This article is written exclusivelyfor PM appears courtesy of the Ameri-can Academy of Podiatric PracticeManagement. The AAPPM has a forty-year history of providing its memberDPM’s with practice management edu-cation and resources.

It’s Tuesday morning at 6:00am,and Mrs. Smith arrives for herscheduled appoint-

ment. Her diabetes is cer-tainly getting the best ofher. Mrs. Smith’s gait is nowshuffling as her legs oftencramp up. She claims thatshe can barely feel the floor.Although she uses a walker,you just know that she is ahip fracture waiting to hap-pen! Just yesterday, shefound a small pebble insideof her shoe that nearlypunctured her skin withouther realizing it. She is forcedto wear slippers since all ofher other shoes irritate herhammertoes.

Sound familiar? If not,you’re probably not lookingclosely enough at a diseasethat affects a significantportion of the U.S. popula-tion and results in health-care costs in the billions ofdollars. In an effort to re-duce the cost of diabeticfoot care, CMS introducedthe Physician Quality Re-porting Initiative PQRI) to

encourage podiatrists to performscreening exams that would identi-fy risk factors for ulceration andother associated conditions.

In this article, we will explorethe revolutionary options availablefor patients with diabetic neuropa-thy and piece together protocolsthat are fundamental for good pa-tient care and collaborative practicemodels. With diabetes now at epi-demic proportions, podiatricmedicine and surgery are perfectly

positioned to thrive throughout thenext decade despite healthcare re-form.

In the United States in 2007, anestimated 23.6 million people—or7.8% of the population—had dia-betes, and that number is expectedto double by 2040.1,2 Among people60 years and older, 23.1% of thatparticular population had diabetes.The cost of diabetes-related ulcera-tion and lower extremity amputa-tion was estimated at $30 billion

year in 2007, up to 2/3 ofwhich is believed to beavoidable with well-de-signed preventative carestrategies.3

In 2007, CMS, in an ef-fort to reduce the cost of di-abetic foot care, introducedthe Physician Quality Re-porting Initiative (PQRI) toencourage podiatrists toperform, on an annualbasis, screening exams thatwould identify risk factorsfor ulceration. Aside frombeing a level-3 E/M service,adequate performance ofthese measures offers podia-trists an end-of-year bonusequal to 2% of their totalMedicare billing.

Comprehensive DiabeticFoot Exam (CDFE)

The Comprehensive Dia-betic Foot Exam (CDFE) wasfirst proposed by KennethMalkin, DPM in 2003 as anannual exam to help qualify

By Benjamin Weaver, DPM and JoshWhite, DPM

Continued on page 70

Following these protocols benefits both your patients and your bottom line.

NOVEMBER/DECEMBER 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 69

Figure 1: CKPA Pain Analysis Survey

Mrs. Smith Gets HerFirst ComprehensiveDiabetic Foot Exam

review Mrs. Smith’s Pain AnalysisForm and CVI form; sign, date. andadd to the chart (Figures 1 and 2).

We proceed with debridementof nails and calluses, and discussthe importance of more compre-hensive evaluation risk factors asso-

patients’ likelihood of ulcer-ation and to help direct ap-propriate care. Subsequent-ly, the approach has beenpromoted by the AmericanDiabetes Association andthe American College ofFoot and Ankle Surgeons.4,5

The CDFE protocol offers athorough survey of the der-matological, neurological,vascular, and orthopedicsystems of patients with dia-betes in order to detectthreatening changes early.

As an integral part ofthis exam, the need fortherapeutic shoes, multi-density inlays, treatmentfor neuropathy, and furthervascular testing can also beassessed. An additionalbenefit of performing theCDFE is that it offers aready way to satisfy Medi-care’s requirements for per-formance of PQRI and canbe billed as a CPT 99213 level pa-tient visit. Performing the pre-scribed protocols is surely goodmedicine, but by creating a dedicat-ed office visit, could also lead tosubstantial revenue production asvalue-added opportunities are lesslikely to be missed.

