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DME Workshop 2010

Jonathan Moore DPM, MS Board Certified ABPOPPM

Fellow/BOT AAPPM AAPPM Board of Trustees

Time to Diversify Vascular Testing

Vascular Testing…Sometimes its really important to spot something

before it finds you… Peripheral Arterial Disease

Hiatt WR. N Engl J Med. 2001;344:1608-1621

Asymptomatic Disease

66%

Symptomatic Disease

34%

Indications for Peripheral Arterial Evaluations

Claudication of less than one block or of such severity that it interferes significantly with the patient’s occupation or lifestyle, Rest pain (typically including the forefoot) usually associated with absent pulses, which becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent position, Tissue loss defined as gangrene, pre-gangrenous changes of the extremity Ischemic ulceration of the extremity occurring in the absence of pulses Aneurysmal disease, Evidence of thromboembolic events Blunt or penetrating trauma (including complications of diagnostic and/or therapeutic procedures), Signs of vascular compromise include all of the following: – Symptoms in the extremity; – Past medical history; and – Abnormal findings on physical exam.

Testing Options

Single level physiologic studies – (e.g., Doppler waveform analysis, volume

plethysmography, transcutaneous oxygen tension measurement) (93922).

Multiple Level: Segmental physiologic studies or with provocative functional maneuvers (93923).

What Does PADnet test?

Ankle-Brachial Indices (ABI) – Description: A test to evaluate and compare

the systolic blood pressures in a patient’s arms and ankles.

PVR (Pulse Volume Recording) – Changes in Volume – Regionalize the disease.

Why Test

1. Saves Limbs, improves Outcomes 2. Builds valuable relationships 3. Convenience for your patients 4. Excellent Marketing Tool 5. Easy To Perform 6. Excellent ROI 7. Center of Excellence

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Why Biomedix Works in My Practice

Documentation In Place to Remain Compliant Excellent reimbursement Easy for staff to perform Sending the reports to referring doctors has excellent benefits Improves credibility in the medical community Protocols in place

PADnet Reports Peripheral Vascular Disease Early Detection Program

Vascular Specialist or DPM DPM

PADNet

ICD-9 Coding ICD-9

440.21 Leg pain with exercise (Intermittent Claudication) 440.22 Leg discomfort at rest (Vascular Rest Pain) 440.23 Non-healing wound on foot or leg (Ulceration) 440.24 Advanced ulcer on foot or leg (Gangrene) 443.10 Embolic discoloration in toes or feet (Buerger’s Disease) 729.50 Pain in limb (Unspecified Limb Pain) 903.00 Injury in limb or foot involving blood vessels (Blunt Trauma) 250.70 Diabetic with vascular disorder (Non-compressible vessels) 443.90 Over age 70 with decreased pedal pulses? 443.90 Over age 50, smoke and/or have diabetes, and decreased pedal pulses?

Coding and Reimbursement CPT Code 93923: Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental volume plethysmography)

Medicare Avg. = $149.00 Per Test/Professional and Technical Medicare Avg. for Technical component only: 127.13 Reading Specialist using modifier -26: Medicare Avg = $22.18 Approximately 160 tests will pay for machine: – At 5 tests per week,

(127.00X5 X52) =33K – Machine is paid for in less

than a year

Vascular Testing LCD Required Documentation

Noninvasive vascular studies are medically necessary only if the outcome will potentially impact the clinical course of the patient A hard copy, or a soft copy convertible to a hard copy, provides a permanent record of the study performed and must be of a quality that meets accepted standards.

Assessing Vascular Status Protocols For Testing

All new diabetic patients are given a short questionnaire to fill out (pain questionnaire) while waiting. If the patient has symptoms (including an open wound) in conjunction with clinical evidence of PVD, a prescription is written for a referral. If pulses are palpable and there are no symptoms, the test is usually not ordered unless accompanied by some other condition. (non healing wound) Chronic wounds with pulses are usually always tested. Claudication symptoms with pulses are referred for the test. Tests for screening purposes can NOT be billed.

