California Podiatric Physician Jan/Feb/March 2015 by California Podiatric Medical Association

California Podiatric Physician The

J a n ua r y | F e b r ua r y | m a r c h | 2015

Celebrate

Years of Disneyland ® at The 2015 Western! The 2015 Western Foot and Ankle Conference, aka The Western, is the must-attend continuing education meeting and exhibition for foot and ankle specialists. Hosted by the Disneyland® Hotel and Convention Center in Anaheim June 25 – 28, 2015, the destination seminar is ideal for Doctors of Podiatric Medicine and Podiatric Medical Assistants to earn their required continuing education contact hours, including radiology, for their medical license renewals. Instructors will present cutting-edge lectures, diverse and relevant hands-on workshops, plus a practice management track and two important workshops on the upcoming ICD-10 changes. Members of California Podiatric Medical Association and American Podiatric Medical Association receive reduced registration as well as discounts on malpractice insurance renewal premiums with Podiatry Insurance Company of America by attending the risk management presentation on Saturday, June 27. The Assistants’ program will educate front and back office on billing and coding, office management, and patient care. Assistants are also welcome to attend the two ICD-10 workshops.

The 2015 meeting will be even more magical as attendees can participate in festivities during Disneyland®’s 60th Diamond Celebration. With major savings on discounted Disneyland® Park and Disney California Adventure® Park tickets, The Western will be not only an exemplary educational seminar not to miss, but also an extra special family affair. For more information call (800) 794-8988 or visit The Western online at www.TheWestern.org.

The 2015 Western Foot and Ankle Conference • June 25 – 28, 2015 Disneyland® Hotel and Convention Center • Anaheim, CA ©Disney

- In This Issue -

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and Extended Tax Laws to Consider 11 New Prior to Filling 2014 Returns Jesse Kaplan, CPA

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Compensation Formulas Doctors who practice in groups often undergo long, arduous, and emotional discussions when developing their formulas for computing salaries. In contrast, the use of compensation formulas is a foreign concept for doctors who practice solo. For them, compensation is simply “whatever is left over” after all the bills are paid. These practices have no “profit” because there is never anything left after the doctor receives his/her compensation. This “formula” works well for solo practitioners, but once two or more doctors join together, the “fairness” of the compensation formula becomes one of the most contentious discussions that the doctors will ever have. Because we expect a continuation in the trend of doctors joining together and creating groups, we should be asking, “Is there an ideal compensation formula for the doctors who are creating these new groups?”

If we view compensation as a reward for achieving the types of performance a group is seeking, we realize that the members must come to a consensus as to what goals they feel will be most important to focus on in order to achieve the best overall performance for the entire group. Members of groups have learned that there are some drawbacks when salaries are fixed and are in no way connected to performance. Many doctors “under-perform” when there are no financial consequences for a poor work ethic. Conversely, doctors with fixed salaries have little incentive to “over-perform” because there is no reward for any additional time or effort they may expend. For these reasons, most groups tie their compensation formulas to productivity – known in the vernacular as, “Eat what you kill.” While compensation based on productivity addresses the problem of under-performance, this

C P M A | C a l if o r n ia P o diat r ic M e dica l A ss o ciati o n

“formula” is focused solely on revenue generation, overlooking – and sometimes undermining – many important behaviors a group may seek – especially intangibles such as teamwork, networking for purposes of new patient referrals, and focusing on building efficient business operations which will be capable of delivering higher quality at lower costs. These and other intangibles which create value that are in the interest of the entire group are not individually measured and rewarded when using a compensation method based solely on productivity. It is important to the success of a practice that these factors also be taken into account when designing compensation formulas. Ideally, compensation should be based on more than productivity. Practices that deliver high quality care and better patient satisfaction will grow under future reimbursement methods based on quality, and if they are efficient as well as productive, they will be able to spread greater patient volume over stable fixed costs, thereby delivering more profit and higher compensation for every doctor in the group regardless of reimbursement method. At the end of the day, equal effort and commitment are required of all doctors if a practice is going to deliver greater patient satisfaction while controlling costs. The efforts to achieve desired goals are not rewarded when practicing under a rigid “eat what you kill” form of reimbursement – a system that encourages individual competition rather than group cooperation. In an ideal situation, compensation is based on ownership and efficiency as well as productivity. I suggest that practitioners utilize a compensation formula that rewards all three of these meaningful aspects of a practice. Data has shown that every doctor earns better in a group in which all of the doctors are owners. Ownership plays a significant role in creating stronger commitment and teamwork and in growing practice value. Ownership entitles a partner to share in the profit created by the group as well as an opportunity to retain a level of control that is not possible for an employed doctor. Efficiency is important because it is required for the delivery of high quality at lower costs. The portion of compensation awarded for productivity could be based on a combination of longevity and practice efficiency (which keeps the overhead percentage lower, creating a situation in which all doctors earn better). A formula focused on all three of these areas assists a group in attaining its most essential goals. The following example is of a group using a flexible formula for determining its doctors’ compensations. Assume six doctors practicing in a group with the following outcome: each doctor collects $500,000 and each is payed 30% of his/her productivity. This results in a $150,000 “base salary” for each doctor. $600,000 in profit remains after taking a 50% overhead into account. If all doctors were equal partners (each with 16.67% ownership), each J a n ua r y | F e b r ua r y | M a r ch | 2015

would receive a $100,000 “bonus” of profit distribution, based on the group’s performance. If the doctors were not equal partners, each would receive a percentage distribution of the profit based on his/her percentage of ownership in the practice. Increasing efficiency by dropping the overhead rate to 45%, would increase profit to $750,000. Note that this creates greater value for all partners, and it creates a greater incentive for associates to become partners – at which time they, in turn. would be incentivized to create even greater value for the group. In the real world, not all doctors are equally productive, nor are they all equal partners. Fortunately, a flexible formula such as the one depicted above can be used to accommodate variations in productivity as well as to incentivize highly productive doctors who choose not to become partners but to, instead, remain as highly compensated employees. It is important to recognize that compensation formulas should not remain static. They should be reviewed periodically for any revisions necessary for addressing any doctor’s perception of “fairness,” or lack thereof. It is easy to “tweak” a formula, making it fair for all doctors in a practice. A formula might specify that a doctor who is not on the “partner track” may have the percentage of his/her pay increased after a specified number of years. Even though this doctor is not a partner, s/he is still contributing to overhead and profit, making it important to the group that s/he is incentivized – feeling fairly compensated. A well designed compensation formula can be adapted as changes occur and helps an office run harmoniously. If one wants to become a partner, the value and means for “buying-in” should be easy to calculate utilizing a well-designed formula. A doctor should be able to estimate the amount of additional compensation s/he could expect – adjusting for the percentage of the practice being purchased. As a practice grows, the ideal is that by adopting efficiency principles, a greater volume of patients can be spread over relatively stable fixed costs – an outcome that lowers overhead and presents the opportunity to increase compensation for all members of the practice as well as to increase the value of ownership for those who prefer to follow this path. The likelihood of achieving the goals essential for the long-term success of a group practice is much greater when using a well-designed compensation formula that is viewed by all doctors in the group as maintaining harmony and fairness.