Meet Mrs. SmithThis presentation will introduce

you to Mrs. Smith, a fictional dia-betic patient presenting for thisnew comprehensive and collabora-tive approach to diabetic foot care.

Introduction to Mrs. SmithA 57 year old white female pre-

sents with a chief complaint ofstinging numbness in her feet.When she shops at Wal-Mart she isable to walk about three aisles be-fore her legs start to cramp and shehas to sit down. She has had non-insulin dependent diabetes for 15years.

Mrs. Smith’s history is signifi-cant for traumatic amputation ofthe left great toe at age five in a bi-cycle accident. She has severe ham-mertoes, fungal nails, extremely dryskin. She has bronzing of the shinsbilaterally with redness to the leftshin and pain with swelling. We will

ciated with her diabetes.Toenails 1-5 on the rightand 2-5 on the left appearcrumbly, discolored, yellow,elongated, incurvated,painful with and without ap-plied pressure, thickened,with dystrophic changes,with subungual debris, Hy-pertrophic colored nails,marked limited ambulationdue to nail pain. Inspectionof left 1st, 3rd, and 5thmetatarsal heads, and rightplantar metatarsal heads 1stand 5th show hyperkerato-sis. We discussed with thepatient the importance ofoff-weight loading the firstmetatarsal head in order todecrease the likelihood of ul-ceration, and the benefits ofa partial foot prosthesis toimprove shoe fit.

A recommendation wasmade for a follow-up visit toperform a comprehensive di-abetic foot exam and deter-mine appropriate therapeu-

tic footwear.

Diagnosis Codes250.60 diabetes mellitus with

neurological manifestations, type iior unspecified type, not stated asuncontrolled

250.70 Diabetes mellitus withperipheral circulatory disorders,type ii or unspecified type, not stat-ed as uncontrolled

729.2 Neuralgia, neuritis, andradiculitis, unspecified

701.1 Keratoderma, acquired457.2 Lymphangitis041.9 Bacterial infection, un-

specified, in conditions classifiedelsewhere and of unspecified site

453.4 Venous embolism andthrombosis of deep vessels of lowerextremity

700 Corns and callosities719.7 Difficulty in walking782.3 Edema454.1 Varicose veins of lower

extremities with inflammation703.9 Unspecified disease of nail729.5 Pain in limb110.1 Onychomycosis703.8 Other specified diseases of

nail459.81 Venous (peripheral) in-

sufficiency, unspecified

Mrs. Smith...

Continued on page 71

70 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

In an effort to reduce

the cost of diabetic

foot care, CMS

introduced the

Physician Quality

Reporting Initiative

(PQRI) to encourage

podiatrists to perform

screening exams that

would identify risk

factors for ulceration

and other associated

conditions.

Figure 2: Chronic Venous Insufficiency Questionnaire

Plantar pressure assessmentusing the PressureStat footprintimaging device (Figure 3) deter-mines there to be greater than 6kg/cm2 beneath the first metatarsal

782.0 Disturbance of skin sensation443.9 Peripheral vascular dis-

ease, unspecified729.81 Swelling of limb703.0 Ingrowing nail735.4 Other hammertoe (ac-

quired)V49.71 Great toe, amputation

status

Procedure CodeCPT 99203 Foot Examination

PerformedCPT 11721 Nail Debridement

6+ CPT11057 Callus > 4 Debridement

Visit 2 (1 Week Later)Perform comprehensive diabetic

foot exam (CDFE). During the CDFEexam, Mrs. Smith was found to bemissing PT pulses bilaterally. She hasclinical fungal nails, plantar callus 2-5 bilaterally because of her severeplantarflexed metatarsals. Her vibra-tion perception is present andmissed 2/10 on SWMF 5.07 testing.X-rays were taken on her last exam-ine due to the structural deformitiesof her feet.

head left and the hallux right. TheTempStat thermal imaging device(Figure 4) indicates there was a “hotspot” beneath the left firstmetatarsal, indicating the presenceof inflammation, a precursor to ul-ceration.

