From the Desk ofDr. White

Keys to Central Casting Success

Dr. Josh White, DPM

January 6, 2018

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  • Benchmark
  • Connect identification of presenting conditions with treatment protocols
  • Coordinate back office and front office protocols
  • Equip practice for effective modifications when dispensing shoes, orthotics and AFOs
  • Always have materials in stock

Step 1 – Identify

Make clear to staff that once the process for fitting diabetic patients with shoes is created that it is to be followed by all.

Patients with Medicare and diabetes are entitled to be fit with a pair of shoes and three pairs of inserts each calendar year based on evaluation and determination of medical necessity. While it seems logical that patients at risk for foot ulceration would look forward to a new pair each year, in reality once patients are fit they are not refit for a second pair. This happens often despite the shoes being available at little to no out of pocket cost to the patient.

While oftentimes shoes have effectively reduced the incidence of ulceration, too many patients do not get the message about the important role that footwear plays in preventing ulceration and that properly fitted, protective shoes should be worn both outside and at home. Patients must have best fits and in styles that best meet their therapeutic needs and aesthetic desires. After all, there’s no benefit in getting shoes that are not worn.

Every patient with diabetes should be scheduled for an annual comprehensive diabetic foot evaluation. If ulcerative risk factors are determined to be present, therapeutic footwear should be prescribed. Office personnel who are part of the shoe fitting program must be trained on shoe fitting, Medicare compliance and the importance of footwear in preventing foot ulceration.

Step 2 – Document

List the major steps needed to ensure that patients fit with shoes one year are fit year after year after year. Have the practice’s shoe fitter record the major steps entailed in fitting diabetic shoes. Each major step should be supported by 1-5 sub-points defining the who/what/where/when/how. Keep it simple (the 20/80 approach); the process should be fully documented in 1-5 pages. Review and approve—every member of the leadership team must agree this is the right way to fit shoes every time

  1. Determine the number of patients in the practice with Medicare and diabetes and create mechanism to identify, determine if have had annual CDFE and if have been fit with shoes that year
  2. Ensure that physicians schedule patients with Medicare and diabetes for separate dedicated CDFE appointment
    1. Possibly billable as 99213
    2. Possibly satisfies MIPS quality measures 126, 127
  3. When CDFE determines patients to be at risk for ulceration, prescribe footwear and have patient seen by Central Casting CPed.
    1. Medicare documentation required:
      1. documentation of medical necessity (CDFE)
      2. prescription
  4. Systemize procurement of Medicare documentation that must be reviewed by medical doctor managing patients’ diabetes
    1. Medicare documentation required:
      1. Report of ulcerative risk factors
      2. Medicare create CMN that elicits date patient last seen by
      3. MD / DO for diabetes management
    2. Use web-based automated procurement service
    3. Follow up with medical doctor office if signed documents not received within three weeks
  5. Once compliance documentation received from MD / DO, schedule patient with Central Casting CPed for shoe selection. Shoe fitter uses the 4S approach taking into consideration:
    1. Size of foot.
    2. Shape of foot.
    3. Stability required.
    4. Style of shoes that will be most worn and offer appropriate protection.
  6. Schedule patient for return visit for shoe fitting with Central Casting CPed.
    1. Medicare documentation required:
      1. Patient receipt
      2. Dispensing chart notes
  7. Repeat year after year after year

Step 3 – Package

Once the shoe fitting process has been defined for the practice, roles must be assigned and expectations set. Some examples:

  1. Billing manager: Determines the number of patients in the practice with Medicare and diabetes and creates mechanisms to identify, determine if patients have had an annual CDFE and if patients have been fit with shoes that year.
  2. Scheduler: Ensures that physicians schedule patients with Medicare and diabetes for separate dedicated CDFE appointment
  3. Office assistant: processes CDFE and shoe ordering information
  • Put the documented shoe fitting process into a binder, online folder or other accessible, easy-to-find package
  • Turn the practice’s list of core processes (from Step 1) into your table of contents
  • Give it a name. The ABC Way, Franchise Model, Operating Model, SOP, etc
  • Call out, identify, discuss and solve issues immediately as they arise—no exceptions
  • Update the process regularly

Following this “3-Step Documentation” approach, the practice will experience the benefits of having a consistent, agreed-upon way of managing priorities. Keep the benefits going by continuing to review and update protocols on an ongoing basis.

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