From the Desk ofDr. White

Essentials for Diabetic Shoe Fitting Success

Dr. Josh White, DPM

February 11, 2018

image Each year presents a new opportunity to set goals and priorities. I recently visited an office that has been fitting diabetic shoes for many years. I appreciated their interested in learning how they could improve what could be considered a "good" shoe program.

We started by making sure that everyone involved, from the front office person who reminds the doctors which patients have diabetes and need an annual comprehensive diabetic foot exam to the person who fits patients' shoes, is critical to the program's success. Also, how when working, the Medicare Therapeutic Shoe Program provides a win – win – win benefit: patients get shoes they like for little or no cost and get decreased risk for ulceration and amputation, the office makes money and improves patient satisfaction and Medicare actually reduces costs.

I reiterated to the office the importance of clearly defining each of the steps in the evaluation and shoe fitting process and confirmed that while there could be more than one person performing each task, there must be a single person responsible for the shoe program's execution.

Lastly, there must be defined metrics for determining the success of each step as well as for the program overall.

Here are the steps for creating a successful shoe fitting program and how to determine its successful execution:

  • Determine the number of patients in the practice with Medicare and diabetes. Every patient should have a dedicated visit for an annual comprehensive diabetic foot evaluation on a separate visit. Can be performed by or overseen by the DPM and billed as 99213 if predisposing condition of ulcerative risk determined and a plan of care prescribed. Printed copies of the CDFE form are available, for free, from SafeStep upon request, http://safestep.net/safestep/PDF/CDFE(Interactive).pdf?id=431.

    • Consider non-invasive vascular testing and vascular consult if PAD present.

    • Consider prescription footwear and inserts if ulcerative risk factors present.

    • Consider fall risk assessment if there is a history of unsteadiness or falls.

Someone should track, on an ongoing basis, the number of CDFE exams performed, and compare it to the number of patients in the practice with diabetes. Read the article, "The Medicare Therapeutic Shoe Program, New Challenges, New Opportunities", http://safestep.net/safestep/Library/podmgmt201010.pdf Performing CDFE will satisfy PQRS / MIPS measures 126, "Peripheral Neuropathy-Neurological" and 127, "Ulcer Prevention-Evaluation of Footwear". Read the article, "Mrs. Smith Gets Her First Comprehensive Diabetic Foot Exam", http://safestep.net/safestep/Library/podmgmt201011.pdf.

  • Conservatively, 75% of patients with Medicare and diabetes will have a qualifying risk factor and should be prescribed therapeutic shoes. Either have a shoe fitting person in the practice available to assist on that day or consider OHI's Central Casting Program such that patient is scheduled with Certified Pedorthist on next scheduled day.

  • Shoe fitter should use the "4S's approach to shoe fitting", http://safestep.net/safestep/Library/ShoeFitting/FourSs.pdf, considering: Size, Shape, Stability, Style to fit with shoe that meets patients' aesthetic desires and therapeutic needs. It's important to have shoe samples in the styles patients most prefer and to update them periodically. Fitting displays or a small fitting inventory will go a long way at improving fitting success and patient satisfaction. Patients whose fitting needs exceed what's possible with depth shoes should either be casted for custom molded shoes or referred to a local footwear clinic.. The SafeStep website displays the practice's "Fit Rate". If not 85% or better, help is available to fit at least as well as is done by the average office.

  • Use WorryFree DME to create Medicare compliance documentation and to procure required authorization from the certifying MD physician. Don’t waste time having someone in practice faxing and calling MD offices, let SafeStep do it!! Someone has to ensure that forms are completed and dated correctly. Also that patients have been to their MD for diabetes management visit in the previous six months.

  • When dispensing shoes, emphasize to patients the importance of their checking their feet each day for signs of ulceration and the importance of the shoes in providing protection. Also, that the shoes and inserts are intended to be worn out and replaced each year.

  • The true indicators of a successful diabetic shoe program is that the number of shoes fit increases each year and the number of wounds treated decreases. While some practices have been deterred from fitting shoes because of the effort required and concerns about Medicare audits, many enjoy the success that this preventative care indicative was intended to achieve. Read the article "Keys for Success for Fitting Diabetic Shoes" http://safestep.net/safestep/PDF/KeystoSuccessforFittingDiabeticShoesWhite1012.pdf.

  • Most patients who qualify for shoes one year will still be in the practice, have a qualifying risk factor and should be fit with shoes the subsequent year. Despite this, most practices refit less than 25% of patients from one year to the next. Your SafeStep homepage displays the practice, "Repeat Rate". There are tools available including patient lists that can be used to facilitate a recall program to ensure that every patient is evaluated annually and if appropriate refit with replacement shoes. Read, "The $40,000, 4 Hour per Week Diabetic Shoe Program" http://safestep.net/safestep/PDF/The4hrperweekDiabeticShoeProgram.pdf. The article describes how little time is actually needed, if the program is organized effectively, to yield significant benefits to patients and to the practice… Also review the presentation on Patient Retention, http://app.sliderocket.com/app/fullplayer.aspx?id=2db3b1e7-d679-4e00-8568-036a8949994a.

  • Successful practices set goals at the beginning of each year and monitor their performance on an ongoing basis. Key metrics for ensuring program success are all displayed on SafeStep website homepage and include:

    • The number of annual CDFE's performed on patients with Medicare. Compare to the number of patients with Medicare and diabetes in the practice. Every patient should have at least one annual evaluation.
    • The number of shoe fit, covered by Medicare. Conservatively, 75% of patients with Medicare and diabetes will have a qualifying risk factor and should be fit with shoes.
    • Shoe fit rate. Should be 85% or better. If lower than it should be, assistance is available to help improve.
    • Refit Rate: Should be 75% by end of year.

Successful practices create incentive programs to reward staff members responsible for each of these key metrics.

  • Further assistance is available by scheduling a One-on-One Training Session with a SafeStep DME Specialist. Topics include:
    • "The WorryFree DME Shoe Ordering Process"
    • Diagnosis Specific DME Treatment Protocols for AFOs
    • AFO and Shoe Compliance Documentation
    • 18 Surefire Ways to Improve Your Shoe Fitting
    • Fall Risk Management Made Easy with Moore Balance
    • The CDFE Strategy

Go to SafeStep.net or call 866.712.STEP to register for a training session.