A Closer Look At Practice Management Aspects Of Treating Heel Pain

By Lowell Weil Jr., DPM, MBA

Heel pain is the single most common reason that patients seek out the care of podiatric physicians. Estimates state that more than 15 million Americans suffer with heel pain and emerging technologies for treatment have ballooned over the past seven years. However, many of these technologies are expensive and may not be covered by all insurance companies. Therefore, it is incumbent upon the podiatric physician not only to know the practice guidelines of the American College of Foot and Ankle Surgeons (ACFAS) for the treatment of heel pain but also the financial considerations for patients with this condition. At the Weil Foot and Ankle Institute, we have developed comprehensive guidelines for treating the patient with heel pain. In arriving at these guidelines, we have given full consideration to designing the treatment program to be cost effective for the “acute heel pain” patient and progressing with more sophisticated (and costly) treatments for the chronic heel pain patients. A Valuable Time-Saver: Delegating The Initial Exam On an initial visit to the Weil Foot and Ankle Institute, my patient coordinator, a certified pedorthist, initially interviews patients. The interviewer notes the chief complaint, duration of symptoms and previous treatment. The patient sees our foot and ankle fellow or resident, who undertakes a more detailed and appropriate medical history and podiatric physical examination. At this time, the fellow or resident obtains a complete medical history, review of systems and lower extremity examination. The examination includes vascular, lymphatic, neurologic, dermatologic and musculoskeletal examinations as well as a visual stance and gait analysis. The fellow will also order digital radiographs, when indicated, and have them available for my evaluation. After collecting all the data, I then introduce myself to the patient and have the fellow present the case to me. The patients really enjoy this aspect of the visit as they are able to hear all of the findings and details that are considered for their condition. From a practice management standpoint, it saves me a considerable amount of time by not having to listen to a long history about five pair of orthotics, 10 weeks of physical therapy and three painful cortisone shots that only worked for a day. For those practitioners who do not have fellows or residents, a well-trained podiatric assistant can obtain much of this information. In order to evaluate and document this type of examination appropriately, one should properly code this examination with CPT 99203 in addition to the diagnostic tests the physician or assistant performs. Commonly, another physician may refer a patient to me for evaluation and treatment of the heel pain. In this circumstance, when one performs the same history and physical as stated above, the proper coding is CPT 99243 (consultation). You must accompany this with a letter to the referring physician. Radiographs should accompany an initial history and physical evaluation. These studies are important to rule out other possible etiologies of heel pain such as stress fracture, infection, bone cyst, bone tumor, coalition or adjacent joint arthritis as well as other possibilities. Additionally, the presence of an inferior heel spur can determine that chronic plantar fasciitis has been present for at least several months. Key Treatment And Coding Tips For Conservative Management After diagnosing plantar fasciitis, one should recommend and institute a treatment plan. I have found that a detailed but simple explanation of the etiology of the problem to the patient makes his or her compliance to the solution more likely. Initially, higher heeled shoes are recommended to relax the tight calf muscle complex, which is a common contribution to the development of heel pain. Any shoe that has at least a one-inch differential from the heel to the toe is beneficial. However, it has been our experience that running shoes provide the greatest support and comfort. Furthermore, patients should avoid going barefoot or wearing slippers, flats, sandals, house shoes or any other type of foot gear that does not offer heel height or support. Several companies offer physicians the opportunities to provide these types of shoe gear options through their offices. These services help assure patients they are purchasing the proper shoes and there is tremendous convenience as patients do not have to go out searching for the proper shoe.

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