IntroducingMr.Smith: HowtoMaximize OutcomesandRevenue ... · an off-loading boot (Bledsoe Con - former) and he has been given Amerigel Hydrogel impregnated gauze (which he has been

OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 81

This article, written exclusively forPM, appears courtesy of the AmericanAcademy of Podiatric Practice Man-agement. The AAPPM has a forty-yearhistory of providing its member DPM’swith practice management educationand resources.

In part 1 of this 2 part series en-titled “Introducing Mr. Smith” (Au-gust 2008), we began to walk thereader through a sample woundtreatment protocol with a fictitiouspatient named Mr. Smith. The goalof this article was to simply demon-strate how well thought out proto-cols, including the implementation

of ancillary services and technolo-gy, can heal patients faster whilebuilding your business and yourreputation. In addition, the goals ofthis presentation include the fol-lowing:

1) To demonstrate how effec-tive protocols can improve out-

By Jonathan Moore, DPM, M.S.

Continued on page 82

IntroducingMr. Smith:How to MaximizeOutcomes and RevenueOpportunities Throughthe Integration ofProtocols–Part 2This case history shows how you can improve carewhile enhancing patient loyalty and compliance.

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tissue (BAT).Certainly, there are many op-

tions for consideration when itcomes to applying advanced tis-sues on chronic wounds, but forthe purposes of this article andfor expediency, Gammagraft bio-logical alternative tissue fromPromethian Life Sciences was cho-sen.

Considerations WhenChoosing a BiologicalAlterative Tissue (BAT)

1) Choose what you knowwill work. This may sound sim-ple, but it’s true. Is it Apligraf? Isit Dermagraft? Either is great.Whatever you use, understand

comes;2) To demonstrate how imple-

menting ancillary services intoyour practice protocols can en-hance outcomes and revenue;

3) To demonstrate how effec-tive communication skills can im-prove compliance and patient sat-isfaction;

4) To demonstrate how to re-main compliant by using docu-mentation tools and templates.

As a summary of who Mr.Smith is and what treatments andservices have been performed tothis point:

1) Mr. Smith is a 65 year oldmale with a PMH of diabetes,Charcot osteoarthropathy, and apartial 5th ray amputation to hisright foot.

2) He presents to you with agrade 2, non-infected ulcer to theplantar aspect of his right foot.

3) The wound has been de-brided twice, he has been givenan off-loading boot (Bledsoe Con-former) and he has been givenAmerigel Hydrogel impregnatedgauze (which he has been usingfaithfully every day for twoweeks).

4) Based upon your physicalexam, and from the informationgleaned from the Pain Manage-ment Form (see Part 1, August2008) that the patient filled outon visit one, Mr. Smith had a vas-cular test performed in your office(ABI’s, TBI’s PVR’s), which cameback within normal limits.

5) The patient at this pointhas had his wound open now forover three weeks and has noticedconsiderable improvement, butthe wound is still approximately1.2 cm. X 1.5 cm. in size. Thewound is granular and clean withminimal fibrosis or necrosis.

Fourth Office VisitMr. Smith presents to you for

his fourth office visit wearing hisBledsoe Conformer boot and it isapparent that Mr. Smith has re-mained compliant with your pre-scribed treatment.

As you inspect the wound andconsider your options to expeditehealing, you decide on the appli-cation of a biological alternative

that these products are costly andrequire time and attention forwound bed preparation as well asthe aftercare.

2) Take into considerationthe type of wound you aretreating. The depth of thewound will often determine thetype of BAT, and the characteris-tics of the wound will most oftendetermine the need for adjunctivetherapies like wound VACs, hyperbaricoxygen, or compression devices.

3) Consider the cost andreimbursement for the prod-uct you choose. Make sure thatyou understand that some of

Protocols—Pt. 2...


82 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2008

FORM 1


day global periods. The timing inwhich you use a BAT is critical.Using a BAT prematurely withoutpreparing the wound properly canresult in getting stuck in a verylong global period.