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Success – Spelling out Good Performance Our practices are only as good as the service and care we provide our patients. If our patients aren’t happy with the service we provide, they’ll entrust their care to another podiatrist’s office. Sometimes it’s hard for us to think that our offices may not be providing care at the highest standard, because we all wish to think that we are. Think about the following: Imagine your company picks up the tab for your lunch at a particular restaurant every day (that does take some imagination!). Now, this restaurant is a nice place with table service. So far, so good.

Patient service is often provided in brief interactions. Each interaction may only last a few minutes, but the impact could last a lifetime. You can dramatically increase the odds of your practice delivering consistently great service when you set these standards. Your standards should describe precisely how your business will try to achieve these measurable service levels. The five questions below can help you find out what standards and protocols your office needs to develop:

Some days, the host warmly greets you by name and seats you immediately at your favorite table in the sunny corner. Other days, you stand at the entrance for ten minutes, get a grunt from the host and are then finally seated after waiting another ten minutes, right smack dab in front of the swinging doors to the kitchen. Or even worse, on other days, no one greets you, you go find an empty table that you have to wait to be cleaned. You then learn the kitchen is out of most the items you like. No wonder no one was eager to seat you. What’s good about this restaurant? It’s free!! Remember?? But if it weren’t free, wouldn’t you be more likely to spend your own money there if you were treated well consistently instead of spending your lunch hour playing some sort of culinary Russian roulette? Consistent good service is not accidental. It comes from standardizing your approach to your service. Nothing is left to chance, or the moods or whims of your team members. You can ensure your office delivers the same standards to your patients each day by following the four steps below: 1. Determine the standard of care you want to provide, then put this in writing.

1. What work do we do that our patients really care about?

2. How might we do a better job at this?

3. Ideally, to what level of perfection would we like to perform this work?

4. What are the expectations of our patients? How do they believe we should perform the work?

5. How can we ensure our patients enjoy interacting with us?

Take time to brainstorm with your staff over these five questions. Getting everyone’s input will help ensure you have their buy-in when it comes time to implement the standards. There are four important reasons why setting standards improves your office:

1. They offer a consistent experience to your patients. Your patients know what to expect from you and are more likely to keep coming back.

2. They help you examine how you do your work. Going through the standards and devloping protocols gives you a great opportunity to reevaluate how you address the work to be done.

3. Employee morale improves – everyone knows exactly what’s expected from them, and they’ve been trained to achieve it. Employees like to know the rules of the game and how to keep score.

4. Standards and protocols guarantee your office quality. You cannot have quality without consistent standards. Quality results from consistency over time. t’s not a one-shot deal.

2. Write protocols on how each standard is to be completed.

3. Hold training sessions so each person in the practice understands the protocol and how to deliver it.

4. Set up ways to measure how everyone in the practice is following these standards.

J a n ua r y | F e b r ua r y | M a r ch | 2015

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CALL FOR VOLUNTEERS Are you interested in serving on a CPMA Committee for 2015-2016? If so, please contact CPMA President-Elect Ami Sheth, DPM at amishethdpm@gmail.com

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CLASSIFIEDS Practice for sale - California Well established Podiatry practice for sale in the beautiful central coast of California. We are a comprehensive, state-of-the-art practice that includes surgical, palliative, wound care, and sports medicine opportunities. Five fully equipped treatment rooms with advanced technologies: EMR, digital x-ray, ultrasound, vascular diagnostics, etc. Our licensed medical staff is experienced and dedicated to the ongoing care of our patients. Revenues include product sales of custom orthotics, shoes, and braces. For further information, contact us: CaliforniaPodiatry@gmail.com

ASSOCIATE DPM POSITION - California -IMMEDIATE OPENING Excellent opportunity in mid coast California for a full time, surgically trained podiatrist with current California license to join a busy well rounded practice including surgery, wound care, and sports medicine. Must be highly motivated, personable, and have good communication skills. Opportunity for future buy-in. Send CV to CaliforniaPodiatry@gmail.com

Find Us on Facebook Like our Page: www.facebook.com/calpma Join or Group (CPMA Members Only): www.facebook.com/groups/calpma J a n ua r y | F e b r ua r y | M a r ch | 2015

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New & Extended Tax Laws to consider prior to Filing your 2014 Business or Individual Income Tax Returns Very important tax changes and developments have occurred in the past three months for individuals and businesses. Please note that this article is not all inclusive of the 2014 and 2015 tax laws, and if more info is needed, feel free to contact us. Wouldnâ&#x20AC;&#x2122;t it be nice if tax laws were simple? Simplicity is a good thing, however, legislation and lawmakers often do not see the challenges and complexities that arise from new tax laws when they craft their laws. Fortunately, we can make the new tax laws and changes simpler for you. In December of 2014, the Tax Increase Prevention Act was signed into law, temporarily extending over 50 expired tax provisions, including bonus depreciation and the increased section 179 depreciation expense limits for businesses. This extension only applies for 2014, so we will have to wait and see which laws will be extended through 2015 until later this year. Individuals: Health care impacts 2014 income tax returns: The IRS has provided details on how health care reform under the Affordable Care Act (ACA) affects the upcoming income tax

return filing season. One of the most important ACA tax provision for individuals and families is the premium tax credit, a new credit. Under another key provision, individuals without coverage and those who donâ&#x20AC;&#x2122;t maintain coverage throughout the year must have an exemption or make an individual shared responsibility payment, as separately detailed in final regulations and a notice issued by the IRS in November. The IRS stresses that most people already have qualifying health care coverage and will only need to check a box to indicate that they satisfy the individual shared responsibility provision when they file their tax returns this year. The shared responsibility payment is basically a tax on the uninsured. Individuals and families who get coverage through the Health Insurance Marketplace (Marketplace, also known as an exchange) may be eligible for the premium tax credit. Eligible individuals and families can choose to have advance credit payments paid directly to their insurance company to lower what they pay out-of-pocket for their monthly premiums. Early in 2015, individuals who bought See TAXES on Page 13