Footwear EvaluationFootwear evaluation reveals the

patient to be wearing well-worn imi-tation leather athletic shoes (Figure5). The upper rubs against the dor-sum of contracted digits 2-4 bilater-

ally, and the shoes are too narrowa c r o s sthe ballof thef o o t .A d d i -tionally,there iso n l y1 / 4 ”s p a c ebetweenthe endof thesecondd i g i t s

and the end of the shoes. The shoes

Mrs. Smith...

Figure 3: PressureStat

Figure 4: Tempstat

Figure 5: Well-worn Footwear

Continued on page 72

Figure 6: Periodic Comprehensive Diabetic Foot Exam Form

NOVEMBER/DECEMBER 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 71

72 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

Mrs. Smith...

Figure 7: Statement of Certifying Physician

ment, CDFE be performed everythree months.

Shoe SelectionWe used a measuring stick and

display stand to properly size Ms.Smith for footwear. We limit herstyle choices to options 2 to 3, con-sidering her style preferences andtherapeutic needs. The styles offeredhave greater depth, removable spac-ers, and stretchable material overthe contracted digits. We cast forcustom, diabetic inlays with pres-sure offloads beneath the metatarsalheads, cast for L5000 of the L foot,and size for diabetic shoes.

We proceed with epidermalnerve fiber density testing b/l, rec-ommend ABI/PVR and CVI testing.

Performance of CDFE (Figures6-7) Satisfies PQRI Measures

PQRI Measure 126: NeurologicalEvaluation

Definition: A lower extremity neu-rological exam consisting of a docu-mented evaluation of motor and sen-sory abilities including reflexes, vibra-tory, proprioception, sharp/dull and5.07 filament detection.

PQRI Measure 127: Evaluation ofFootwear

Definition: Includes a foot exami-nation documenting the vascular,neurological, dermatological, andstructural/biomechanical findings.The foot should be measured using astandard measuring device and coun-seling on appropriate footwear shouldbe based on risk categorization.

PQRI Measure 163: Foot ExamDefinition: Foot examination per-

formed (includes examinationthrough visual inspection, sensoryexam with monofilament, and pulseexam—report when any of the threecomponents are completed).

Dispense to patient diabeticfoot care instructions and copies ofPressureStat sheets with depictionof pre-ulcerative hot spots.

Dispense Amerigel blue for xero-sis, and Neuremedy for numbness.

Reschedule patient in one totwo weeks for biopsy site check,ABI/PVR, Neuremedy check.

Send results of CDFE to physi-cian managing the patient’s dia-betes. This satisfies the Medicare re-quirement that the MD has in the

contain a well-worn and com-pressed, non-removable sock liner.

The patient was educated aboutthe relationship between diabetesand loss of protective threshold,and the significance to proper shoefit. The PressureStat was used todemonstrate the areas of high pres-sure beneath the metatarsal heads.The areas of high pressure were cir-cled with a marker and the Pres-sureStat sheets given to the patient.

The TempStat was used todemonstrate how the increasedtemperature beneath the firstmetatarsal head has caused an in-flammatory response. The area ofhigh pressure beneath themetatarsal head corresponds to thearea of increased temperature, re-sulting in an inflammatory re-sponse, a precursor of ulceration.

From results of the CDFE exam,the patient was determined to be afoot-risk category 3 and prescribeda pair of ready-made therapeuticdepth shoes with partial foot pros-thesis, longitudinal arch supportfor the left foot and three singlecustom-molded inserts for the rightfoot. ADA recommendations arethat, based on the foot risk assess- Continued on page 74

patient chart documentation of thesecondary diagnoses indicated asqualifications for prescription oftherapeutic footwear.

Diagnosis Codes250.60 Diabetes mellitus with

neurological manifestations, TypeII or unspecified type, not stated asuncontrolled.

