Mrs. Smith s 1st CDFE. Bringing It All Together Sound Protocols, Presentation and Compliance Tools. Disclaimer. What is a CDFE.

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1 Benjamin W. Weaver, DPM, CWS, DABPOPPM, FACFAOM, FAPWCA, FCCWS, FAAPPM, Physician Certified in Wound Care CMET Secretary of the American Academy of Podiatric Practice Manangement Disclaimer The opinions given are not necessarily the opinion of the AAPPM and are subject to interpretation by each individual. It is not a substitute for professional legal, financial, or medical advice---coding rules and payment policies can differ from carrier to carrier. Bringing It All Together Sound Protocols, Presentation and Compliance Tools Mrs. Smith s 1st CDFE What is PQRI In 2007, CMS, in an effort to reduce the cost of diabetic foot care, introduced the Physician Quality Reporting Initiative (PQRI) to encourage podiatrists to perform on an annual basis, more comprehensive exams that would identify risk factors for ulceration. Aside from a level 3 E/M service, adequate performance of these measures offers podiatrists an end-of-year bonus equal to 2% of their total Medicare billing. What is a CDFE The Comprehensive Diabetic Foot Exam (CDFE) was first proposed by Kenneth Malkin, DPM in 2003 as an annual exam to help qualify patients likelihood of ulceration and to help direct appropriate care. The CDFE protocol offers a thorough survey of the dermatological, neurological, vascular, and orthopedic systems of patients with diabetes to detect threatening changes early. As an integral part of this exam, the need for therapeutic shoes, multi-density inlays, treatment for neuropathy, and further vascular testing can also be assessed.

2 What is a CDFE An additional benefit of performing the CDFE is that it offers a ready way to satisfy Medicare s requirements for performance of PQRI and can be billed as a level patient visit on patients who present with a variety of symptomatologies. Complacency versus Growth Indifference versus Vision Wasteful versus Efficient Status quo versus Success Rationale Uniquely similar Consistent quality outcomes Perceptual credibility Anticipatory staff Streamlined processes Cost reduction Improved revenues Meet Mrs. Smith 57 year old white female presents with a chief complaint of stinging numbness in her feet. When she shops at Wal-Mart she is able to walk about 3 aisles before her legs start to cramp and she has to sit down. She has had non-insulin dependent diabetes for 15 years. Before the Patient Arrives Insurance Benefits are Prepared by Staff Physical Therapy Benefits Durable Medical Equipment Orthotics Diabetic Shoes Pain Management Questionnaire is Completed by Patient Insurance Verification NEVER guides treatment Scan back of page Insurance Verification Date Procedure: Diagnosis Code: Patient s Name: Chart# Patient s DOB: Insurance Policy# Group # Phone # Spoke to: Pay % Reasonable & Customary Deductible Amount Met Co-Insurance Amount Met LMN required? Yes NO Letter of Pre-Determination? Yes No Completed Does Patient have Out of Network surgical Benefits Y or N Does patient have separate deductible for DME equipment Y or N if Y Amount Does patient have Max amount of Benefits on DME Y or N If Y Amount Phone#:_ Spoke To: Fax #: Attn: Pre-Cert #: Date range Precert good for - Misc information please see back of verification check upper left box Call made by The above information is correct to the best of my knowledge and I consent to such diagnostic procedures and medical care as deemed necessary by the doctor for my treatment. I understand that the staff has called my insurance to verify coverage. This does not confirm or verify eligibil ity for coverage or pay ment, nor does it assure cov erage under my benefit plan. I am responsible for any charges incurred during any v isit or treatment by th e doctors and staff of Central Kansas Podiatry Associates. Central Kansas Podiatry w ill file my insurance w hen appropriate, but I will be ultimately responsible for all charges. Patient Signature:

3 Visit One Director of First Impressions Front office staff greets Mrs. Smith with a smile Asks the patient to fill out all paper work and questionnaire Making the Most of the Reception Room Education Feeling of Comfort Internal Marketing Accept co-pays and establish a good first impression It s Tuesday morning at 6:00am, and Mrs. Smith arrives for her scheduled appointment. Her diabetes is certainly getting the best of her. Mrs. Smith s gait is now shuffling as her legs often cramp up. She claims that she can barely feel the floor. Although she uses a walker, you just know that she is a hip fracture waiting to happen! Just yesterday, she found a small pebble inside of her shoe that nearly punctured her skin without her realizing it. She is forced to wear slippers since all of her other shoes irritate her hammer toes The Patient is Interviewed By Medical Assistant Mrs. Smith s history is significant for traumatic amputation of the left great toe at age 5 in a bicycle accident. She has severe hammertoes, fungal nails, extremely dry skin. She has bronzing of the shins bilaterally with redness to the left shin and pain with swelling.

4 Preparing To Meet the Patient Review the Insurance Verification Form Review the Pain Analysis and CVI Forms By following our Clinical Protocol the Nursing Staff Have Anticipated What Will be Needed to Treat Mrs. Smith Connecting With the Patient Entering the Patient Room Eye Contact Body Language and Mirroring Skinetics Setting the Tone Be sincere Don t Rush (despite the fact you have seen 10 other patients with swollen legs that day) Set Expectations for treatment (this is a chronic problem, not an acute one) Give the big picture (This may entail using several different treatment approaches) Treating swollen legs is NOT one treatment fits all.