By Jesse Kaplan, CPA Gilbert Associates, Inc., CPAs and Advisors J a n ua r y | F e b r ua r y | M a r ch | 2015

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TAXES from Page 11

health insurance through the Marketplace will receive Form 1095-A, Health Insurance Marketplace Statement, which includes information about their coverage and any premium assistance received in 2014. Form 1095-A will help individuals complete their return. Individuals claiming the premium tax credit, including those who received advance payments of the premium tax credit, must file a federal income tax return for the year and attach Form 8962, Premium Tax Credit. The IRS Describes (at www.irs.gov) this new forms use as “ Use Form 8962 to figure the amount of your premium tax credit (PTC) and reconcile it with any advance payments of premium tax credit (APTC).” Businesses: The IRS is having budget woes in2015, so may be best to have written correspondence prepared from a tax professionals to provide assistance in resolving federal issues, as the IRS will have long wait times on their phone lines due to being under staffed. Here are some important new federal tax options to consider for your 2014 tax returns: The law passed the end of December extended the Section 179 election to expense up to $500,000 in the costs of equipment placed in service in 2014, without this extension the limit would have only been $25,000. Also the extension allows a 50% bonus depreciation in the first year for new equipment placed in service in 2014. • Consider the annual safe harbor election for de minimis repairs and tangible property for business and rental activity ($500 with no CPA audited financial statement and $5,000 with CPA audited financial statement.) If you make this election for example, a $400 computer (which is tangible property) would be an expense and not an asset that needs to be capitalized then depreciated. • Consider the small taxpayer/small building election to deduct up to 2% (limited to $10,000) of the building’s unadjusted basis in repairs and improvements. No capitalization is required on improvements included in the 2% amount. • Consider the partial disposition election if the taxpayer adds a capital improvement to his or her business or rental property. A new roof might have to be capitalized and depreciated, but the disposition of the “old roof” will generate a loss to help with the tax bill.

• Consider filing a Form 3115, Change in Accounting Method, for a business that qualifies in a prior year for a partial disposition loss because of capitalizing an improvement to their business or rental property in 2014. For 2014 the $7,000 fee associated with this form is waived, meaning there won’t be a fee of $7,000 required to be paid to the IRS when filing this form. This IRS imposed fee may apply in future years so we recommend all businesses file this form with their 2014 returns as a protective change even if the filing has no change in the amounts reported. Now that California has finally managed to solve its budget woes, the state is taking a much more strategic approach to providing targeted tax incentives to help businesses expand and grow. California’s Enterprise Zone programs were repealed last year, and more targeted programs were enacted in their place. There have been many changes in the area of state taxes and credits over the last few years, here’s a short overview. These include: • New Employment Credit: If you qualify, your business can receive a tax credit of up to 35% of wages paid to qualified employees for up to five years. Businesses must be located in a designated geographic area to qualify, but these areas are located throughout the state and throughout many of our local communities. The credit is no longer limited to entry level, but to higher wages paid to more highly skilled workers. • California Competes Credit: You may qualify for a credit through the Governor’s Business and Economic Development Office (GO-Biz) for creating new jobs, and growing investments in California business. Twenty-five percent of these credits will be awarded to small businesses. So what’s in store for 2015 taxes? We expect that they will be very similar to 2014, with more IRS scrutiny on health care compliance and the repairs & maintenance regulations compliance, with higher tax rates for those that have high incomes. Also similar to 2014, many of the extended tax provisions were only extended through 2014, so it will be up to congress to extend them further, which we predict may happen towards the end of 2015. Have a great year and be proactive with your return this year as there are many items you’ll not want to miss.

The News You NEED to know!

Delivered to your in box each month. Don’t miss it! Be sure CPMA has your correct email on file. J a n ua r y | F e b r ua r y | M a r ch | 2015

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On your toes Medi-Cal Benefits Restored for Hospital-Based Places of Service

CPMA posted several notices on tax fraud scams targeting doctors in 2014

In 2014 CPMA introduced AB 1868 to restore adult podiatric services to Medi-Cal. During the legislative process, the Department of Health Care Services (DHCS) became aware of the fact that podiatric physicians were providing services to Medi-Cal beneficiaries in the ER and inpatient setting without reimbursement.

At that time the United States Secret Service and the Internal Revenue Service (IRS) were investigating how the identity thieves obtained the practitioners’ personal information needed to file the fraudulent returns. Then, some speculated that the fraud may have been related to Medicare’s online Open Payments report that listed practitioners’ NPI numbers.

For the past several months, CPMA and DHCS have been attempting to correct this. DHCS recently sent us proposed changes to 2 sections in the Medi-Cal Provider Manual, which governs how Medi-Cal services can be provided and billed. At this time, DHCS has approved the proposed changes and has informed CPMA that the new policies are effective immediately.

The recent Anthem breach that exposed the personal data of 80M individuals, including names, social security numbers, birthdays, addresses, email address and phone numbers of 80M individuals makes this tax filing season ripe for massive fraud. Members are urged to be extra vigilant.

What We Got

If you learn that your identity has been compromised in any way, act quickly and consider the following steps.

• Podiatric physicians can be reimbursed for services in the emergency room, inpatient hospitals and hospital-based outpatient clinics. This change in policy is also binding on MediCal Managed Care Organizations (MCMCO).