250.70 Diabetes mellitus withperipheral circulatory disorders,Type II or unspecified

Type, Not stated as uncon-trolled

729.2 Neuralgia, neuritis, andradiculitis, unspecified

457.2 Lymphangitis041.9 Bacterial infection, un-

specified, in conditions classifiedelsewhere and of unspecified site

453.4 Venous embolism andthrombosis of deep vessels of lowerextremity

719.7 Difficulty in walking782.3 Edema454.1 Varicose veins of lower

extremities with inflammation729.5 Pain in limb459.81 Venous (peripheral) in-

sufficiency, unspecified782.0 Dis turbance of sk in

sensation

443.9 Peripheral vascular dis-ease, unspecified

729.81 swelling of limb735.4 Other hammertoe (ac-

quired)V49.71 Great toe amputation

status356.9 Hereditary and idiopath-

ic peripheral neuropathy; unspeci-fied

Procedure CodeCPT 99213 Foot Examination

PerformedG8404 Neurological Exam Per-

formedG8410 Footwear Evaluation Per-

formed2028F Foot Examination Per-

formedEpidermal nerve fiber density

testing, B/LCPT 11101 x1CPT 73630 x2 X-ray, 3 views

Visit 3 (2-4 Weeks)Check Mrs. Smith biopsy sites,

review Neuremedy, review biopsyresult, perform ABI/PVR, write Rxfor Metanx. At next visit will goover ABI/PVR results, schedule CVIexam, and review Metanx.

Continued on page 76

74 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

Figure 8: Periodic Comprehensive Diabetic Foot Exam Form

Mrs. Smith...

76 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

Diagnosis Codes250.60 Diabetes mellitus with neurological mani-

festations, type ii or unspecified type, not stated as un-controlled

250.70 Diabetes mellitus with peripheral circulato-ry disorders, type 2 or unspecified type, not stated asuncontrolled

729.2 Neuralgia, neuritis, and radiculitis, unspecified457.2 Lymphangitis041.9 Bacterial infection, unspecified, in conditions

classified elsewhere and of unspecified site453.4 Venous embolism and thrombosis of deep

vessels of lower extremity719.7 Difficulty in walking782.3 Edema454.1 Varicose veins of lower extremities with in-

flammation729.5 Pain in limb459.81 Venous (peripheral) insufficiency, unspecified782.0 Disturbance of skin sensation443.9 Peripheral vascular disease, unspecified729.81 Swelling of limb735.4 Other hammertoe (acquired)V49.71 Great toe amputation status356.9 Hereditary and idiopathic peripheral neu-

ropathy; unspecified

Procedure CodeCPT 99213CPT 93923 Non-invasive Physiologic Studies Of

Upper Or Lower Extremity Arteries, Multiple Levels OrWith Provocative Functional Maneuvers, Complete Bilat-eral Study

Visit 4 (4-6 Weeks)Do final biopsy site check for final healing, review

Metanx with patient; go over ABI/PVR results-which wereabnormal. Dispense ready-made depth shoes with L5000partial foot filler, left, three single custom-molded diabet-ic inserts for the right foot. Advise the patient of break-ininstructions and have the patient sign a certificate of re-ceipt. Provide a copy of CMS 26 Supplier Standards.

We will schedule Mrs. Smith with our vascular inter-ventionalist, and perform CVI exam on the patient.

Diagnosis Codes250.60 Diabetes Mellitus with Neurological Mani-

festations, Type II Or Unspecified Type, Not Stated AsUncontrolled

250.70 Diabetes Mellitus with Peripheral Circulato-ry Disorders, Type II Or Unspecified

Type, Not Stated As Uncontrolled729.2 Neuralgia, Neuritis, and Radiculitis, Unspecified457.2 Lymphangitis041.9 Bacterial Infection, Unspecified, In Condi-

tions Classified Elsewhere and Of Unspecified Site453.4 Venous Embolism and Thrombosis of Deep

Vessels Of Lower Extremity719.7 Difficulty in Walking782.3 Edema

Mrs. Smith...

Continued on page 77

Visit 6 (12-14 Weeks)Patient was seen in follow-up

from laser ablation of great saphe-nous vein, and has been wearing acompression sock daily, but is stillswelling. Review results of cardio-rehab, and write orders for lym-phedema therapy.

Perform CDFE (Figure 8) be-cause of the risk class of this pa-tient, she is to be seen every threemonths.

Schedule CDFE for threemonths.

