Cindy Pezza, PMAC
What is Considered Ancillary Care?
Any service or treatment above and beyond the
diagnosis and statement of treatment plan. .
Which Type of Care do you Provide?
Addressing the immediate problem or conditionderiving a diagnosis and suggesting treatment options?
Or. . .
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?
Either way, your Patients Improve, Right?
Possibly. . .
However, physicians who provide much needed ancillary
services to their patients, see improved results, in less
time.
Improved compliance= improved outcome
They Also See. . .
Happier patients
A greater referral base
An improved reputation
AND. . .
The reward of increased practice revenue.
Beware of Tunnel Vision
DPMs are too busy “seeing” patients, and may
overlook what is truly needed.
Which Services are you Offering?
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)
The advantages of being a Doctor of Podiatric
Medicine:
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 Infamous and Misunderstood
CDFE
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 Diabetic Shoe Program
Yes, the compliance regulations are becoming more
taxing and it seems as if it’s not worth the trouble.
Don’t Go it Alone
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 .
Consider This:
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?). . .
Numbers Don’t Lie
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?
So Start Looking
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.
Measure and Manage
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.
But, That’s Not All
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
And Then. . .
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?
Mr. Greene May Need:
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 . . .
By NOT Addressing the Issues:
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.”
You have the Knowledge and Resources
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
Again, the numbers. . .
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)
Okay, Take a Vacation
Do the Math
$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!
What about This Patient?
Are you Just Cutting her Nails?
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
What would you Choose?
Staff can be your Eyes and Ears
If they are trained to understand all that you can offer
patients and how easy it is to help.
Teach Them
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.
Let’s Talk Cash
Increased copayments, enormous deductibles, and
other out of pocket expenses, make it an ideal
opportunity to offer cash products and services to your
patients.
The Wave of the Future is Here Now!
Become a One Stop Shop
Carry items that you recommend the most:
Antifungals
Shoe Sprays
Diabetic Safe lotions
Proper Footwear
Drying agents
Medical Grade orthotics
Only if You are a Believer
If you do not truly believe in the quality and efficacy of
the products, get out your dust rags.
Expensive, Shiny Things
The same concept applies to lasers, and other modern
technologies with lights and buzzers.
If you Invest the Money
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
Take a Closer Look. . .
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.
Choose Wisely
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
Measure and Manage
To increase compliance, outcome and revenue. . .
All through the proper utilization of Ancillary Services
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 antiinflammatories)?
 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 dispensed
Assistant 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
Questions
If you need help with implementing or improving the
Ancillary Services in your practice. .
cindy@pinnaclepa.com
THANK YOU!