• Alert the IRS Identity Theft Protection Unit at 800.908.4490, complete Form 14039 and submit it to the IRS with any supporting documentation. More information is available at IRS.gov

• Retroactive billing for ER services provided within the previous 12 months

• Contact the Office of the California Attorney General to register the identity theft at www.oag.ca.gov/idtheft

What We Didn’t Get Office or non-hospital clinic follow up care

What We’re in the Process of Determining • If there will be any restrictions on the type of services or number of services • Specific billing instructions on how to bill these services to Medi-Cal • TAR and other documentation requirements for reimbursement • When MCMCOs will be notified of these changes CPMA has submitted a request for clarification of these issues and will be meeting again with DHCS to obtain further information and clarification about exactly how members should bill for these new services. Although DHCS has informed CPMA these changes are effective immediately, CPMA advises members that their claims for the new services may be initially denied due to billing errors or TAR authorization issues. We are working diligently to solve these problems as they arise and will keep our members informed of any new information as it becomes available.

SCAM ALERT: Podiatric Physicians Targeted in Tax Refund Fraud CPMA has been contacted by several members regarding fraudulent tax filing in their names. Upon filing a legitimate tax return, the doctors were informed by the IRS that a return has been already filed, most likely by an identity thief. Affected doctors may also learn of the scam by receiving a 5071C letter from the IRS alerting them of possible fraud. 14 |

• Contact the Federal Trade Commission at 877.438.4338 and create an Identity Theft Report at www.consumer.ftc.gov/ • Place a fraud alert on your credit report with the three consumer reporting agencies (Equifax: 800.525.6285, Experian: 888.397.3742 and TransUnion: 800.680.7289). • File a report with local law enforcement in the jurisdiction where you reside. Bring with you all documentation available, including the state and federal complaints you filed. • Call the Social Security Administration’s fraud hotline at (800) 269-0271 to report fraudulent use of your Social Security Number. In case your number is being used for fraudulent employment, you can also request your Personal Earning and Benefits Estimate Statement from the Social Security Administration ssa.gov or call (800) 772-1213. Make sure to check the report for accuracy. • Consult the Department of Justice (DOJ) website at www.justice.gov for additional information

CMS Fingerprint-Based Background Checks CPMA has received several inquiries from members regarding receiving letters requesting that they provide fingerprints to CMS. The Centers for Medicare and Medicaid Services (CMS) implemented a fingerprint-based background requirement on August 6, 2014, which required the Department of Health and Human Services to establish procedures for screening providers and suppliers participating in federal health care programs (specifically, Medicare, Medicaid, and the Children’s Health Insurance Program). Among other things, the final rule applies various screening tools, including unannounced site visits, background checks, and fingerprinting, based on the level of risk associated with different C P M A | C a l if o r n ia P o diat r ic M e dica l A ss o ciati o n

provider and supplier types. CMS established three levels of risk - limited, moderate, and high - and every provider and supplier category is assigned to one of these three levels. Individuals who maintain a 5 percent or greater direct or indirect ownership interest in a provider or supplier in the high risk category -- including newly-enrolling home health agencies (HHAs) and newly-enrolling durable medical equipment, orthotics, prosthetics, and supplies (DMEPOS) suppliers -- are subject to a fingerprint-based criminal history report check of the Federal Bureau of Investigations (FBI) Integrated Automated Fingerprint Identification System. Providers and suppliers subject to the fingerprint requirements will receive a notification letter from their Medicare Administrative Contractor (MAC), and applicable individuals will have 30 days from the date of the notification letter to be fingerprinted. Failure to comply with the fingerprint requirements could result in denial of your Medicare enrollment application or revocation of your Medicare billing privileges. Visit Accurate Biometrics for fingerprinting procedures, to find a fingerprint collection site, and to ensure the fingerprint results are accurately submitted to the Federal Bureau of Investigation (FBI) and properly returned to CMS. For more information on this requirement, see MLN MattersÂ® Special Edition Article #SE1427, If you have any questions, contact Accurate Biometrics at 866361-9944, or visit their website at www.cmsfingerprinting.com

transferring funds to them from plans that enroll lower risk individuals. Such transfers are intended to reduce or eliminate premium differences among plans based solely on favorable or unfavorable risk selection in the individual and small group markets. Through the program, a plan’s risk profile is evaluated against that of other plans offered within that plan’s state and within that plan’s market. How you should respond to a chart request depends on which insurance company is directing the audit, and how you keep your records. CPMA recommends that members first verify that request is indeed from the payer and that the chart retrieval company has been contracted by the payer to perform the service. Members should then contact their professional liability insurance company to seek guidance on how to respond to requests from a third party for patient information covered under HIPPA’s patient privacy laws.

(Source: Debra A. McCurdy; Health Industry Washington Watch, April 16, 2014)

Chart Requests for Risk Adjustment Audits Under the Affordable Care Act Some members have reported receiving letters from ECS Chart Retrieval Service requesting “full chart” patient records on behalf various payers as part of an Affordable Care Act (ACA) required audit. ECS, however, is not the only chart retrieval company payors have contracted with. The audits are being driven by risk adjustment provisions of the Affordable Care Act (ACA), and are new to providers and to health insurers. Passage of the ACA means a larger segment of the population has entered the market, many of whom were previously uninsurable. The ACA requires that non-grandfathered individual and small group health plans, inside and outside of the Exchanges operate in state-based risk adjustment programs effective January 1, 2014. States can either elect to establish and operate their own risk adjustment program, which must be approved by the Department of Health & Human Services (‘’HHS’’), or allow the federal government to operate a risk adjustment program on the state’s behalf. Federally operated risk adjustment programs will implement the risk adjustment methodology that has been adopted by HHS through regulations. All of the states, except for Massachusetts, have elected to operate under the federal risk adjustment program. The ACA Risk Adjustment Program will provide payments to health plan issuers that attract higher risk populations by J a n ua r y | F e b r ua r y | M a r ch | 2015

(Source: Theresa C. Carnegie and Tara E. Swenson; Caution: Risk Adjustment Hurdles Facing Plans and Providers Under the Affordable Care Act Bloomberg BNA Health Insurance Report - Vol. 19, No 29 July 17, 2013)

New Radiation Machine Fees, Forms Required As 2015 begins, there are new fees and forms doctors should be aware of regarding the use of radiation machines. The new fee schedule can be found here http://www.cdph. ca.gov/programs/Documents/RHBFeeIncrease-2015-01-01.pdf See on your toes on Page 24

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“Angels” Serving the Homeless Population of Berkeley

Podiatry students volunteer at the Suitcase Clinic Humanitarian Organization to fill a needed medical specialty to the underserved. Since 1989, the Suitcase Clinic has been offering free health and social services to underserved populations. They have structured their organization around the principles of public health, social welfare, community activism and empathy. In addition, the Suitcase Clinic strives to educate students, promote health care access, engage in community organization, and support public policy efforts that address homelessness and the needs of the underserved in the local community. Since April 2014, students at the California School of Podiatric Medicine (CSPM) have embodied the principles of the Suitcase Clinic twice monthly as they volunteer at the Women’s Clinic in Berkeley. During the National Foot Health Awareness Month of April, the California Podiatric Medical Association (CPMA) would like to acknowledge these students and their service to the residents of California.