Diagnosis Codes250.60 Diabetes Mellitus with

Neurological Manifestations, TypeII Or Unspecified Type, Not StatedAs Uncontrolled

250.70 Diabetes Mellitus withPeripheral Circulatory Disorders,Type II Or Unspecified

Type, Not Stated As Uncontrolled729.2 Neuralgia, Neuritis, and

Radiculitis, Unspecified701.1 Keratoderma, Acquired457.2 Lymphangitis041.9 Bacterial Infection, Un-

specified, In Conditions ClassifiedElsewhere and Of Unspecified Site

453.4 Venous Embolism andThrombosis of Deep Vessels OfLower Extremity

700.0 Cornsand Callosities

719.7 Difficul-ty in Walking

782.3 Edema454.1 Varicose

Veins of LowerExtremities withInflammation

703.9 Unspeci-fied Disease ofNail

729.5 Pain inLimb

110.1 Ony-chomycosis

703.8 OtherSpecified Diseasesof Nail

459.81 Ve-nous (Peripheral)Insufficiency, Unspecified

782.0 Disturbance of Skin Sen-sation

443.9 Peripheral Vascular Dis-ease, Unspecified

729.81 Swelling of Limb735.4 Other Hammertoe (ac-

quired)

V49.71 Great Toe AmputationStatus

356.9 Hereditary and idiopathicperipheral neuropathy; Unspecified

Procedure CodeCPT 99213 Foot Examination

PerformedG8404 Neurological Exam Per-

formedG8410 Footwear Evaluation Per-

formed2028F Foot Examination Per-

formed

Visit 7 (22-24 Weeks)Patient was seen to follow up

on lymphedema therapy and forquarterly CDFE. The patient hasbeen wearing the compression sockdaily, and swelling is diminishedsince the last visit following lym-phedema compression therapy.

Perform CDFE because of therisk class of this patient to be seenevery three months (Figure 9).

TempStat temperature evalua-tion reveals increased temperaturebeneath the right 1st metatarsalhead. Custom insert, right demon-strates compression and dark spotat first metatarsal head. Shoesdemonstrate even wear across theball. Replace the custom insert

right with the sec-ond of three pairsoriginally dis-pensed. The pa-tient purchases apair of CrocsRxCustom Cloudshoes to be wornwith partial footprosthesis andcustom inserts,when indoors.The patient statesthat she previous-ly had been wear-ing only sockswhen walkingaround thehouse.

We proceedwith debridement

of nails and calluses and discuss theimportance of more comprehensiveevaluation risk factors associatedwith her diabetes. Toenails 1-5Right and 2-5 left appear crumbly,discolored—yellow, elongated, in-curvated, painful with and without

Continued on page 80

78 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

782.3 Edema454.1 Varicose Veins of Lower

Extremities With Inflammation703.9 Unspecified Disease of Nail729.5 Pain in Limb110.1 Onychomycosis703.8 Other Specified Diseases

of Nail459.81 Venous (Peripheral) In-

sufficiency, Unspecified782.0 Disturbance of Skin Sen-

sation443.9 Peripheral Vascular Dis-

ease, Unspecified729.81 Swelling of Limb703.0 Ingrowing nail735.4 Other Hammertoe (acquired)V49.71 Great Toe Amputation

Status356.9 Hereditary and idiopathic

peripheral neuropathy; Unspecified

Procedure CodeCPT 99213 Foot Examination

PerformedCPT11721Debridement of +6NailsCPT 11057Callus > 4Debridement

Mrs. Smith...