So, Mr. Smith’s wound iscleaned and prepped while youroffice staff prepares the room forthe procedure. The BAT is pre-pared for application along withthe dressing material you plan on

these products have J codes (prod-uct codes) while some do not. Inaddition, even those BATs with Jcodes often carry a price whichmakes it cost-prohibitive for youto dispense. Find out from thecompany that you order fromhow long they will carry the bal-ance for the product you are or-dering as it may take months toget reimbursement for the J codealong with the procedurecodes.

4) Local carrier determi-nations (LCDs) for most ofthese advanced biologicalalternative tissues areavailable either online orthrough the carrier. Theseguidelines usually have infor-mation regarding the numberof applications of the BAT thatare allowed as well as docu-mentation requirements.

5) Be ready for the glob-als. Most (Apligraf being oneof the few exceptions) have 90-

applying OVER the BAT. In ouroffice, an Amerigel hydrogel im-pregnated gauze pad will be ap-plied over the BAT to maximizeincorporation and wound heal-ing.

An aggressive excisional de-bridement of the wound, as need-ed, can be performed in prepara-tion for the BAT which will betterprepare the wound bed for thegraft material (CPT 15004). CPTcode 15004 is not intended to be

reported for simple graft appli-cation alone or application sta-bilized with dressing. An opera-tive note is needed for both thewound preparation using the15004 and the appropriate ap-plication code.

Mr. Smith’s wound was sur-gically prepped for the BAT andcare was taken to make sure thatthe wound was not bleeding inorder to achieve the best adher-ence of the BAT. Steri -str ipswere applied over the BAT fol-lowed by the hydrogel-impreg-



Figure 1: Gammagraft is applied to the wound sitewith the Amerigel Gauze as the secondary dress-ing to provide a moist, antimicrobial environ-ment to maximize incorporation and healing.

with no signs of infection or con-tamination. There is a clear filmover the wound bed that WILLNOT be debrided as this is a signof healthy incorporation of theBAT.

Mr. Smith is told to begin ap-plying a piece of the hydrogel im-pregnated gauze (dispensed in of-fice visit one) over the wound bedevery day after a gentle cleanse.Mr. Smith is told to remain in hisboot and follow up in one week.

Sixth Office VisitMr. Smith returns to your of-

fice two weeks status post-applica-

nated gauze and a secondarydressing (Figure 1). Mr. Smith wasgiven instructions for how to carefor the BAT (do not remove, keepdry, continue use of the Bledsoe),and the patient was instructed toreturn to the clinic in one week.

Learning Points for VisitNumber Four

1) Make sure the patient un-derstands that the material placedon his foot is expensive and morethan just a “traditional dressing.”Failure to do this may result innon-compliance and BAT failure.

2) Make sure you review yourLCDs to use the appropriate appli-cation code, J code, and prepara-tion code (15004) as needed.

3) Make sure you have docu-mented the characteristics of thewound and failure of conservativeoptions.

4) Non-weight bearing afterapplication of the BAT is vital.

5) Having a template op-notedescribing the procedure canmake effective documentation asnap (Form 1).

Coding Summary for VisitFour

1) Wound bed preparation fora BAT: CPT 15004 (this may notbe indicated for every wound inwhich a BAT is being applied. Re-view your LCD’s for further infor-mation.

2) Application of allograft forwound closure: CPT 15320.

3) Appropriate J code: J734_.

Fifth Office Visit for Mr.Smith: The Beginning of theGlobal

Mr. Smith presents for hisfifth office visit with his dressingintact, and with no significant ap-pearance of exudate or odor. Asthis is a global visit, care is takento make sure the patient under-stands the plan and the goals oftreatment as well as to remind thepatient of what he needs to con-tinue to do in order to remain onschedule.

As you remove the secondarydressing, care is taken to makesure that the BAT is not disrupt-ed.Mr. Smith’s wound looks good

tion of the BAT. His wound hasdramatically reduced in size andoverall Mr. Smith is thrilled to seethe dramatic improvement. As itis apparent that the wound willbe totally healed within the nextweek or two, Mr. Smith is toldthat now is the time to start theprocess of putting in place toolsto prevent future complicationsand skin breakdown.

