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. Studies have shown that it is best to treat plantar fasciitis with an “arch support” of some sort. Initially, we utilize an over-the-counter device that we always customize for the patient at the time of initial visit, thereby starting the healing process immediately. There are many devices available on the market that are effective and one can easily customize these in the office by simply grinding the device or adding modifications to the device. When providing this service, you would code it as L3060 for both the left and right foot. While some insurance companies like Medicare do not cover this code, many others will reimburse for this service in the $75 to $150 range. Addressing the tight calf muscle complex is crucial to successfully treating plantar fasciitis. We commonly refer the patient to our physical therapists or prescribe physical therapy to help train patients on proper stretching techniques, and then monitor their compliance over a span of time. Additionally, researchers have found night splints to be effective for treating chronic plantar fasciitis. One would code the night splints with L1930, which is commonly reimbursed by insurance companies. Using antiinflammatory medications is very effective in reducing swelling and pain associated with this condition. Breaking the pain cycle of this problem is key to getting the patient moving toward recovery. In many circumstances, over-the-counter or semi-custom arch supports are not sufficient to properly support and control the patient’s biomechanical problems. In those cases, customized orthotics are very valuable. When it comes to patients with heel pain, we have found that softer, accommodative orthotics have greater success and compliance with our patients than the more typical, plastic, functional devices. The accommodative devices that we utilize for heel pain are produced by The FootCare Depot (footcaredepot@gmail.com). The FootCare Depot’s high medial and lateral phlange (UCB type) offers more support and control of the foot. One would code these devices with L3000, which offers a higher reimbursement than standard orthotics that one would commonly code as L3020. When billing for orthotics, it is important to bill for both the left and right device individually. Pertinent Insights On Coding For Cortisone Injections When these initial treatment options do not successfully control the heel pain, more aggressive alternatives may become necessary. A cortisone injection is a very effective adjunctive treatment to the heel pain treatment regimen. It is my belief that one should only utilize cortisone after initiating proper mechanical control of the foot and addressing the factors that initially caused the problem. At that point, cortisone can be very helpful. However, cortisone injections to the heel have a very traumatic reputation with regard to procedural pain. Many times, I have heard patients state that a cortisone injection to their heel was the most painful experience of their life. To obviate that, I always perform a local anesthetic, medial calcaneal nerve block several minutes prior to the introduction of the cortisone injection. This nerve block significantly reduces the pain associated with the cortisone injection and allows greater ease in performing the cortisone injection. One should bill both the nerve block and the actual cortisone injection in these circumstances. Code the nerve block as CPT 64450 and bill the cortisone injection as CPT 20550. Additionally, in selected cases, if one has a musculoskeletal ultrasound available, you can utilize it to help target the placement of the cortisone injection and help facilitate greater success. This is especially helpful with a fragmented heel spur. One would code this additional tool as CPT 76942. It is unusual for me to utilize more than two cortisone injections for the treatment of plantar fasciitis and I usually do not go beyond a single injection. When the aforementioned treatment regimen fails over a period of four to six months, it is necessary to consider more aggressive treatment alternatives. It has been my experience that most people will respond to the above treatment. However, in the cases of failure, we have often found that the plantar fascia itself has changed and become scarred and thickened. This entity is more appropriately termed plantar fasciosis. What About Extracorporeal Shockwave Therapy? It is very difficult to treat plantar fasciosis conservatively. My preferred initial treatment for plantar faciosis is extracorporeal shockwave therapy (ESWT). Over the last seven-plus years, we have treated hundreds of chronic plantar fasciosis patients successfully with ESWT. Dozens of prospective placebo-controlled, double-blind studies have proven ESWT effective. This modality offers a completely non-invasive alternative with no risks or complications. Over the past year, we have utilized multiple treatment, low-energy ESWT with tremendous success. The EMS Swiss DolorClast was FDA approved in the spring of 2007 and has been our mainstay of treatment ever since. This technology offers patients the benefits of treatment without the use of any anesthetic whatsoever. Research has shown that the use of ESWT without anesthetic is superior to the use of anesthetic as biofeedback is controlling the treatment. We have found that this technique offers us results at least as favorable as higher energy treatments with anesthetic. There are also the added benefits of reduced costs to the patients and the elimination of the need for sedation or local anesthetic. I believe one should consider ESWT as synonymous with LASIK procedures for the eyes. LASIK is a proven technology that physicians perform hundreds of times on a daily basis yet insurance companies do not cover the procedure. Patients are accustomed to and comfortable with paying cash for this simple and low risk procedure with great benefits. Extracorporeal shockwave therapy is no different in this respect. We should feel comfortable telling patients that this is a beneficial procedure but that it is an out of pocket expense. With the DolorClast, the costs can be much more affordable. Typically, three treatments are necessary for optimal results and one would usually perform these treatments on a weekly basis. Charges for this procedure are commonly quoted at $300 to $500 per treatment or $900 to $1,500 for the series. If the patient receives only 80 percent success, it is easy to throw in a fourth treatment, gratis, with no extra cost to the podiatric physician. The Swiss DolorClast is the only ESWT device that is available under $100,000 and we have two devices that we use daily. This easily allows us to recoup or investment while providing our patients with the most up-to-date treatment available. Percutaneous Microfasciotomy: A Viable Option For Plantar Fasciosis? When ESWT fails or circumstances do not allow for ESWT as an option, we have utilized percutaneous Topaz microfasciotomy (Arthrocare) for cases of plantar fasciosis. Over the last two years, we have utilized the Topaz radiofrequency technique and created a percutaneous approach to it. We introduce the Topaz wand into the plantar fascia through tiny “pin prick holes” on the plantar aspect of the affected heel. One can perform multiple Topaz microfasciotomies in the plantar fascia. This stimulates angiogenesis and normalization of the tissue. Patients wear a short CAM walker (usually DJO with air code) for four days and may subsequently resume wearing their normal footwear. Total healing can take 12 weeks but virtually everyone is continuing activities of daily living within one to two days. In an evidenced-based research study that we are conducting, we have found that patients heal much faster with this technique than any other open or endoscopic release of the plantar fascia without the complications associated with releasing the fascia. In Conclusion As insurance companies continue to reduce payments, it is necessary for podiatric physicians to continue to properly care for their patients but get reimbursed appropriately for their services. Heel pain is the most common condition podiatric physicians see in practice and having a regimented treatment protocol that has proven successful with the reimbursement knowledge in place can help create and maintain a thriving practice. Dr. Weil is the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.

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