The CDFE protocol

offers a thorough

survey of the

dermatological,

neurological, vascular,

and orthopedic

systems of patients

with diabetes in order

to detect threatening

changes early.

specified, In Conditions ClassifiedElsewhere and Of Unspecified Site

453.4 Venous Embolism andThrombosis Of Deep Vessels OfLower Extremity

700.0 Corns and Callosities719.7 Difficulty in Walking782.3 Edema454.1 Varicose Veins of Lower

Extremities with Inflammation703.9 Unspecified Disease of

Nail729.5 Pain in Limb110.1 Onychomycosis703.8 Other Specified Diseases

of Nail459.81 Venous (Peripheral) In-

sufficiency, Unspecified782.0 Disturbance of Skin Sen-

sation443.9 Peripheral Vascular Dis-

ease, Unspecified729.81 Swelling of Limb703.0 Ingrowing Nail735.4 Other Hammertoe (ac-

quired)V49.71 Great Toe Amputation

Status356.9 Hereditary and idiopathic

peripheral neuropathy; Unspecified

Procedure CodeCPT 99213 Foot Examination

PerformedG8404 Neurological Exam Per-

formedG8410 Footwear Evaluation Per-

formed2028F Foot Examination Per-

formed11721 Debridement of +6 Nails11057 Callus > 4 DebridementSelf pay—Crocs

By following protocols of in-cluding quarterly follow-up ap-pointments for CDFE, we have ef-fectively prevented development ofulceration beneath the metatarsalheads and the likelihood of otherulcerations in the future. Referralfor vascularization procedure en-abled the patient to ambulate fur-ther and without pain. Followingthis comprehensive approach tocare can effectively reduce costlycomplications, improve the lengthand quality of patients’ lives, andsignificantly enhance practice rev-enue. The increased cost of the de-scribed clinical care is easily offsetby the savings associated with pre-vented hospitalization costs. �

The American Academy of Podi-atric Practice Management (AAPPM)has a forty-year history of providing itsmember podiatrists with practice man-agement education and resources theyneed to practice efficiently and prof-itably, through personal mentoringand sharing of knowledge. To ContactAAPPM call 978-686-6185, e-mailaappmexecdir@aol.com or visitwww.aappm.com, or circle #150 onthe reader service card.

References1 National diabetes fact sheet: nation-

al estimates on diabetes. Centers for Dis-ease Control and Prevention Website.Available at:http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed March 20, 2010.

2 Venkat Narayan KM, Boyle JP, GeissLS, et al.: Impact of recent increase on inci-dence on future diabetes burden. DiabetesCare 29: 2114, 2006.

3 Rogers, LC, Lavery, LA, Armstrong,DG: The Right to Bear Legs—An Amend-ment to Healthcare: How Preventing Am-putations Can Save Billions for the USHealth-care System. Journal of the Ameri-can Podiatric Medical Association: March /April 2008,Vol 98, no. 2.

4 Comprehensive Foot Examinationand Risk Assessment; Diabetes Care, Vol.31, No. 8, 2008; 1679-1685.

5 Comprehensive Foot Examinationand Risk Assessment; Reprinted in JAPMA,Vol. 99, 2009 No. 1 74-80.

80 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

applied pressure, thickened, withdystrophic changes, with subun-gual debris, hypertrophic colorednails, marked limited ambulationdue to nail pain. Inspection of left1st, 3rd, and 5th metatarsal headand right submet 1st and 5th showshyperkeratosis. Due to off-loadingthe first submet, the callus has de-creased. Schedule CDFE for threemonths.

Diagnosis Codes250.60 Diabetes Mellitus with

Neurological Manifestations, TypeII or Unspecified Type, Not StatedAs Uncontrolled

250.70 Diabetes Mellitus withPeripheral Circulatory Disorders,Type II or Unspecified

Type, Not Stated As Uncon-trolled

729.2 Neuralgia, Neuritis, andRadiculitis, Unspecified

701.1 Keratoderma, Acquired457.2 Lymphangitis041.9 Bacterial Infection, Un-

Mrs. Smith......

Dr. Weaver isboard-certified inpodiatric ortho-pedics and pri-mary podiatricmedicine and isa Fellow of theAmerican Col-lege of Footand Ankle Or-thopedics andMedicine. He is aFellow of theAmerican Profes-sional WoundCare Associa-tion, a CertifiedWound Special-ist, and a mem-ber of the Ameri-can Academy ofPodiatric PracticeManagement.

Dr. White is a certified pedorthistand is president and founder ofSafeStep. He is an expert panelist forCodingline, and a corporate member ofthe American Academy of PodiatricPractice Management.