Clearly, several viable optionsfor off-loading Mr. Smith’s Char-cot foot deformity are availablethat include custom orthosis, cus-tom/non-custom shoes, rocker




FORM 2

sion for an AFO, in cases like Mr.Smith’s in which you have bonydeformity, I prefer to cast the pa-tient in neutral suspension. Withthe patient’s foot suspended, youcan accurately capture the plantardeformity inorder to makesure you have anaccurate “pock-et” for the spe-cific anatomicaldeformity.

2) Further-more, it is vitalto make surethat you nevercast the patientin equinus. Withthis in mind,care must betaken to make sure the patient’sfoot is captured at 90 degrees.

3) In cases where spastic con-tracture is involved, having thepatient in a semi-weight-bearingposition is preferable. Keep inmind, however, that when youwant to capture plantar deformi-

bottom accommodations,among several other options.For Mr. Smith, however, anoth-er option was decided uponbased on his specific deformityand overall condition.

Due to the need to stabilizeMr. Smith’s neuropathic footand ankle as well as offload hisplantar deformity, an anklefoot orthosis (AFO) was chosenas the preferred vehicle to pro-vide long-term support and of-floading of Mr. Smith’s foot. Inaddition, Mr. Smith will be mea-sured for a diabetic shoe that willbe worn with his AFO (on thecontra-lateral foot).

Per the protocol, Mr. Smith isshown an example of the AFOthat he will receive. This helps apatient understand what thebrace looks like and often pre-cludes the typical “surprise” thata patient experiences when seeingthe brace for the first time. Next,the medical assistant applies anSTS casting sock to the right footwith care taken to make sure thesock goes up to the lower leg (nottoo low on the ankle) and tomake sure the sock captures accu-rately the plantar deformity. Last-ly, as Mr. Smith has a partial 5thray amputation on his right foot,a f i l ler wil l be ordered to beplaced on the Plastizote custominlay within the AFO.

Here Are Some FurtherConsiderations

1) Although there are severaloptions for fabricating an impres-

ty, you have to make sure theSTS sock is “smoothed” out andappropriately marked (with apermanent marker) to makesure the lab knows where topocket the AFO.

4) Mr. Smith’s gauntlet-styled AFO will have several keycomponents:

a) A full foot plate (attachedto the AFO) that will extend tothe toes and fully accommodatethe patient’s deformity (rockerbottom).

b) A custom plastizote in-sole (inlay) that will perfectly

accommodate the patient’s defor-mity from the heel to toe, includ-ing a filler for his partial foot am-putation.

c) The gauntlet component ofthe AFO will stabilize the ankle as

well as reducepressure to foot.

d) All Velcrolatches wil l beused without anylaces or latchesthat can make ithard for the pa-tient to apply thebrace.

e) As youhave marked theSTS at all sites ofbony promi-nence, the AFO

will accommodate the malleoliand all other deformities to pre-vent rubbing or friction.

Shoe Considerations for Mr.Smith

Choosing the right diabeticshoe is a lot more difficult than

finding the rightsize and color. For apatient who is highrisk, careful consid-eration is vital. Con-sider these pointers:

1) Take into ac-count the patient’sfoot type. This in-cludes not only thelength and width ofthe foot, but alsothe thickness (girth)of the foot. In otherwords, patients whohave swell ing orcondit ions l ike




Figure 2: With meticulous wound care and appro-priate offloading, Mr. Smith’s wound heals com-pletely.

Figure 3a: An Arizona AFO with a full force platealong with accommodation for Mr. Smith’s Char-cot deformity has arrived.

Figure 3b: With the anatomical accommodationfor Mr. Smith’s Charcot deformity along with afiller for his partial 5th ray amputation, every-thing is in place to help prevent further ulcera-tion.

Take into

consideration

the type of

wound

you are

treating


Documentation Pearls forDispensing Ankle FootOrthosis and Diabetic Shoes

1) As mentioned in part one ofthis series, a prescription for anyDME device is a necessary compo-nent for compliance. Therefore,for Mr. Smith, a prescription forhis AFO and his diabetic shoesand insoles were placed into thechart (Forms 2 and 3).