J a n ua r y | F e b r ua r y | M a r ch | 2015

“[Their] presence has definitely made a difference,” states Bhaani Singh, co-coordinator of the Women’s Clinic in Berkeley, CA. “Every woman [they] have seen has said extraordinary things about [their] work. We have received no complaints and just lots of compliments. I don’t know how many of these kind words are passed on to [them], but please know that [they] have been often labeled as ‘angels,’ ‘life-savers,’ and ‘geniuses.’” The CSPM volunteers include 3rd, 2nd, and 1st year podiatric medical students and are supervised by a licensed podiatrist at each clinic. Some of the foot problems they have encountered so far include foot ulcerations, sinus tarsi syndrome, plantar fasciitis, osteoarthritis, and ankle sprains. Most importantly, they do routine diabetic foot checks, as many of women in the clinic do not have regular access to a podiatrist. The funding for these students to volunteer was based on the generous donation from the American Podiatric Medical Student Association Corporate Advisory Board Service Grant. Not only do podiatric medical students perform a humanitarian service for their community but also they develop clinical and empathic skills needed as future doctors. “I hope that all students [who volunteer] find it worthwhile knowing that they made a positive impact on another person’s life,” says co-director and CSPM 2016 class president Stephanie Mita. “We hope to start expanding our efforts into the other clinics and provide meaningful treatment at the general clinic and to keep it going [after I graduate].”

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2015 CPMA House of Delegates will convene

Wednesday, June 24, 2015 Disneyland Hotel Anaheim, CA

2014/2015 board of directors President  Thomas J. Elardo, DPM  Los Gatos, CA 95032  P: (408) 358-6234

Directors John A. Chisholm, DPM  Chula Vista, CA. 91910  P: (619) 427-3481

President-Elect  Ami A. Sheth, DPM  Los Gatos, CA 95032  P: (408) 358-6234

Adam S. Howard, DPM  Cupertino, CA95014  P: (408) 446-5811

Vice President  Rebecca A. Moellmer, DPM  Pomona, CA 91766  P: (909) 469-8413 Immediate Past President  Carolyn E. McAloon, DPM  Castro Valley, CA 94546  P: (510) 581-1484 Secretary-Treasurer  Devon N. Glazer, DPM  Mission Viego, CA 92691  P: (949) 272-0007

Thomas J. Tanaka, DPM   Ontario, CA 91761  P: (909) 724-5052 Mark A. Warford, DPM  Fair Oaks, CA 91316  P: (916) 548-0218 Vladimir Zeetser, DPM  Encino, CA 95628  P: (818) 907-6100 Student Representatives Luke Hultman (CSPM)  Dayna Chang (Western U)

Executive Director  Jon A. Hultman, DPM 2430 K St Ste 200 Sacramento, CA 95816 P: (916) 448-0248 (800) 794-8988 jhultman@calpma.org jonhultman@gmail.com  General Counsel  C. Keith Greer, Esq.  San Diego, CA 92128   Governmental Representative  Jodi Hicks  Sacramento, CA 95814   Parliamentarian/ Recording Secretary  Roderick Farley, DPM,JD/  Nedra L. Farley

2014/2015 COMPONENT SOCIETY PRESIDENTs ALAMEDA/ CONTRA COSTA COUNTY  Michael Grimes, DPM  Pinole, CA 94564  P: (510) 724-1530

June 25-28, 2015 J a n ua r y | F e b r ua r y | M a r ch | 2015

MONTEREY BAY AREA  Bobby Yee, DPM  Monterey, CA 93940  P: (831) 646-8242

CENTRAL VALLEY  John Abordo, DPM   Merced, CA 95341  P: (209) 383-7441

NORTHERN CALIFORNIA KAISER  Cristian Neagu, DPM Santa Clara, CA 95051 (408) 851-1957

COACHELLA VALLEY  Harvey Danciger, DPM  Palm Desert, CA 92260  P: (760) 568-0108

ORANGE COUNTY  Thomas Rambacher, DPM  Mission Viejo, CA 92692  P: (949) 916-0077

INLAND  Stephen A. Boykins, DPM Moreno Valley, CA 92556 P: (954) 734-0713

REDWOOD EMPIRE  Paul Weiner, DPM Vallejo, CA 94590  P: (707) 643-3687

LOS ANGELES COUNTY  Gabriel Halperin DPM  Los Angeles, CA 90063  P: (323) 264-6157

SACRAMENTO VALLEY  Daniel Lee, DPM, PhD   Sacramento, CA P: (916) 688-2030

MID-STATE  Richard Motos, DPM  Visalia, CA 93291  P: (559) 734-1171

SAN DIEGO/IMPERIAL   Nicholas DeSantis, DPM  San Diego, CA 92101  P: (619) 239-3286

SAN FRANCISCO/  SAN MATEO  Bill Metaxas, DPM  San Francisco, CA 94108  P: (415) 433-3668 SAN LUIS OBISPO/ SANTA BARBARA  David Sterling, DPM  Santa Maria, CA 93455  P: (805) 928-5645 SANTA CLARA VALLEY  Mehryar Amirkiai, DPM  Sunnyvale, CA 94087  P: (408) 245-3230 SHASTA REGION  Gordon Shumate, DPM  Redding, CA 96001  P: (530) 246-4800 SOUTHERN CALIFORNIA Diane Branks, DPM Fontana, CA 92355 VENTURA COUNTY  Heather McGuire, DPM  Ventura, CA 93003  P: (805) 648-2016

