Cath Lab Digest

Pointers For Measuring And Ensuring A Proper Fit
Currently, more diabetic shoes are being dispensed from “medical supply (DME)” stores than out of podiatric offices. Why? Prescribing DPMs certainly know more about the foot and diabetic risk factors than any pedorthist or physical therapist.
Much of what is involved in fitting and molding patients for shoes is common sense. Here are some considerations.
• Measure right the first time. The first thing you need to have is an accurate measuring device. Some diabetic shoe companies have their own specific measuring tools for their shoes so it’s important to measure correctly for the prescribed shoe.
When measuring the patient, be sure to measure both feet as sizes may differ. Measure the width of the foot and be aware and educated as to what shoe types come in the wider widths. Avoid putting a patient with a 4E width into an “extra wide shoe.” Some shoes only go up to an extra wide width while others (like the New Balance 810) go up to a 4E width. Include the size and width on your prescription along with your recommended shoe.
Most vendors will send you information or will even send a rep to your office to educate you on how to appropriately and accurately measure for shoes. Don’t be afraid to ask.
• When the patient comes in for fitting, it is well worth your time to make sure the shoe fits his or her foot well. If it doesn’t fit, reorder. Make sure you also have a policy in place that informs your patients when you will and will not accept returned shoes for replacement.
• Be aware of the rules on molding inserts. Medicare will only cover diabetic inserts that are either custom fabricated (A5511) or heat molded by an external heat source (A5509). For heat molded, pre-fabricated inserts, Medicare mandates that these inserts must achieve “total contact” with the patient’s foot. Keep in mind that many prefabricated inserts sold as heat moldable diabetic devices do not meet this criteria.
• Lastly, keep in mind that some patients with certain foot types (cavus foot) will absolutely require a custom made device as opposed to a prefab, heat molded insert. In addition, patients with severe deformity (Charcot osteoarthropathy or a partial amputation) should not use a heat moldable prefab. In these cases, you should take a cast impression and send for a custom insert (A5511). Companies like SureFit fabricate custom devices and can help with other additions like toe fillers and bars.

Other Pearls For Maintaining A Thriving, Efficient Program
• Don’t get caught up with high profits while compromising quality and proper fit. Avoid using cheap shoes and cheap inserts in order to increase profits. Word gets around quick and sometimes the shoes you dispense represent you as a physician. Provide a great product and people will come.
• Consider sending the CMN with the patient to get it signed. Sometimes mailing the CMN takes weeks to months to get it returned. Also be aware that Medicare requires an original copy of the CMN in the chart.
• Always include a self-addressed stamped envelope when you are mailing the CMNs or even if you are sending the CMN with the patient.
• Send reminders to patients when it is time for them to change their inserts or when they are eligible for new shoes. You’ll be surprised at how many patients come in that you haven’t seen in a year.
• Start the process a month before the patient is eligible for new shoes. It will take four to six weeks from evaluation of the patient’s feet to fitting of the shoes.
• Many private insurers also cover diabetic shoes and inserts (A5500 x 2, A5509 x 6). It behooves you to have someone call on these patients to see if their insurance will cover yearly therapeutic shoes.
• Take great care in measuring your patients’ feet and set policies on when you will and when you won’t replace or accept returned shoes. Reordering and returning shoes can eat up your profit if it gets out of hand.

Jonathan Moore, DPM, MS, is a former University of Texas Diabetic Foot Fellow who practices in Somerset, Ky. Kimberly Moore, OTR, currently serves as the diabetic shoe coordinator at Cumberland Foot and Ankle Center in Somerset, Ky.