DME and What you May be Missing

Cindy Pezza, PMAC President/CEO Pinnacle Practice Achievement, LLC

PMAC President

If you were wondering how Medicare and CMS determine the rules and changes to the rules for dispensing, billing, and documenting Durable Medical Equipment (DME), you are not alone. In fact, it seems as if podiatrists in general are dispensing and billing less and less DME (therapeutic shoes, walking boots, night splints, pre-fabricated ankle braces and custom ankle foot orthoses) due to the fact that it seems nearly impossible to keep up with changes (and who could blame them?). Why would anyone want to go through all of that trouble only to have claims rejected or monies taken back later? You could look at DME this way, or, you could invest some time, obtain the facts, and surround yourself with contacts and professionals who live and breathe this “stuff “ everyday. With the exception of diabetic shoes, which require additional documentation and permission of sorts from the physician managing the patient’s disease (to be discussed in depth in a later article), podiatrists may dispense any ethical and medically necessary device while serving as the prescriber and provider.

For example, 67-year-old Mrs. Smith visits your office every 3 months with painful fungal toenails. Today however, your newly (properly) trained medical assistant asks Mrs. Smith if she has any other issues that she would like to discuss with the doctor today. This question triggers a response a bit of thought that a moment later reveals consistent pain, redness and swelling in the left ankle that seems to be getting worse. “I don’t’ know if he can do anything about it, but it is bothering me quite a bit.” (You have no idea how many times patients hold back additional concerns if not prompted to divulge them).

Upon examination and x-rays taken prior to entering the room (as your assistant was trained to take based on chief complaint and history), you determine that Mrs. Smith has Posterior Tibial Tendon Dysfunction and would benefit from a ankle brace that would stabilize her foot and ankle, improving mobility and decreasing pain and swelling. While you debride her nails, you describe the condition at length and the options for treatment including the possible use of custom devices versus surgical correction. You also discuss the benefits of trying a pre-fabricated brace first to provide relief and to determine which type of custom device would be most appropriate in the future (remember, you are trying to satisfy the rule of “least expensive method of treatment” first). Today you may decide to fit her with a multi-ligamentous brace (L1902) if the condition is mild to moderate, or a more substantial device with a rigid foot bed and hinges (L1971) if more severe. You make sure to include a prescription in Mrs. Smith’s chart stating the diagnosis along with the recommended device (to be dispensed today). You include ankle pain and swelling that is worsening over time in the subjective portion of your chart note and state the therapeutic objectives (as listed above): to improve mobility, decrease pain and swelling and to determine if a custom brace would provide even more relief in the future. You also provide a detailed report of the device that was dispensed, how it will support the foot and ankle (to again, decrease pain and swelling and facilitate mobility) and state that the patient will be monitored closely (to document degree of improvement or lack there of) at a three week follow up visit. You then have the patient sign their acknowledgement form/receipt (including patient name, address, date of dispensing, diagnosis, device dispensed, signature of witness, physician name, address and NPI- {Oh, you didn’t receive that email from Mr. Medicare informing you of the additional requirements included as of 2015?}, make a copy for the patient to take home (and scanning one into the chart), and document that you offered a copy of the 30 DME Medicare Supplier Standards (it is no longer required to provide this to every patient, only the ones who want it – I guess you missed that email too!).

Wow! That seems like a lot, but consider this. . . You have pre-printed patient acknowledgement forms (with check boxes next to all of the common/pertinent diagnoses, dispensed DME items, your information filled in and blank lines to complete the patient’s information). Within your electronic health records, you have templated prescriptions with choices of all the most commonly treated conditions (diagnoses) and dispensed devices (DME items) loaded, along with a therapeutic objective lists, and dispensing verbiage. Each back office staff member is trained to properly assist with the dispensing and documenting of DME (preparing forms ahead of time, fitting patients with devices, providing instruction for proper use and care and making sure that the receipt is signed and copied prior to the patient checking out) and life is easier as you (the DPM) can focus on recognizing the needs (or additional concerns) of your patients (so you can move onto the next).

Now let’s look at it from a patient prospective. Mrs. Smith may have been coming to see you for the past few years for the treatment of her painful, unsightly nails, but did not think to mention anything about her ankle. Why, because she wasn’t asked and she wasn’t aware that you treated ankles! So few understand the scope of practice of a podiatric physician and surgeon and so we should make it our mission to educate our current and future patients (through the use of internal and external marketing campaigns- also to be discussed in a later article). These “add ons” not only provide patients with relief and an improved quality of life, they allow practices to ethically increase revenue and patient volume to steadily increase through referrals. So, the next time your “every three month” patient enters the treatment room, ask her if she would like to discuss anything else foot or ankle related. You may be surprised to find just how valuable those toenails can be!

If you would like more information on implementing or improving your current DME program, please contact