At Risk Foot Care Protocol Menu New Patient /Existing Patient Update Evaluation Questions: Are you Diabetic? If yes, how long have you been Diabetic (when was it diagnosed?) Is your diabetes under control with diet and/or medication? Do you check your Blood sugar daily? o What was it this morning? o What is it averagely? o What was your last A1C? Have you seen a podiatrist before? Have you had any complications with your feet such as: o infections, open sores, tingling/numbness, pain Do you or have you experienced problems with balance, falling or feeling unsteady? o If yes, perform Fall Risk Assessment (or ready form for DPM) Do you usually trim your own toenails? When was the last time you saw your primary car physician or physician responsible for the management of your Diabetes? **Always verify and include PCP as well as Date Last Seen (DLS) in chart note and on insurance claim. This must be within 6 months of the date the patient is seen in your office.**
Post- Evaluation Actions: o Debride nails o If nails are thickened, discolored, perform nail biopsy Staff to prepare ahead of visit (biopsy kit and patient demographic sheet) o Debride Corns/Calluses o Discussion of importance of professional nail care and daily inspection of feet including use of appropriate moisturizer o Discussion of proper foot wear o Perform a Biomechanical exam/fall Risk Assessment (if patient reports unsteadiness or has history of falls) o Staff to be trained on fall risk assessment upon evaluation and rooming of patient (see evaluation questions) o High/Extreme fall risks may be casted for balance devices (custom) and/or referred to PT if DPM deems appropriate o If patient is Diabetic: o Perform Comprehensive Diabetic Foot Exam - to include evaluation and documentation of: o Vascular compromise o Neurologic compromise o Non-traumatic amputation of foot or integral skeleton portion o Absent posterior tibial or dorsalis pedis pulses o Advanced trophic changes o Decrease or absence of hair growth o Thickening of nails (nail changes) o Pigmentary changes (discoloration) o Thin or shiny skin texture o Rubor or redness (skin color) o Claudication o Temperature Changes o Edema o Paresthesia o Perform Temp Stat and Pressure Stat exams o Document temperature differences and high pressure areas of the foot that can suggest break down of skin/ulceration without proper support o Dispense Diabetic foot care and prevention educational brochure
Documentation/Billing Pearls: Mycotic Nails CPT 11721: debridement of 6 or more nails CPT 11720: debridement of 5 or less nails CPT G0127: debridement of dystrophic nails, any number CPT 11719: debridement of non-dystrophic nails, any number Dx: Appropriate ICD-10 Diabetic or Vascular code Pain Diagnosis needs to be included for non-diabetic patients qualified through either pain or at risk conditions: -- Vascular compromise Hyperkeratosis CPT 11055: paring/cutting of single callus CPT 11056: paring/cutting of 2-4 calluses CPT 11057: paring/cutting of more than 4 calluses Use appropriate Q modifiers for Medicare: Q7: One class A finding: Non-traumatic amputation of foot or integral skeleton portion thereof. Q8: Two class B findings: 1. Absent posterior tibial pulse 2. Absent dorsalis pedis pulse 3. Advanced trophic changes; three of the following are required: hair growth (decrease or absence) nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) Q9: One class B and two class C findings: 1. Claudication 2. Temperature changes 3. Edema 4. Paresthesia 5. Burning When billing for callus care and for nail care, use modifier 59 (distinct procedural service) on the lesser of the codes (i.e. 11719-59) Recommendations based on CDFE findings to include: o Need for Therapeutic shoes and custom or pre-fabricated inserts If qualifying risk factors are present, fit (measure and select )for DM shoes and inserts (custom or pre-fab depending on risk findings) Begin compliance paperwork to include letters from PCP/ MD or DO managing disease)
Rx (Detailed Written Order) for shoes/inserts Including Therapeutic Objectives Copy of CDFE note for PCP to sign off/agree with risk findings and file as documentation in his/her office o Vascular testing If symptomatic perform ABI/vascular exam or schedule for return to office for exam o Recommend or dispense Compression stockings o Recommend or dispense Anti-fungal medications for skin/nails o Recommend or dispense Anti-fungal Cream (Clarus, Fortinia, Fungi-Foam, etc.) o Recommend or dispense Anti-fungal topical nail solution (Clarus, Formula 3, Fortinia, etc.) o Recommend or dispense Anti-fungal/Anti-microbial shoe spray (Clarus, Mycomist, etc.) o Recommend or dispense for severely thick nails Kera Nail Gel (47% urea) to be used in combination with anti-fungal solution/cream o Recommend or dispense for severe calluses Kera-42 o Recommend or dispense Diabetic safe lotions/moisturizers for daily use o Amerigel Care Lotion o If Neuropathic symptoms are noted: o Schedule for small fiber biopsy o Consider In-Office dispensed supplement (Neuremedy, Neu-Rx, etc.) o Discuss the possible need for Casting/Dispensing of custom devices (balance or gauntlet brace) if deformity, pain and/or balance issues are a concern Patient to return to office in: 4-6 weeks 8-10 weeks 3 months
Diabetic/ At-Risk Foot Care Follow Up visits Assistant Questions: o Do you have any medical or medication changes since your last visit? o If Diabetic, Is your Diabetes under control (according to your PCP or MD/DO managing the disease)? o Double check managing physician name and DLS o When was the last time you checked your blood sugar (what was the reading)? o (If applicable) Have you been using the topical medication/cream/lotion prescribed for your nails/calluses/skin at home? o Do you check your feet daily? *It is especially important to note any changes or lack there of when patients present on a regular basis for the same condition (Diabetic Foot Care (Preventative visit)/at Risk Foot Care, etc.). Remember, each patient encounter needs to be unique. Post Evaluation Actions: o Position patient comfortably MA Patient to return in: o Take and record BP, height, weight MA o Fall Risk Assessment (FRA) (if not previously performed and appropriate) MA o If casting for balance devices occurred during visit one, dispensing of braces with Rx for PT (if not casted at visit one and categorized as high or extreme high fall risk), further discussion with possible casting at this visit) MA o Shoe measure and selection and possible biofoam impression (for custom inserts) - (if not previously performed) MA o Compliance paperwork started if not performed at initial visit (for letters to be signed by PCP) MA o Dispense diabetic shoes and inserts (if compliance paperwork is completed from visit one) MA o Debride Nails and Calluses (billable if at least 61 days since visit one) o If positive nail culture recommend appropriate product or continue treatment as suggested at visit one DPM o Perform Nerve Biopsy if appropriate DPM o Patient advised to continue with at home treatment of calluses, dry skin, fungus o Assist patient with shoes and socks and moisturizing feet prior to end of visit MA o 4-6 weeks o 8-10 weeks o 3 months
Visit 3: o Discuss Nerve Biopsy Results o If positive for neuropathy discuss/ dispense medical food/in office dispensed supplement (NeuRx, Nuremedy, etc.) o If casted for balance or other custom device at visit two, dispense today o Place into a regimented at risk foot care schedule (continue at home skin/nail treatment) for nail care and debridement of corns/calluses (see patient to return below) o If medication/supplements have been prescribed for neuropathy and biopsy performed, repeat biopsy should occur at 6 month intervals to show improvement (great information for referring docs) Patient to return in: o 4-6 weeks o 8-10 weeks o 3 months