The California Podiatric Physician is the official publication of the California Podiatric Medical Association. CPMA and the California Podiatric Physician assume no responsibility for the statements, opinions and/or treatments appearing in the articles under an authors’s name. For editorial or business information and advertising, contact California Podiatric Medical Association, 2430 K Street, Suite 200, Sacramento, California 95816; telephone, (916) 448-0248; facsimile; (916) 448-0258; e-mail; calpma.org.

| 19

We’re looking forward to the Western Foot and Ankle Conference! Biopsy Instruments

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Doe, John Z 770-634-6616 3/19/1985 (28) / M 3/27/2013 3/28/2013

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JANE DOE, DPM 111 YOUR ADDRESS HERE ST ATLANTA, GA 30309 877-376-7284/

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PODIATRIC PATHOLOGY REPORT DIAGNOSIS:

SKIN, RIGHT ANTERIOR LOWER LEG, PUNCH BIOPSIES (two): - SPONGIOTIC DERMATITIS, SUBACUTE, MOST CHARACTERISTIC OF NUMMULAR (eczematous) DERMATITIS. - A PERIODIC ACID SCHIFF REACTION FAILS TO DEMONSTRATE FUNGAL ELEMENTS. COMMENT: These histopathologic features may be seen in association with conditions as disparate as acute allergic contact dermatitis, early-evolving nummular (eczematous) dermatitis, and Id reaction. In light of the constellation of both clinical and histopathologic features in this case; one potential therapeutic course for this patient could include the application of a low potency (class 6-7) topical corticosteroid. The therapeutic value of such steroids may be augmented by concomitant use of topical urea.

CLINICAL INFORMATION: Dermatitis. Rule out tinea corporis. Lower leg. GROSS DESCRIPTION: Received in formalin fixative are two 2-mm punch biopsy specimens which are submitted en toto for processing in 2 cassettes. MICROSCOPIC DESCRIPTION: Sections demonstrate a superficial perivascular infiltrate comprised of lymphocytes. There is diffuse spongiosis and an admixed compact and basket-woven stratum corneum with intracorneal serum. Scattered intradermal eosinophils are seen. A PAS stain fails to demonstrate fungal organisms. Final Diagnosis performed by Bradley W. Bakotic DPM,DO. Electronically signed 3/28/2013

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CPT Codes:88305 ICD9 Codes: 692.9

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Current Legal Issues In response to member requests, here is a short synopsis of the most prevalent legal issues we are working on for CPMA Members:

X-Ray Policies and Procedures: The Department of Radiologic Health continues to perform unannounced site audits. The primary things they are looking for are: (1) whether you have an up to date written radiologic policies and procedures manual; (2) whether only licensed or certified staff are aligning the patient and â&#x20AC;&#x153;pushing the button;â&#x20AC;? (3) whether hazard signs are properly posted; and (4) whether you have your x-ray machine checked regularly to confirm it is compliant with safety standards. Fortunately, the first offense is generally dealt with by having you sign a warning document, acknowledging your lack of compliance and your commitment to rectifying the problem and avoiding further violations.

Subsequent offenses can result in suspension or revocation of your x-ray certificate, fines (generally between $2,500 and $7,500) and additional education requirements (including an ethics course). Although these matters are forwarded to the Board of Podiatric Medicine for further review, we have not seen the Board take further action beyond interviewing the affected doctor. Resolution: check your office paperwork and procedures now to make sure they are in compliance. The California Podiatric Medical Association (CPMA) has materials on its website (www.CalPMA.org) to help members become and stay compliant. If an auditor shows up at your practice unannounced, and you are not absolutely certain you are in full compliance with the relevant law, let them know that you have counsel and have them take a seat in the waiting room. Immediately call your malpractice insurance carrier. You can also call the 1-800-FOOTLAW number and you will be immediately passed through to me. I will then attempt to set up a date that the auditor can return to meet with you and counsel. EHR Incentive Bonus Audits We continue to be deluged with HITECH EHR Meaningful Use audits by Figliozzi & Company. All members who received or have applied for the EHR Incentive Bonuses should take the time now to check the report card generated by their software to determine if there are any inconsistencies with their attestation. We have seen changes in practice volume and demographics, software glitches and administrative errors by billing and coding staff result in challenging hurdles to overcome during active audits. It is much easier to resolve these problems when they are caught early. It is particularly important to make sure that you perform a security risk analysis and prepare a plan to address any identified concerns. The analysis should include the security of private patient information being stored and transmitted (e.g., regular password changes, data encryption, limit access to those that need it, etc.), confirming that the computer system has appropriate battery and data back-up and the physical facility is secure. Failure to fulfill a single core element on the audit results in a repayment demand of the entire amount. Moreover, failure of an audit for one year will likely result in an audit for other years. Quality Assurance Audits Both Medicare and Medi-Cal have stepped up promotion of their quality assurance programs. Notices are sent in the mail, requesting copies of the patientsâ&#x20AC;&#x2122; records, a summary of treatment, and an explanation for specific complaints made by the patient. The time to respond can be fairly short, with the provider only having a week or two to respond. Extensions are available if timely requested. If the auditor identifies a breach of the standard of care, some organizations simply save the complaint in order to see if a pattern of substandard care becomes apparent. Others forward the complaint to a separate department to obtain confirmation that the doctor understands See Legal Issues on Page 23

J a n ua r y | F e b r ua r y | M a r ch | 2015

| 21

360º of PEMF treatment to improve fracture

healing of challenging

nonunions

1-7

Orthofix Osteogenesis Stimulators provide a safe and effective non-surgical treatment to improve fracture healing. Physio-Stim’s PEMF (pulsed electromagnetic field) signal induces an electrical field at the fracture site which stimulates fracture repair.*, 4-6

Proven Fracture Healing Success 7

Fibula: Tibia: Metatarsal:

91.4% 89.0% 90.9%

* The results of preclinical studies may not be indicative of human clinical trials. 1. PMA P850007. February 1986. 2. Garland DE, Moses B, Salver W. Fracture healing: Long-term follow-up of fracture nonunions treated with PEMFs. Contemp Orthop. 1991;22(3):295-302 3. Data on file. Field mapping analysis conducted by M. Zborowski, Ph.D., Cleveland Clinic. 4. Marino, AA and Becker, RO: Piezoelectric effect and growth control in bone. Nature. 1970 October; 228: 473-74 5. McElhaney, JH: The charge distribution on the human femur due to load. J Bone Joint Surg Am. 1967; 49(8): 1561-71 6. Midura RJ, Ibiwoye MO, Powell, KA, et al. Pulsed electromagnetic field treatments enhance the healing of fibular osteotomies. J Orthop Res. 2005;23:1035-46 7. Orthofix patient registry. PMA P850007/S20. Data on file. Brief Prescribing Information: The Physio-Stim® is indicated for the treatment of an established nonunion acquired secondary to trauma, excluding vertebrae and all flat bones, where the width of the nonunion defect is less than one-half the width of the bone to be treated. A nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing. Use of this device is contraindicated where the individual has synovial pseudarthrosis. Demand type pacemaker operation may be adversely affected by exposure to pulsed electromagnetic fields. The safety and effectiveness of this device has not been established for individuals lacking skeletal maturity or individuals with a nonunion secondary to, or in connection with, a pathological condition. The safety of this device for use on patients who are pregnant or nursing has not been established. Rare instances of reversible minor discomfort have been reported. Full prescribing information can be found in product labeling on our patient education website www.bonestimulation.com or by calling Patient Services at 1-800-535-4492. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

1.800.535.4492 www.bonestimulation.com www.orthofix.com BSA-1505-CPMA © Orthofix Holdings, Inc. 3/2015

Legal Issues from Page 21

the problem and can provide a corrective action plan to assure that the identified problem will not reoccur. These audits do not generally result in any monetary fine or repayment demand, but they nevertheless should not be taken lightly. Repayment Demands All government and private third party payors continue to use random audits for quality assurance and overpayment detection. Most commonly, the demands are for a single patient. Although the specific amounts in question may be relatively small, each and every repayment demand should be taken seriously and appeals should be aggressively pursued in all circumstances where the doctor believes that the billing was appropriate. Appealing a repayment demand will not increase your chances of being audited in the future. There are fill-in the blank forms on the CPMA website to help you appeal these relatively small repayment demands without tying up staff for an excessive amount of time. We are currently looking for third-party payor decisions that are the result of bias against Podiatric Medicine or arise from a misunderstanding of the scope of practice for a DPM. In particular, we would like to know of all denials of coverage for services that are determined to be “outside of the provider’s scope of practice.” Administrative Defense Coverage It is highly likely that your malpractice insurance policy covers the defense for all of the issues discussed above in this article.

Unfortunately, very few doctors appear to know this, or use it. The best way to make sure that your response to an on-site Radiologic Health inspection, EHR Incentive Bonus audit, Quality Assurance audit or repayment demand is handled properly, is to get an expert on board that is covered by your insurance carrier. This takes the stress off of you, the excess work away from your staff and results in better handling of the matter by experts who deal with this type of thing all the time. Business Protection It is incredible how many professionals don’t have a trust and how many of those that do have trusts have failed to properly protect their practices through the trust. If you do not have a trust, your estate will go through the long and expensive probate process. A trust lets you avoid probate and have your estate handled privately, away from the public scrutiny of the probate process. This year we are focusing on helping doctors get their practices in shape for potential sale, addition of a partner or disposition due to disability or death. Setting up the best business structure (generally a corporation), branding a name that can stay with the practice (rather that your individual name) and setting up proper contracts with staff, associates and third party payors, can position your practice to better maintain its value when going through the various transitions you may face. If you have questions about any of these matters, or have a topic you would like discussed in future editions, please contact CPMA at 800-798-8988.

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| 23

on your toes from Page 15

The reporting requirements of the California Department of Public Health for installation, or receipt, sale, transfer, disposal or discontinuance of use, of any reportable source of radiation have stayed the same, but the way in which it is reported has changed. To report the discontinuance of use of a radiation machine, dentists should notify the California Department of Public Health by submitting a completed “Radiation Machine Registration for Changes to Registrant or Machine Information - RH 2261C” form. To report that a doctor is no longer in possession of any functional radiation machine, they should notify the California Department of Public Health by submitting a completed “Radiation Machine Registration for Withdrawal of Registration - RH 2261W” form. To register a new facility with a radiation machine, notify the California Department of Public Health by submitting a completed “Radiation Machine Registration for New Registrants - RH 2261N” form. REVISED Radiation Forms noted above http://www.cdph.ca.gov/ certlic/radquip/Documents/RHB-RegistrationInformationNotice.pdf For a radiation machine to be inactivated from the CDPH-RHB registration database, the radiation machine has to be incapable of producing radiation or no longer in the possession of the registrant. Incapable of producing radiation means a radiation machine is no longer functional. Members are reminded that unplugging a machine or placing a functional machine in storage on site or off site, for use at a later time, does not mean that a machine has been made incapable of producing radiation. Failure to report the sale, transfer, disposal or discontinuance of use of a radiation machine(s) will result in continued registration billing. For more information, visit cdph.ca.gov/rhb.

59 Modifier Migration Clarification Dear Members: CPMA has received some questions regarding CMS’ announcement on the shift from the -59 modifier. According to Dr. Harry Goldsmith “There is nothing about the 59 modifier that automatically changes on 1 January, 2015.” CMS will be implementing CR 8863 on January 5, 2015. CR 8863 states that 4 new more selective modifiers are available and describes the general situations in which they can be used. However, it also noted that, at the present time, modifier -59 may continue to be used [emphasis added by APMA]. The CR system instructions specify that Medicare edits will initially consider the -X{EPSU} modifiers to be equivalent (interchangeable from an edit perspective) with modifier -59, a situation which will also allow providers time to slowly adjust to the new modifiers. CMS wrote these instructions in order to allow a transition period as additional coding advice and educational programs 24 |

are developed. As with all codes and modifiers, until such time as additional coding advice is published, providers should take the new modifiers at face value. The “XE” modifier, for example, defines a separate encounter, so it should only be used when services provided at multiple encounters are reported. CMS intends to promote transparency and consistent coding by pairing additional education and guidance with any future edit changes that depend on these new modifiers, so additional guidance on their appropriate use with specific codes and specific situations will be forthcoming. So for now, you can keep using -59, or you can start using the new codes based on when you are currently using -59 to signify a different encounter, etc. [Dr. Goldsmith: emphasis added] Again, CMS will be publishing more details as it starts requiring these specific modifiers. In addition, it applies to all codes that can take the 59 modifier” (Sources: Harry Goldsmith, DPM and Tony Poggio, DPM)