Biomedix PADnet

Reading Waveforms A rapid rise in the upstroke during systole A sharp peak at maximum amplitude A gradual downstroke following peak amplitude Usually the presence of a dichrotic notch

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A New Concept in Bracing

Custom-Made AFO Reduces Fall Risk

Decreased postural control can occur because of ankle instability. Loss of normal sensation, such as in diabetes and other causes of peripheral neuropathy, also lead to a loss of postural control.

The Benefits of An AFO The use of an AFO has been reported to improve postural control under both monopedal (standing on one foot) and bipedal (standing on both feet). Proprioceptive information at the level of the foot/ankle, the vestibular or balance system within the inner ear, and vision are all important factors in the measurement of postural sway.

The Balance AFO The AFO stabilizes the foot/ankle even in the absence of visual information by providing: – Increased sensorimotor function offered by the ankle

support – Postural control is improved when ankle movement is

controlled by the use of an AFO – Stabilizes with fatigue, osteoarthritis, and pain.

Proprioception Numerous studies have reported that a localized fatigue of the ankle muscles, known to alter the force- generating capacity of the ankle joint, also affect the function of the proprioceptive system. An AFO can prevent fatigue and improve proprioception in the foot and ankle.

The Balance AFO Recent experiments have shown that an AFO can actually stimulate cutaneous (skin) mechanoreceptors (cells in the skin that respond to mechanical stimulation). The stimulation by the pressure contact of the material on the skin leads to additional nervous information sent to the brain and central processing center.

The Custom Balance AFO The AFO becomes another source of sensory information and improves balance under conditions in which other sensory cues are eliminated.

So What Will an AFO do? Lead to sensory reorganization for postural control Will help to reduce the risk of falling and its potential for injury in the older patient An AFO reduces postural sway thus giving the patient more confidence and less fear of a fall A custom fit AFO restricts undesirable motion at the foot and ankle and enhances joint mechanoreceptors to detect disturbances and provide structural support for controlling postural sway.

Why Custom is Better A custom-made AFO (taken from a mold of the patients foot and ankle) guarantees maximum cutaneous mechanoreceptor sensory activity. It also covers part of the foot sole, part of the upper part of the foot, both ankle bones medially and laterally, and several inches of the leg above the ankle bones. This provides a significant amount of surface area and covers key areas of the foot/ankle to maximize skin mechanoreceptors.

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Postural Sway Increased postural

sway is a significant risk factor for falling. This can be managed by appropriate foot wear and stability around the foot and ankle Most falls occur in the house BAREFOOT or in HOUSE SHOES

What is a Balance AFO? Completely surrounds the ankle to provide as much somatosensory feedback as possible (i.e. Gauntlet style) Light Weight Easy to Fit Into Shoes Easy to Put on Padded to Prevent rubbing or friction Cost effective Easy to fabricate

Three Lines of Treatment for Fall Prevention

(OTC)Peromax AFO: Light weight, easy to fit into shoes, but no ankle stability, no somatosensory feedback L1951 Reimbursement 700+

Weakness of the OTC Peromax AFO as Balance Tool

No ankle stability Little Somatosensory feedback Bulky Harder to apply

Treatment Options for Balance Bledsoe Axiom or the Ossur Rebound L1971 Reimbursement: $400+

Weakness of the OTC Ankle Gauntlet as a Balance Tool

Poor somatosenory feedback Non custom Harder to get on No foot orthosis component No dropfoot support

The First Podiatric Balance AFO

www.fallpreventionbrace.com

www.fallpreventionbrace.com All Compliance documentation Easy to Perform Fall Risk Assessment Form Over 50 patients already studied yielding, reduced fall risk, overwhelming patient satisfaction and compliance

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Balance Treatment Algorithm

Opportunities

In-office setting (Bilateral bracing) Nursing Home setting (in conjunction with some objective balance testing) Assisted Living Facilities Physical Therapy Home Health Agencies (Review your AFO protocol) Lecture Opportunities unending

