Cindy Pezza, PMAC

Understanding and Responding to your Ancillary Care

Weaknesses

Any service or treatment above and beyond the diagnosis and statement of treatment plan. .

What is Considered Ancillary Care?

Addressing the immediate problem or condition- deriving a diagnosis and suggesting treatment options?

Which Type of Care do you Provide?

Do you strive to provide your patients with the highest quality comprehensive care, utilizing your expertise, modern technologies and the best possible products

and services available?

Or. . .

Possibly. . .

However, physicians who provide much needed ancillary services to their patients, see improved results, in less time.

Improved compliance= improved outcome

Either way, your Patients Improve, Right?

Happier patients

A greater referral base

An improved reputation

AND. . .

The reward of increased practice revenue.

They Also See. . .

DPMs are too busy “seeing” patients, and may overlook what is truly needed.

Beware of Tunnel Vision

Digital X-ray

Vascular Testing

ENFD testing (for neuropathic patients)

Medical Supplements

Prescription and medical grade orthotics

Diabetic Prevention/Treatment plans

Fall Prevention programs

In-Office dispensing products

Laser treatment (nails, skin, warts, pain)

Which Services are you Offering?

DPMs act as the Prescriber and the Supplier for many of the much needed items and services that patients

require.

A WIN, WIN for the practice and the Patient!

The advantages of being a Doctor of Podiatric Medicine:

By taking the time to perform and document the findings of the “Comprehensive Diabetic Foot Exam” you can determine a patient’s need for

many different ancillary services.

The Infamous and Misunderstood CDFE

Yes, the compliance regulations are becoming more taxing and it seems as if it’s not worth the trouble.

The Diabetic Shoe Program

Train your staff to assist with (or run) these types of programs.

Once they understand the rules and become confident in their ability, staff becomes invaluable.

Don’t Go it Alone

You have 200 Diabetic Patients in the Practice.

150 of them qualify for therapeutic shoes and inserts.

You fit only 100 (who wants to chase all that paperwork?). . .

Consider This:

Your average profit from A5500 (2 units) and 3 pairs of A5512 (pre-fabricated inserts) (6 units) is about $200.

100 patients x $200 = $20,000

Imagine if you fit nearly ALL of your patients who qualified?

Numbers Don’t Lie

Train Staff to look ahead in the schedule and make sure each diabetic patient has been scheduled for an annual

(more frequently if they are at higher risk) CDFE.

So Start Looking

Have staff assist with the exam, the documentation (including PQRS qualifying measures), procurement of compliance paperwork, measuring shoe size, selecting

the appropriate shoe style and proper dispensing technique.

Measure and Manage

If you find that during the CDFE, the patient has increasing neuropathic symptoms, diminished pulses,

discoloration of the lower legs and feet, they may need:

ENFD testing (biopsy)

Vascular testing

Medical supplements

Compression stockings

But, That’s Not All

Your Medical Assistant (trained in performing a fall risk assessment and casting for custom braces) notices that it

took Mr. Greene 3 tries to get out of her chair in the reception area, and that she had to hold on to the wall

as she shuffled towards the treatment room?

And Then. . .

An Assessment to determine his risk of falling

A referral to Physical Therapy (within your practice or to a mutual referral source)

Casting and dispensing of B/L balance devices . . .

Mr. Greene May Need:

You provide a dis-service to your patients

And become. . .

Just another doctor who says: “You’re just getting older, these things happen.”

Or (the worst one of all)

“It’s just arthritis, no need to worry.”

By NOT Addressing the Issues:

You have the elderly population that is unsteady

(and falling or that is afraid of falling)

Set a goal to perform just ONE Fall Risk Assessment (FRA) per day

You have the Knowledge and Resources

Perform 4-5 (FRA) per week (1 per clinic day)

Cast (and dispense) ONE high or extreme fall risk patient for bilateral balance braces

Custom balance devices - *cost to the practice = $600-700/pair

Reimbursement averages$2100 per pair (a little over $1000 per brace)

Profit of $1400-$1500 per pair (patient)

Again, the numbers. . .

Okay, Take a Vacation

$1400/week x 50 weeks = $70,000

Worth a little paperwork, and the ability to keep our patients off the floor and enjoying their quality of

life!

Do the Math

What about This Patient?

Or, are you giving options?

1. Do nothing and the condition gets worse

2. Have surgery and use a fixation device to stabilize the ankle?

3. Offer a low profile, custom brace that will allow her to stay active and comfortable and slow the

progression of the condition

Are you Just Cutting her Nails?

What would you Choose?

If they are trained to understand all that you can offer patients and how easy it is to help.

Staff can be your Eyes and Ears

The appropriate questions to ask during initial evaluation and follow-ups, to allow you to quickly diagnose and

develop a treatment plan.

The more they know, the more value they add to patient care and practice revenue.

Teach Them

Increased copayments, enormous deductibles, and other out of pocket expenses, make it an ideal

opportunity to offer cash products and services to your patients.

Let’s Talk Cash

The Wave of the Future is Here Now!

Carry items that you recommend the most:Antifungals

Shoe Sprays

Diabetic Safe lotions

Proper Footwear

Drying agents

Medical Grade orthotics

Become a One Stop Shop

If you do not truly believe in the quality and efficacy of the products, get out your dust rags.

Only if You are a Believer

The same concept applies to lasers, and other modern technologies with lights and buzzers.

