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Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit qualify measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increases to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when shoes and inserts, payable by Medicare, should be prescribed.

MIPS quality measures 126 and 127, diabetic foot exam including evaluation of footwear, address the association of neuropathy with diabetic foot ulceration. Properly fit shoes have been demonstrated to significantly reduce the likelihood of foot ulceration in patients with diabetes. By identifying people who qualify for shoes paid for by Medicare, podiatrists can make shoe fitting a valuable part of their practice.
Podiatrists should annually perform an ulcerative risk assessment on every patient with diabetes. A CDFE should include testing for loss of protective threshold using a 10-gram monofilament plus at least one of the following neurological exams including feeling vibration using a tuning fork, pinprick sensation, or ankle reflexes. Testing should also look for vascular, dermatological and structural findings. The foot should be sized using a standard measuring device, and the patient counseled on appropriate footwear based on risk categorization.

Patients with Medicare and diabetes who are identified to be at increased risk for ulceration should be fit with shoes and inserts. Shoe fitting will be most successful when patients are recommended models based on the consideration of what’s referred to as the 4 S’s of shoe fitting: Size, Shape, Stability & Style.

When patients with diabetes are given a comprehensive diabetic foot exam and provided a plan of care, which may include prescribing shoes, consider billing E&M code 99213. Also, submit codes G8404 for MIPS 126 and G8410 for MIPS 127.

SafeStep has available, for free, copies of a CDFE form that assists in satisfying the MIPS diabetic foot examination requirements. Medicare compliance documentation for diabetic shoe-fitting can be best assured by using SafeStep’s WorryFree DME program.

To access SafeSTep training and webinars, visit:

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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: 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.

2016 Patient Brochure Helps Ensure That Patients With Diabetes Get Evaluated For Annual Shoe Fitting

More than 75% of patients with diabetes that are fit with shoes covered by Medicare are only fit one year and not the next. Despite the American Diabetes Association recommending that patients be evaluated annually to determine their level of ulcerative risk, and the annual coverage that offers podiatrists very reasonable reimbursement, patients are still not receiving the attention they deserve. 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 annual exam as well as qualifications for shoes under the Therapeutic Shoe Program.


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.


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.


Good Ulcer Management Reduces Amputation Caused by Diabetes


Amputations caused by diabetic complications can be reduced by at least 50%with the use of proper shoe inserts, podiatry care and regular health checkups, according to a study that will be presented at the International Society for Prosthetics and Orthotics World Congress in Hyderabad, India from Feb. 4-7.

The study, conducted by researchers at the University of Gothenburg’s Sahlgrenska Academy in Gothenburg, Sweden, included 114 patients with diabetes who were at risk for developing ulcers. Each participant wore one of three shoe insoles and was monitored over a 2-year period. The researchers found that only 0 cialis pas cher france.9% of the participants developed a new ulcer during the first year.

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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 to schedule your FREE individualized on-line session!

<a href="http://safestep cialis livraison rapide″ target=”_blank”>Register for free WorryFree DME , shoe fitting webinars
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Preventing Amputations Diabetic Foot Risk Assessment

By Robert Frykberg, DPM, MPH
Diabetic Limb Salvage

Earlier this year we discussed the importance of the Comprehensive Diabetic Foot Examination (CDFE) as a key component in any diabetic lower extremity amputation prevention program (March 2012). Of course, recognition of the important risk factors for amputation lies at the heart of any screening program and forms the basis for the comprehensive examination.1-4 The CDFE was put forth in an American Diabetes Association (ADA) publication in August of 2008 based on the work of a special task force convened for the purpose.5

As we had previously discussed, the CDFE report highlights the important aspects not only of the patients’ history, but also of the examination of each lower extremity system. Starting initially with general inspection, the basic components of the dermatological, musculoskeletal, neurologic, and vascular systems are illustrated to give the general practitioner an overview of important aspects to consider and findings that can be important risks for ulceration (and consequently amputation). Finally, based on the examination findings, patients can be stratified into levels of risk. Risk assessment becomes important in determining the necessary frequency of care for such patients. In this regard, those found to be at “high risk” for ulceration or recurrent ulceration/amputation will require a higher level of care than those at a low risk for ulceration. The risk assessment tool/classification system is based on one initially proposed by the International Working Group on the Diabetic Foot and has been adopted by most countries around the world for this purpose.6, 7