2) A signed certification of re-ceipt must be in the chart for theAFO and for the supplier stan-dards and warranty/wear informa-tion. This information can be onone form as long as your instruc-

Charcot, need a shoe that has theability to expand (flex) withoutcausing friction or rubbing.

2) Don’t ignore the presenceof swelling. This can alter shoe fitin a major way. Get your patientsin compression garments and ed-ucate them regarding the risk ofswelling while confined in a non-expandable type shoe.

3) When it comes to choosinga shoe to fit with an AFO, consid-er shoes with a Lycra fore-foot/tongue component with Vel-cro.(e.g., Orthofeet Lycra Velcro,Apis Lycra, Pedor Lycra, or the Dr.Zen Lycra shoe) Shoes that comewith extra-wide widths are alsoimportant for the best shoe fit.

4) With certain types of AFO’s(Gauntlet style) finding the rightshoe to fit over the AFO and thecontra-lateral foot can be diffi-cult, especially without the bene-fit of having specialty shoes instock (Lycra, depth, extra-widewidths). And in some cases, twodifferent size shoes may be neces-sary as long as function and sta-bility are not compromised. Al-though in most cases the samesize shoe can be found to fit theAFO and the contra-lateral foot,having to order two different sizeshoes (one shoe larger to accom-modate the AFO) can sometimesbe costly as many shoe companiesdon’t allow this.

After Mr. Smith was cast forhis AFO, a step box was procuredfor custom diabetic insoles for theleft foot only. As Mr. Smith willhave a custom orthosis and fillerbuilt into his AFO, no diabetic or-thosis will be needed for the rightfoot.

Custom diabet ic or thoseswere chosen for the right foot(as opposed to heat-molded) dueto the patient’s cavus, intrinsicminus foot type and severe neu-ropathy.

Mr. Smith was told that hisshoes (in this case, the OrthofeetLycra Velcro Shoe), his custom di-abetic insoles (Safestep) and hisAFO (Arizona AFO) would beavailable in approximately fourweeks and until this time, he wasto continue the use of his off-loading boot.

tions and warranty information isclearly laid out for the patient tounderstand.

3) Furthermore, several key com-ponents are necessary for documen-tation when prescribing a customAFO. They include the following:

• The patient could not be fitwith a pre-fabricated AFO.

• The condition necessitatingthe orthosis is expected to be per-manent or of longstanding dura-tion. (more than six months)

• There is need to control theankle or foot in more than oneplane.



FORM 3

ceipt must be in the chart for thediabetic supplies and for the sup-plier standards and warranty/wearinformation. This informationcan be on one form as long asyour instructions and warranty

information isclearly laid outfor the patient tounderstand.

At the end ofvisit six, Mr.Smith has beenSTS-cast for anArizona AFO thatwill include a cus-tom, accommoda-tive orthosis witha filler. In addi-tion, diabeticshoes and insoles

have been ordered that are appro-priate for the AFO and forprevention of ulceration onthe contralateral foot. Mr.Smith has been told to stayin his Bledsoe boot until theitems have arrived into theoffice. Mr. Smith will be ap-plying the hydrogel impreg-nated gauze to his foot everyday until seen again in twoweeks.

Office Visit Seven:Dispensing Day

Mr. Smith presents toyour off ice now completely

• The patient has documentedneurological, circulatory, or or-thopedic condition that requirescustom-fabrication over a modelto prevent tissueinjury.

• The patienthas a healing frac-ture which lacksnormal anatomi-cal integrity or an-thropometric pro-portions.

4) For Mr.Smith’s diabeticshoes, the fol-lowing docu-mentation pearlsare key:

• The patient’s physical exammust be documented, clearly indi-cating that the patient meets thecriter ia for receiving diabeticshoes. Include the presence ofneuropathy, deformity, the loca-tion of pre-ulcerative lesions, orthe presence of previous ulcera-tion or amputation.

• As noted above, a prescrip-tion for the diabetic shoes mustbe in the chart. This template-based prescription should havethe name/type of shoe being pre-scribed along with the type of in-soles. (custom or heat-molded)

• A signed certification of re-

healed. (Figure 2). The AFO andshoes have arrived and Mr. Smithis excited to get out of his boot(Figures 3a, b & 4).

