Examining the Synergy of the Diabetic Foot Exam, Therapeutic Shoes and Remote Patient Monitoring

Patients with diabetes and a history of ulceration occupy the highest category of risk for reulceration and amputation. Studies report recurrence rates of up to 58 percent within 1 year and as high as 61 percent at 3 years. The average cost of treatment per ulceration is approximately $13,000. Diabetic shoes have been shown to reduce recurrence of ulceration up to 58 percent. Increased foot temperature and increased plantar pressure have been demonstrated to be early indicators of impending ulceration.¹ “Smart” devices offer the opportunity to monitor these predicators of ulceration and alert patients and care providers of need for intervention. Medicare’s new remote patient monitoring program combined with the therapeutic shoe program offer the opportunity to achieve the “triple aim of healthcare:”

·      Improving the experience of care;

·      Improving the health of populations; and

·      Reducing the per capita cost of care.

In my opinion, there has never been a better time for podiatrists to fit diabetic shoes; I feel there are many fewer Medicare audits than there once were and almost every practice has several hundred patients who qualify for coverage. See the Medicare allowable amounts in the examples below for explanation of how, when combined with Medicare’s new Remote Patient Monitoring (RPM) program, there is the opportunity for podiatrists to more than triple the amount earned per patient versus fitting shoes with inserts alone. The key to successfully implementing shoe fitting with RPM is to adopt a proven process and to stick with it. This blog briefly describes such an approach and how following American Diabetes Association Standard of Care can keep diabetic foot ulceration in remission and significantly increase practice revenue.

Every patient with diabetes should, according to the ADA, be scheduled for an annual ulcerative risk assessment (CDFE, comprehensive diabetic foot exam). The CDFE documents determination of “medical necessity” and supports DPM prescription of therapeutic footwear and RPM.² Providing patients with shoes and RPM, versus referring it out, offers patients greater convenience while allowing the DPM to keep the revenue earned by providing these covered services within the practice.

In my experience, implementing shoe fitting and RPM works best by using a team approach to care. It’s often helpful for DPMs to make a practice of scheduling routine visits like the annual CDFE.  When a provider determines a patient has an increased ulcerative risk, patients should see a person in the practice trained in shoe fitting and in providing one several podiatric remote patient monitoring services. It is the fitter’s responsibility to ensure correct sizing and provide desirable shoe styles, not just necessary therapeutic features. While the goal of wearing prescription shoes is for patients to remain active and independent, shoes only provide protection if worn. RPM can encourage shoe wearing, for instance, by providing early detection of potential ulceration and sending notifications to patients and practitioners if foot temperature rises. Increased foot temperature of 2 degrees Celsius is a recognized precursor of foot ulceration.³

Medicare’s RPM program requires that providers communicate with patients about their foot temperature and risk of ulceration at least 16 days per month and inform patients are monthly about any detected conditions increasing the chance of ulceration.⁴ In my opinion, ongoing monitoring and patient communication is generally best outsourced to one of several services that are allowed to work under the DPM’s general supervision. These services will signal patients to take weight off their feet and obtain professional care when detecting increased foot temperature. 

The time is now for podiatrists to help their patients with diabetes to lead active lives free from foot ulceration. Medicare makes it possible for patients to get the shoes that they need and the protection they require. Combining annual ulcerative risk assessment, diabetic shoe fitting and remote patients monitoring offers benefits for patients, practices and Medicare alike.

Dr. White is the Vice President of OrthoFeet and a member of the AAPPM Board of Trustees.

This blog was created in partnership with the American Academy of Podiatric Practice Management.

(Example) CDFE, SHOE FITTNG, RPM: ROLES AND RESPONSIBILITIES

DPM

• Performs CDFE all patients with diabetes
• Prescribes shoes / RPM insoles when history of ulceration present
• Supervises dispensing of shoes / insoles
• Provides general supervision of RPM.

Front Office Person

• Schedules patients with Medicare, diabetes and history of ulceration for dedicated CDFE appointment with DPM in addition to at-risk foot care visit. 

Fitting Person

• Works under the direct supervision of the DPM to select shoes that are therapeutically appropriate and aesthetically acceptable fits
• Completes Medicare compliance documentation based on CDFE
• Dispenses diabetic shoes
• Dispenses remote patient monitoring device

RPM monitoring service

• Works under the general supervision of the DPM
• Performs monthly 20 minutes review of patient foot temperature, plantar pressure and step count. 
• Provides interactive communication with patient.

(Example) DPM Profitability Summary

Potential Annual Revenue, per patient:

Total potential annual revenue, per patient                                $1,974.89

Costs, per patient:

Total costs, per patient, per year                                                  $940.00

Potential Annual DPM Profit, per patient:                                    $1034.89

*   CPT rates shown are for Manhattan.  The applicable CMS reimbursements for these CPT codes vary by region.

DMEPOS fee schedule

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule

Physician Fee Schedule

https://www.cms.gov/medicare/physician-fee-schedule/search

References

1.    Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. New Eng J Med. 2017;376;2367-75.

2.    American Diabetes Association Professional Practice Committee, Draznin B, Aroda VR, et al. Retinopathy, neuropathy and foot care: standards of medical care in diabetes – 2022. Diabetes Care. 2022;45(Suppl1):S185-S194.

3.    Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: Use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14-20.

4.    Final policy, payment and quality provisions changes to the Medicare Physician Fee Schedule for calendar year 2021. CMS.gov website. Available at: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1 . Published December 2020. Accessed April 25, 2021.