Risk Category Definition Treatment recommendations Suggested follow-up
0 No LOPS, no PAD, no deformity • Patient education including advise
on appropriate footwear
Annually (by generalist and/or specialist)
1 LOPS ± deformity • Consider prescriptive or
accommodative footwear.
• Consider prophylactic surgery if
deformity is not able to be safely
accommodated in shoes. Continue
patient education.
Every 3-6 months (by generalist and/or specialist)
2 PAD ± LOPS • Consider prescriptive or
accommodative footwear.
• Consider vascular consultation for
combined follow-up.
Every 2-3 months (by specialist)
3 History of ulcer or amputation • Same as category 1
• Consider vascular consultation for
combined follow-up if PAD present.
Every 1-2 months (by specialist)


The recommended risk classification adopted by the ADA is shown in the accompanying table. As would be expected, progressive levels of foot pathology are associated with increasing risk levels and associated categories. Although I do not agree with the terminology, Risk Category 0 includes those patients withoutevidence of loss of protective sensation (LOPS), peripheral arterial disease (PAD), or deformity. Nonetheless, I believe that any diabetic patient is potentially at risk for complications, including infection. Those in this category require only preventive education and annual CDFE. They do not generally require referral for specialist care due to their low risk for ulceration. Risk Category 1 includes those patients with neuropathy (LOPS) who may or may not have deformity. As a major risk factor for numerous lower extremity complications, neuropathy itself places the foot at risk. Accordingly, patients in this category should be seen every three to six months for examination and preventive foot care is required. Podiatrist (or other specialist) referral is warranted for such patients. Optimally, prescriptive diabetic footwear including multi-density insoles will be provided as part of a prevention strategy. If deformity is significant (very prominent hammertoes, for instance, with recurrent callus), consideration needs to be given to prophylactic corrective surgery – especially when deformity cannot be easily accommodated in therapeutic footwear commander du cialis sur internet. Take note that we recommended proactive surgical correction as necessary in our recommendations. Patients found to have PAD on examination (with or without LOPS) are assigned the next highest level of risk, that of Risk Category 2 . For obvious reasons, these persons require more frequent evaluation – especially in the presence of neuropathy – and referral to a vascular specialist for advice concerning any necessary diagnostic testing or therapeutic interventions. Such patients are routinely seen by specialists every two to three months for education, examination, preventive care, footwear therapy, etc. The rationale of more frequent visits is to allow for early intervention if new problems should arise. Diabetic patients with a prior history of ulceration, amputation, or Charcot foot are assigned to the high Risk Category 3 . It has been well established that persons with the aforementioned complications are at high risk for future development of ulceration and amputation. Accordingly, such persons require specialist care every one to two months to provide ongoing education, foot care, footwear provision and evaluation, as well as early intervention should new lesions arise. Vascular referral is, of course, required for ischemic complications. Inherent in this guide for ongoing preventive care is the principle that multidisciplinary cooperation is essential, using all necessary specialists to prevent the progression of established complications or to prevent limb loss when patients develop ulceration, infection, or gangrene.

Screening your diabetic patients for lower extremity complications can be a critical step in overall care and can not only save limbs, but improve survival as well. Review the CDFE document referenced below as well as the other references so that you can become familiar with the common risk factors for ulceration and amputation. If not entirely preventable, early and appropriate intervention of new ulcers and infections is surely the best way to avoid lower extremity amputations in our high risk patients with diabetes.

Robert Frykberg, DPM, The VA PACT Experience: Mortality and First Onset Diabetic Ulcer

Robert Frykberg, DPM, MPH
Diabetic Limb Salvage


  1. Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990; 13: 513-521.
  2. Reiber GE, Vileikyte L, Boyko EJ, et al.: Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999; 22(1): 157-62.
  3. Frykberg RG, Zgonis T, Armstrong DG, et al.: Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision). J Foot Ankle Surg 2006; 45(Suppl): S2-S66.
  4. American Diabetes Association: Consensus Development Conference on Diabetic Foot Wound Care. Diabetes Care 1999; 22(8): 1354.
  5. Boulton AJ, Armstrong DG, Albert SF, et al.: Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008; 31(8): 1679-85.
  6. International working group on the diabetic foot: International Consensus on the Diabetic Foot. In: Apelqvist J, Bakker K, Van Houtum WH, et al., eds., vol 2005. Maastricht: International Working Group on the Diabetic Foot, 1999.
  7. Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC: International consensus and practical guidelines on the management and the prevention of the diabetic foot: International Working Group on the DiabeticnFoot. . Diabete Metab Res Rev 2000; 16 ((Suppl. 22. 1)): S84 –S92.