patients, already in the practice, with shoes.

According to the Center for Disease Control, in 2011 an estimated 10.9 million people with age 65 or older had diabetes.  The Bureau of Labor Statistics states that in 2010 there were 12,900 podiatrists in the US.  Assuming 25 patient enrollment in Medicare managed care programs and also that only half of patients with diabetes even see a podiatrist, there is the opportunity for every podiatrist to see on average 316 patients with Medicare and diabetes.  If 75% of patients with Medicare and diabetes have risk factors that qualify them for footwear according to Medicare’s requirements, that means that an  average of 237 patients with Medicare and diabetes should be fit by for every one of the 12,900 podiatrists, each year.  Fitting approximately one pair of shoes per day would earn every single podiatrist approximately $47,000 more each year.  Contrast this with that in 2010, approximately 5676 podiatrists fit an average 54 pairs of shoes and earned a profit of approximately $10,800.

The number of people over 65 with diabetes is expected to quadruple over the next 20 years.  The bottom line is that by following Medicare and American Diabetes Association protocols, podiatrists have the potential to significantly increase  their median net incomes. Medicare has embraced such an approach via its PQRS program that will pay podiatrists an additional 0.5% of the total amount they collect from Medicare.  Medicare recognizes that should such a preventative  approach to care actually become widely adopted, it has the potential to save money even after all shoes and inserts are paid for.

Why Some Podiatrists Have Stopped Fitting Diabetic Shoes And What They Should Do To Start Again

As reflected in the 2012 Podiatry Management Practice Management survey that approximately one third of podiatrists fitting shoes have stopped, it’s clearly been a challenging past few years.  A host of issues have contributed to many not utilizing the Medicare shoe program.  Some of the most common and how each can be addressed are listed below:

Issue:  Fear of Medicare audits based on lack of understanding of compliance requirements.


  • While there is the perception that there have been widespread Medicare audits, according to Podiatry Management’s 2012 survey, the percentage of podiatrists audited by Medicare dropped from 5.2% in 2011 to 3% in 2012.  Paul Kesselman, DPM, reports in Podiatry Management that while durable medical equipment suppliers have initially failed more than 90% of audits, most commonly for lack of appropriate compliance documentation, upon appeal, more than 90% of DPMs have had favorable outcomes resulting in claims being paid.

Issue:  Difficulty complying with revised Medicare documentation requirements


  • The supplier fitting footwear must perform an examination that directs the style of shoe most appropriate for patients’ pathology.  This can be easily addressed by performing an annual comprehensive diabetic foot evaluation (CDFE) on every patient with diabetes.
  • CMS requires that physicians managing patients’ diabetes be aware of the specific predisposing foot pathology.  This can be best accomplished by podiatrists sending certifying physician the significant findings of the CDFE.
  • Patient must been seen by certifying physician no more than 6 months prior to receiving shoes.  Shoes must be fit no more than 3 months after the Certifying Statement is completed by the MD / DO.  The podiatrist must be certain to fit shoes before these deadlines are passed.

Issue:  Difficulty understanding new enrollment requirements and encountering NPI crosswalk error.


  • DME suppliers are required to “link” their Medicare NSC # (DME supplier number) to their NPIID (National Plan Identifier).  Linkage can be ensured by going to the NPPES website,

Issue:  Tri-annual $505 Medicare registration fee


  • This new fee, payable every three years, is well worth paying given the allowable reimbursement for DME products.

Issue:  Failure to renew Medicare DME enrollment as required every 3 years.


  • Medicare sends DME suppliers a letter requesting updated information every 3 years.  If not responded to within 30 days, Medicare will inactivate the PTAN supplier number, requiring the DPM to reenroll, a process that can take several months and prevents payment for claims submitted during that time.

Issue:  Feeling overburdened by implementation of electronic medical records.


  • For many practices, the opportunity to receive incentive bonus for implementation of EMR has been top priority, has required tremendous effort and has superseded many other desires.  Now that most offices have made the transition, the opportunity exists to focus back on shoe fitting.

Issue:  Lack of cooperation from certifying physicians who are required to sign and date compliance documentation


  • Some MDs have felt burdened by frequent requests for their certification of qualifying risk factors.  Combined with a lack of understanding of the Medicare program, some have been resistant to comply with their Medicare requirement and made it difficult for their patients to receive shoes.  Generally the situation can be improved if better communication is initiated by the referring DPM.  Ideally physicians managing diabetes should refer all patients to DPMs to be evaluated and fit for shoes when indicated.

How Successful Podiatric Practices Make the Medicare Therapeutic Shoe Program Work

Podiatric practices fitting diabetic shoes are, on average, fitting more pair each year.  These practices have figured out how to work with Medicare’s ever changing requirements and have adapted their office protocols to capitalize on the opportunity that literally walks through their door every day.  The results are better patient outcomes, significant growth in practice revenue and overall savings to Medicare.  Despite the success of some practices, the number of diabetic shoes fit by podiatrists overall has decreased as a significant number of practices have given up fitting footwear.  In this 6 part series, we’ll share the keys to success of practices that have figured out how to make therapeutic footwear an increasing effective part of patient care and a significant contributor to practice profitability.

With an obesity epidemic and 10,000 baby boomers turning 65 every day, demographers predict that the number of people with Medicare and diabetes will quadruple over the next 20 years.  How then can it be that podiatrists fit less diabetic shoes in 2010 than in 2008?  The numbers of pairs of shoes paid for by Medicare decreased from 310,640 in 2008 to 309,223 in 2010, the most recent year that BMAD (Part B Medicare Annual Data) information is available.

The Therapeutic Shoe Program offers patients with diabetes at risk for ulceration the opportunity to be fit with shoes and inserts each year.  Patients are protected from ulceration and amputation.  For each pair successfully fit, podiatrists earn approximately $200.  Medicare benefits from the cost effectiveness of including therapeutic footwear as an important component of a comprehensive approach to diabetic preventative foot care.

Despite these advantages, Podiatry Management reports a significant drop in the percentage of podiatrists who participated in the Medicare Diabetic Shoe Program.  In the PM 2012 Annual Survey, only 44 percent of 363 surveyed DPMs said that they fit shoes using the program versus 65% in the 2011 study.

In the next 5 blog posts, we’ll address the reasons why podiatrists have dropped out of the Medicare shoe program and present solutions to encourage them to get back in.  We’ll also identify a significant opportunity that exists in most practices fitting shoes and suggest how it can be used to help both patients and the practice.

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.