Zero-G Offloading AFO Indications for Use • Charcot’s Joint (Neuropathic Joint Disease) • Arthritis • Spina Bifida • Osteochondritis Dissecans • Heel Ulceration • Metatarsal Ulceration • Fractures of the distal tibia, talus, or calcaneous • Pre or Post surgical intervention of the mid and hind foot • Crushing injuries of the mid and hind foot

Zero-G

APC+ (Autologous Platelet

Concentrate) USING PLATELET CONCENTRATE TO INCREASE

BIOACTIVITY

• Diabetic • Obese • Smoker • Immune Compromised • Chemo/Radiation • Elderly • Infected • Vascular Compromised • Redo’s

Patient Profiles Affecting Healing

The Healing Challenged Podiatric Applications for Autologous Platelet

Grafting/Gel

Chronic Wounds Tendonopathy

Decubitis/Venostasis Ulcers Plantar Fasciitis

Diabetic related Ulcers Tendonitis (achilles,

Post Surgical posterior tibial) Orthopedics Fractures Non Union

APC All codes and reimbursement are LCD dependent Coding: – 76942 Ultrasound Guided

Injection: approx. $87.20 – 20926: Tissue Graft

Harvest: approx. $396.29 – Unlisted Procedure:

28899: ?

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In Office Orthortripsy EMS Dolorclast

The Swiss Dolorclast® consists of a control unit and a handpiece with the treatment applicator mounted on the end. The treatment applicator is held in contact with the heel. Compressed air is used to drive a projectile (metal cylinder) within the handpiece toward the applicator. When the projectile hits the applicator inside the handpiece, a shock wave is generated which is transferred to the treatment site. The highest energy density will be at the point of contact of the applicator (the treatment site), but the shockwave will travel radially outward into the soft tissue surrounding the point of contact. Peter Segers Office +1 972 690 8382 Fax +1 972 690 8981 11886 Greenville Avenue Suite 120 Dallas , Texas 75243

EMS Swiss DolorClast® Non invasive treatment without the need for ultrasound guidance, anesthesia, medication or surgical procedures to achieve effective results. Treatment session takes minutes to complete, the patient feels virtually no pain and is able to walk upon treatment completion.

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Orthotripsy Reimbursement

Podiatric Physician Owned Physical Therapy

In Office Physical Therapy

What is the Reasoning Behind Offering In-Office P.T.?

Added Service To Your Patients

Enhanced Patient Satisfaction Low Up Front Cost Improved Outcomes Unlimited potential to grow Excellent Potential Added Revenue Immediate Access Supervision of services

Models for Offering Physical Therapy Models for Offering Physical Therapy

Model for Delivery of P.T. Incident To Podiatric Billing Physical Therapists must be contract employees - Limited to Your Scope of Practice - Podiatric Physician writes the P.T. orders and the

Physical Therapists carry out the treatment plan - All Billing is Performed under physician group ID. - All therapy must be performed under the roof of the

podiatric physician Multidisciplinary Group Status Physical therapist is a full time employee and all services are builed

through the physical therapist.

What About Starks Laws? The Building Blocks Starks and State Law Survey/Compliance Plan – Health Care attorney – Physical Therapy Consultant can offer “Turn Key”

Find a physical therapist (full or part time) Evaluating existing referrals within your practice Equipment Needed to Start (Consultant) Contract with a Physical Therapist (must be designated as an employee) Billing/Coding for Physical Therapy Primer Group Number Staff to Do the Therapy (PTAs) Scheduling for P.T. (Developing a Plan) Developing Protocols for Referrals.

Small Fiber Disease

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ENFD: CPT 11100

Reimbursement 11100 = $85.00 ($71-112.00) 11101 = $30.00 ($25-36) Diagnosis: 356.8, 356.4, 357.2

CPT 11100

Reimbursement 11100 = $85.00 ($71-112.00) 11101 = $30.00 ($25-36)

Thanks!