Expensive, Shiny Things

Train your staff on:How it works

How to use it properly (if allowable)

The benefits of use

The cost of the machine

The cost to patients

The importance of compliance

If you Invest the Money

If you do your research and find the right ancillary services to meet the needs of your patients and they

don’t produce the desired effect.

Take a Closer Look. . .

Select the appropriate products, services and treatments to fit the needs of your patients.

Train your staff

Market your services within and outside of your practice

Educate your patients

And reap the benefits of improved outcomes

Choose Wisely

To increase compliance, outcome and revenue. . .

All through the proper utilization of Ancillary Services

Measure and Manage

The First Step:Developing treatment Protocols:

Plantar Fasciitis/heel pain

Classic Presentation

Assistant questions/evaluation

Where is the pain (ask patient to point to where the pain is located and if it radiates)?

How long ago did you notice this pain (days, weeks, months, longer)?

Describe the pain (aching, burning, throbbing, stabbing, sharp, dull, constant, intermittent)

Can you recall an injury or change in routine that may have caused this pain (trauma, increased or more strenuous exercise, different or new shoes, etc.)?

Evaluation continued. . . Is your pain at its worst in the morning (upon your first

steps) or upon standing after you have been sitting or driving for an extended period of time?

What have you tried at home to relieve the pain (icing, stretching, rest, OTC pain relievers or anti-inflammatories)?

Do you wear or have you ever worn any type of insert in your shoe? Yes/No

• Do not use verbiage like “orthotics” on the first visit, most patients do not know what an orthotic device is or what it does

Have you ever experienced a similar condition in the past?

Actions/treatment plan

Post Evaluation: by DPM or MA=Medical Assistant

3 views of the foot and 2 calcaneal views are taken [MA]

Diagnostic ultrasound is performed to measure the thickness of the plantar fasciia: (LT or RT or B/L to compare “normal” foot) [MA or DPM]• It is important to relay that ligament in its “normal” state measures

between 2-3mm/compared to their measurement

Injection w/cortisone: [DPM]

Dispensing

Dispense Air Heel, PF strap or similar: L1902 (LT or RT) • Instructions for use and wear reviewed by Assistant

Or. . .

Strapping (if not dispensing Air Heel/PF strap):

29540 (LT or RT); use -59 modifier on this w/ injection

Educate your patients

Discuss the importance of proper arch support and Dispense Footsteps (segway to custom devices or as stand alone) • Break in instructions reviewed by Assistant to include:

Wearing devices 1-2 hours per day initially and increasing wear time gradually until comfort is achieved

Proper verbiage

Some fatigue of the feet or legs is common (be careful not to use verbiage like “ You may be in pain at first.” Better to say; “You may experience discomfort or mild achiness in the feet or legs while your body adjusts to

wearing the devices. These are medical grade and much more substantial than OTC arch supports. This

is completely normal and you should not be concerned.”)

Be confident in your approach

With any item dispensed (Self Pay or Billable), maintaining a high level of confidence with introduction, education, and instruction are essential (for both DPMs and staff). . .

Encourage your staff to stay in the treatment room and listen to your “spiels” once they are perfected.

Avoid phrases such as: “You may want to try” or “You can go to the pharmacy and look for something topical to use, that might help”

Remember. . .

You are the foot and ankle EXPERT. . . Believe in what you dispense and your patients will too!

If yes to A.m. Pain . . .

A Nightsplint is prepared to be dispensedAssistant to review instructions for use with patient

L4397

**DME acknowledgement (receipt is signed by patient and copied for chart. Patient receives original receipt

along with 30 Supplier Standards)**

In addition

Consider physical therapy if condition is of extended duration

Assistant to prepare patient education (best to link commonly used Dx codes to URL and pull from Patient Education within EHR (for MU requirements)

Examples: • Heel pain handout • Stretching exercises/icing/rest instructions• Instructions for proper break in of orthotics

A complete treatment plan

Rx for NSAIDs (if no contraindications or allergies)

Biofreeze or other Topical Analgesic is Dispensed – instructions for use provided by MA

Theraband Foot Roller (Kit) – instead of frozen water bottle, can of soup and dishtowel by the nightstand

Follow-up Appointment is made - RTO in 2 weeks (to monitor compliance and improvement and to cast for orthotics (if amendable)

Follow up visit

If little or NO improvement:• Consider immobilization with cam walker (L4361)

• Non-Pneumatic walker- does NOT inflate • Consider serial injections• Consider CT scan or MRI• Consider labs for rheumatologic etiologies• Consider TENS/ESWT

Continue to monitor condition closely

• Follow up in 1-2 weeks to review CT or MRI results (patient to remain in boot until improvement is noted)• With any condition, consider less conservative (invasive) methods of

treatment (surgery, PRP, etc.) only after traditional treatment plans have been exhausted and thoroughly documented

condition improved

Continue with R.I.C.E.

Consider serial injections to assist with healing process

Cast for custom orthotics

Follow up in 2 weeks to dispense orthotics and monitor continued progression

Integrating protocols

To integrate protocols for all common conditions in your practice, it is important that doctors and staff are “on the same page” and understand the measurable benefits of following them. These include:

• Increased patient compliance • Increased referrals (patients will refer friends and family a

comprehensive treatment plan is clear and they feel better in a shorter amount of time)• Increased revenue (PVV)

A win-win situation

If you need help with implementing or improving the Ancillary Services in your practice. .

cindy@pinnaclepa.com

THANK YOU!

Questions