The gauntlet-style AFO is fit tothe patient’s foot and the shoesand insoles are all put in place.The Lycra-styled Velcro shoeslides easily over the AFO; howev-er, the same sized shoe is slightlylarge on the left foot. So, twoshoe fillers (which come standardwith many diabetic shoes) areplaced under the diabetic insolein the left shoe, which seems tomake the fit perfect.

The patient is now asked towalk to assess stability and com-fort. Mr. Smith is thrilled. As Mr.Smith prepares to leave today, thefollowing information is preparedfor the chart:

1) Aside from the above-men-tioned certification of receipt andwarranty/wear information whichmust be signed and put into thechart, a dispensing note needs tobe placed in the chart which de-scribes the fitting process, yourgait evaluation, and the overallcondition of the products beingdispensed. For an example of thisnote, see Form 3.

2) Make sure the patient (andfamily) is educated thoroughly re-garding the importance of skin in-spection after the wearing of acustom device or a new shoe. AsMr. Smith is profoundly neuro-pathic, it is vital that he under-stands that pain will not be thereas a warning sign of potentialproblems.

Coding Summary of VisitSeven

1) Arizona AFO with Filler:




Using a BAT

prematurely without

preparing the wound

properly can result in

getting stuck in a very

long global period.

Figure: 4: Due to its flexible soft Lycra tongue andits easy-to-latch Velcro, the extra-depth OrthofeetLycra Velcro shoe is chosen to fit over the AFO.

ing his mother, wife, and kids,but you have a patient that youwill be seeing for life.

In another two to threemonths, Mr. Smith will be com-ing to see you for his skin andnail check-up and next year Mr.Smith wil l need new diabeticshoes. In about another five years,Mr. Smith will need a new AFOand may likely need many moreservices that your office will offeras a diabetes center of excellence.Effective protocols are more thanjust ancillary services and prod-ucts; they are a friendly staff andimproved efficiency too. Make ev-erything that you do in your of-fice patient-centered, and you willbe rewarded many times over.

The author would like to ac-knowledge the assistance of JohnGuiliana, DPM, MS, in the prepara-tion of this article.

The American Academy of Podi-atric Practice Management (AAPPM)has a forty-year history of providing

L1940, L2275, L2280, L2820,L5000 (filler).

2) Diabetic shoes X 1 pair:A5500.

3) Three single diabetic cus-tom insoles for Left foot: A5513.

Although much more can besaid about the impact of effectiveprotocols, there is no greater re-ward than a healed patient. Proto-cols are about improving out-comes, one patient at a time andNOT about making more money.It just so happens that improvedrevenue comes natural ly as abyproduct of well-executed ethi-cal protocols as illustrated above.Protocols should be in place forall of the most common diag-noses that you see in your prac-tice, including heel pain, ony-chomycosis, and others.

The beauty of having madesuch an impact on a patient’s life(as we did with Mr. Smith) is thatnow we have a devoted patientfor life. Not only will you be see-

its member podiatrists with practicemanagement educat ion and re-sources they need to practice effi-ciently and profitably, through per-sonal mentoring and sharing ofknowledge. To Contact AAPPM call978-686-6185, e-mail aappmex-ecdir@aol .com or vis i twww.aappm.com, or circle #150 onthe reader service card. n



Dr. Moore isboard certifiedwith the Ameri-can Board of Po-diatric Orthope-dics and Prima-ry PodiatricMedicine andF e l l o w s h i p -trained in dia-betic foot sal-vage at the University of Texas HealthScience Center. He serves on the Boardof Trustees of the American Academy ofPodiatric Practice Management and isEditor of AAPPM News. Dr. Moore is alecturer and author on diabetes andpractice management topics and is inprivate practice in Somerset, KY.

Documents

IntroducingMr.Smith: HowtoMaximize OutcomesandRevenue ... · an off-loading boot (Bledsoe Con - former) and he has been given Amerigel Hydrogel impregnated gauze (which he has been