Should Podiatric Physicians Surrender AFO Therapy To Pedorthists?

Doug Richie Jr. DPM FACFAS

I often give workshops at scientific symposia covering topics relevant to ankle-foot orthotic (AFO) therapy. Often, people ask me questions about Medicare regulations for coding and billing for these devices. Recently, someone asked me about a new program in which a commercial AFO company offers to have a certified pedorthist (CPed) evaluate and treat patients in podiatric medical practices.

The question arose about the legality of the podiatric physician being able to bill Medicare for the services of the CPed. While this is not legal in my opinion, I have a more important concern about what appears to be a very distorted perception of the competency of podiatric physicians to provide biomechanical treatments.

What has raised my concern is the fact that a commercial company has now determined that podiatric physicians are either too busy or are not qualified to evaluate and treat patients for ankle-foot orthotic therapy. In the past, podiatric physicians would perform their own biomechanical examinations and casting for foot orthoses and AFOs. Patients in a podiatric practice would get referrals to other practitioners for orthotic therapy only when an insurance or HMO contract mandated it. Now, there is an apparent perception that most podiatrists are not comfortable evaluating and treating their own patients for foot orthotic and ankle-foot orthotic therapy, and now need an “outside consultant” to provide the most important treatments in the office setting.

I am astounded that any podiatric physician would be too busy or overwhelmed with any part of practice to be able to take the time to provide a proper patient evaluation for AFO therapy. Furthermore, why would the doctor not want to take a few minutes to take an accurate cast and be in the treatment room for the fitting and adjustment of the device? As the typical custom ankle-foot orthosis provides a reimbursement equivalent to any complex rearfoot or ankle reconstructive surgery, time spent to implement this treatment in the office setting must be at the highest level of priority from a practice management standpoint.

It is unthinkable that any podiatric physicians would consider themselves less qualified than any certified pedorthist to evaluate a patient and implement effective AFO therapy. The training of podiatric physicians in basic anatomy, biomechanics, gait analysis and understanding of neuromuscular disease makes them more than qualified than any other medical specialty to implement ankle-foot orthotic therapy. Yet, I read new testimonials from my colleagues who have discovered that a CPed in their office provides expertise for measurement, casting and fitting of an ankle-foot orthosis, which frees the doctor up for "more important” patient treatments.

I have to ask: What patient requires more attention and expertise from the podiatric physician than one with stage II adult acquired flatfoot? Do you really need to delegate this critical patient to an individual hired by a commercial interest who will direct business to his or her employer?

As for the legality of allowing a CPed into your office who is hired by an outside commercial AFO company, consider the following observations:

1. The CPed is not your employee and you have not vetted or credentialed him or her.
2. A commercial company hired the CPed and will mandate that all AFO prescriptions and foot orthotic prescriptions go to the lab that hired the CPed. This could be a violation of Federal Stark Laws.
3. A presumed benefit of the outside CPed is the fact that this hired individual provides the patient evaluation, casting, dispensing and adjustment of the ankle-foot orthosis to the patient in the podiatry office. Yet the podiatric physician, who is the “supplier” of the device, bills Medicare. All of my colleagues in the podiatric profession tell me this is illegal. If the physician did not do the casting, fitting and adjustment, then he or she is not the supplier. The podiatric physician is at great risk for punitive action from Medicare if there would be an audit of the patient medical record and evaluation of who actually participated in the treatment.

Until recently, there has never been a suggestion that podiatrists need the help of a pedorthist to do patient evaluations and implement the entire orthotic treatment intervention. Even if this sad state of podiatry was ever to become a reality, the billing and payment of these services will have to go to the CPed, not the podiatric physician, who has now admitted that he or she doesn’t know enough to participate in the treatment of his or her own patient.

Comments

A good example of how too many podiatrists (especially those who finished residency and/or fellowship in the past 5 years) tend to neglect podiatric medicine and focus more on podiatric surgery in the clinic office. The pre-op and post-op mentality. It should rather be: medicine first, surgery last. Not all medical cases are pre-op cases and they don't have to be. Just extra money for surgery that was not necessary. Don't be surprised if Medicare and other insurances are soon targeting podiatrists who are keen on too much podiatric surgery and less to no podiatric medicine in their practices (i.e. denial of payment and audits) in the next 10 years.

Although I agree with your perception of a trend towards total focus on surgery, I do not think our profession has abandoned interest and treatment of patients using non-surgical biomechanical based interventions. Keep in mind that a commercial interest, not myself, has made this erroneous perception of who we are and what we know.

I believe that the majority of my colleagues are just as insulted as I am at the suggestion that I need the help of an outside health professional whose training is approximately one tenth of mine to come into my office and treat my patients. I know many highly qualified podiatric surgeons who use ankle-foot orthotic therapy as first-line treatment before considering surgery. None would consider surrendering non-surgical treatments to a lesser trained individual who is hired by an outside commercial interest.

Yes, if Medicare discovers that podiatric physicians are delegating all supplier duties to lesser trained CPeds, there could be repercussions for our status as DME providers.

The decision to turn common podiatry services over to non-podiatrists, mid-level practitioners, pedorthists or podiatric assistants is often an economic one. One needs to assess the level of skill needed to effectively perform specific services before specific services are delegated.

If one considers the act of performing a biomechanical exam or orthotic/AFO casting to be highly skilled, then that is a service that need reside with the podiatrist. I am a bit "old school" in that area in that I feel that biomechanical exams, when performed thoroughly, require skills consistent with the training of podiatrists. I am not sure that the majority of the new generation of 3-year residency trained podiatrists would agree.

There is a perception among the public and a number of healthcare professionals, in my experience, that the podiatry profession has lost interest in biomechanics. I would like to think that perception is incorrect.

Just to be the devil's advocate. I must explain to patients that even if the AFO fits perfectly today, their foot and skin pressure points will change over time. The rigid plastic orthotic will not change. Also, the padding may need to be adjusted or replaced. It is these adjustments over the five-year expected orthotic life that are difficult, whether you are attempting this in your office or mailing to an outside lab. Old chiropodists who made orthotics had a lab room in their office or home. I try to fit the occasional patient but sometimes it is easier to refer directly to a full service lab available in the metro area.

We perform a valuable service in diagnosis and patient education but a good lab filling the RX will save a lot of "Doctor, it was wonderful last year but now it hurts here and here and the leather is dirty" complaints.

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