5 H&P Treatment At risk nail care At risk callous care Diagnostics Nail Biopsy Education Recall Visit #1 Mrs. Smith Mrs. Smith, after examining your feet, ankles and legs wounds, there are some important things I need to go over with you. First, the good news is there is no signs of infection, but we will need to a CDFE in one week. Performance of CDFE satisfies PQRI PQRI Measure 126: Neurological Evaluation Definition: A lower extremity neurological exam consisting of a documented evaluation of motor and sensory abilities including reflexes, vibratory, proprioception, sharp/dull and 5.07 filament detection. PQRI Measure 127: Evaluation of Footwear Definition: Includes a foot examination documenting the vascular, neurological, dermatological, and structural/biomechanical findings. The foot should be measured using a standard measuring device and counseling on appropriate footwear should be based on risk categorization. PQRI Measure 163: Foot Exam Definition: Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam report when any of the three components are completed) Dispense to patient diabetic foot care instructions and copies of PressureStat sheets with depiction of preulcerative hot spots. Performance of CDFE satisfies PQRI PQRI Measure 126: Neurological Evaluation Definition: A lower extremity neurological exam consisting of a documented evaluation of motor and sensory abilities including reflexes, vibratory, proprioception, sharp/dull and 5.07 filament detection. PQRI Measure 127: Evaluation of Footwear Definition: Includes a foot examination documenting the vascular, neurological, dermatological, and structural/biomechanical findings. The foot should be measured using a standard measuring device and counseling on appropriate footwear should be based on risk categorization.

6 Performance of CDFE satisfies PQRI Cont PQRI Measure 163: Foot Exam Definition: Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam report when any of the three components are completed) Additional Considerations Dispense to patient diabetic foot care instructions and copies of PressureStat sheets with depiction of pre-ulcerative hot spots Dispense Amerigel blue for xerosis, Metanx, and Neuremedy for numbness RTC 1 week for ABI and shoe dispensement with L5000 and heat molded inserts 3 rd Visit Vascular Assessment Mrs. Smith is coming back for her Padnet- ABI/PVR study because

7 DPM Coding and Reimbursement DPM Referral or no referral PADNet Primary Care More referrals Interventionalist Vascular surgeon CT angiogram CPT Code 93923: Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental volume plethysmography) Reading physician More ABI s DPM Saved limbs and lives JAMA 2008 Ankle-brachial index improves CV risk prediction ABI is rarely applied in routine clinical practice, as most clinicians are not aware that a low ABI is a marker of cardiovascular risk and would not know how to perform the test Results showed that a low ABI (0.90 or less) predicted vastly increased risks of 10-year cardiovascular mortality in both men and women. Biomedix PADnet System 3 rd Visit Cont Dispense diabetic shoes A5500 x 2 Dispense Heat molded inserts x 3 Right foot Dispense L5000 x 1 Left foot 4 th Visit Go over ABI results Refer to PT for cardiac rehabilitation. Mrs. Smith is coming back for her CVI because RTC 1 week for ABI results, CVI, f/u on Metanx, Neuremedy, and hydration of feet

8 Biomedix PADnet+ What tests will my patient need? Venous Refill Time (PADnet +) Venous Refill Testing Photoplethysmography uses infrared light to asses capillary filling following exercise. Increased capillary filling is indicative of venous reflux and, consequently, incompetent veins. Venous Refill Testing Non Invasive Study of Extremity Veins (CPT Code TC, 26) Effects of dorsiflexion maneuver Venous Refill Time (1 Block = 1 Second) 48

9 49 Venous Study Venous Study 50 Chronic Venous Insufficiency Early Detection Program 5th Visit DPM PADNet Physical Therapist Vein Specialist Mrs. Smith we have the results from you vein test last week. They are abnormal, and I want to schedule with a vein specialist to discuss the treatment options they have available to you. 5 th Visit Cont CDFE Revenue Calculator Today, I am going to write order for a special trained Physical Therapist called a Certified Lymphedema Specialist, who will work on get some of the addition swelling out of your legs. They will teach how to take care of this chronic health condition on a day to day basis.

10 Its coming We were recently audited on 2 patients who received shoes and we submitted all the required DME paperwork that we have on file for all such patients. This was a prepayment audit and they denied both. There was a note about these audits in the June 24 APMA Alert and that APMA was working on it. It seems DME wants to see actual notes in the certifying MD/DO charts written or dictated by them that they treat the pt for diabetes and agree with our findings and that the pt should have shoes. The usual faxed sheet that many of us send for a signature won't cut it anymore. As we all know, we have no control over what the MD/DO dictates into the chart and it doesn't seem likely that we can start directing them to do this. I'm writing this to you to see what you or other members of the group might have to say about it. Thanks for any help, xxxxx Total Reimbursement over the Course of Treatment For Mrs. Smith The Smart Way Instituting CDFE s on all diabetic The Not-So Smart Way No CDFE New Paradigm Approximate profit $2500 Approximate profit $59 BWEAVER@AAPPM.ORG BWEAVER@AAPPM.ORG ORG