Remember to Notify Staff of Sick Leave Law Changes On January 1, 2015 California employers were to have posted notices about the changes to the paid sick leave law in California. The new law, which takes effect on July 1, requires nearly every employer in California to allow all of its employees at least three paid sick days each year. The law provides that employees receive an hour of paid sick leave for every 30 hours worked. (Caring for themselves or family members can be the reasons for taking the sick leave.) CPMA recommends that everyone on staff should be notified of these changes. Notices should be posted conspicuous place, have a staff meeting about the change or changes in policy and have each employee sign a document that acknowledges, ‘These changes replace or are an addition to the current manual on this date,’ and place a copy in each employee’s file. This helps the doctor cover their bases if a dispute should ever arise. Information regarding sick leave that should be included in an employee manual includes, but is not limited to: the employer can limit an employee from using the leave for the first 90 days of employment; an employer who chooses to provide leave on an accrual basis, no less than one hour for every 30 hours worked, can limit the amount of paid sick leave to 24 hours/three days each year and can cap the total rollover accrual banked by an employee to 48 hours/six days; and if an employee should leave the practice, sick leave does not need to be paid out unless the employer’s policy combines the sick leave and vacation into a paid time off policy. In addition to this, employers are supposed to comply with displaying a required poster for employees by Jan. 1. The notice can be found under Work Place Postings on the Department of Industrial Relations website http://www.dir.ca.gov/ Noncompliance can result in fines and state penalties.

C P M A | C a l if o r n ia P o diat r ic M e dica l A ss o ciati o n

Doctors should review their employee manual every year and make any necessary changes so that the practice remains in compliance with current state requirements.

CPMA Collaborates on Development of ACA Provider Non-Discrimination Provision Toolkit The California Podiatric Medical Association (CPMA) has collaborated with the APMA (American Podiatric Medical Association) to create an ACA Provider Non-Discrimination Provision toolkit to educate members on the provision and CPMA/APMA’s advocacy efforts. The toolkit also includes draft language that members can use to communicate with health plans in order to resolve conflicts involving the provision. The provision prohibits discrimination “with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.” It is CPMA’s and APMA’s position that pursuant to the provision, the following practices are prohibited: 1. Discriminating in terms of coverage based on the licensure or certification of the provider furnishing the service, through both explicit exclusion practices 2. Any policies that result in a discriminatory impact CPMA and APMA will continue to advocate for members and will provide additional updates, as they become available. The toolkit is available to Members on the ACA and Covered California page of the CPMA website CalPMA.org.

New Toolkit Developed For Physicians Facing Medical Audits Medical audits are disruptive to physician practices and often cause substantial financial hardship as. However, physicians need to consider medical audits as a routine part of their businesses and plan accordingly. There are many actions that physicians can take to mitigate both the risk of being audited and the potential for adverse audit findings in the event of an audit, some of them quite simple. The Physicians Advocacy Institute and the American College of Emergency Physicians have developed a toolkit that contains practical tools for physicians facing medical audits. The toolkit provides information and tips to guide physicians in anticipating medical audits, responding to auditors’ requests for medical records and appealing erroneous audit findings. The toolkit also includes detailed information regarding the various types of governmental and private payer audits, appellate procedures and extrapolation methodologies used by some payers to calculate alleged overpayments. The toolkit can be found in the Legal Resource Center on the CPMA website CalPMA.org.

Dual Eligible Opt-Out Percentage High Enrollment remains low and opt-outs remain high for the state’s duals demonstration project, particularly in duals-rich Los Angeles County. In addition, a sizable percentage of enrollees have disenrolled from the program, according to the most recent data from the Department of Health Care Services, which oversees the project as part of its Coordinated Care Initiative (CCI). In the governor’s proposed fiscal year 2015-2016 budget, the CCI still is listed as cost-effective but that’s primarily because the scales are weighted by a managed care organization tax. Without that tax money, the CCI would show a cost, rather than savings. If those numbers don’t improve by January 2016, the CCI would end operations. (Source: David Gorn, California Healthline, 2/4/2015)

Durable Medical Equipment Dear CPMA Members: I recently met with Noridian officials regarding on billing and coverage for cam walkers/AFO as well to get clarification on the definition of an off-the-shelf prefabricated device/ custom fitted vs. a true custom fabricated devices. The definition of a brace is a rigid or semi-rigid device used for the purpose of: • supporting weak or deformed body member or restricting or eliminating motion in diseased or injured part of body, and • must provide support and a counterforce on a limb or body part that it is being used to brace Some of the more common HCPCS codes for AFOs include: – AFOs, codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 – KAFOs, codes L2000-L2038, L2126-L2136 and L4370 Coverage for these devices varies depending on if the patient is ambulatory or not and if the device is a custom fabricated device or a prefabricated device. As always, documentation is important. Some basic points to document are whether the patient is ambulatory or non-ambulatory and why there is a need for a custom fabricated vs a prefabricated device. There needs to be a detailed Written Order in your chart. If you are sending the patient out to an orthotist, a separate RX would be required. If you are both prescribing and dispensing the device the written order can be part of your chart note. Regardless the following information needs to be listed on the RX or within your chart note: ( as a reference see: Chapter 3 of the Noridian Supplier Manual on Standard Documentation requirements. https://www. noridianmedicare.com/dme/news/manual/chapter3.html ) See on your toes on Page 26

J a n ua r y | F e b r ua r y | M a r ch | 2015

| 25

on your toes from Page 25

–Provide the product that is specified by the ordering physician -Type of orthosis dispensed -Written Order

A custom fabricated device is covered for ambulatory patients when one of the following criteria is met/documented in the medical record: 1. Beneficiary could not be fit with prefabricated AFO, or

-Proof of delivery

2. Condition necessitating orthosis expected to be permanent or

-Medical Records *documentation of the patient’s condition *documentation to support the medical necessity of a custom vs prefabricated device *Why a prefabricated device would not meet the patient’s needs

of longstanding duration, or 3. Need to control the knee, ankle or foot in more than one plane, or 4. Documented neurological, circulatory, or orthopedic status that

*Method of fitting and/or fabrication (OTS or custom fitted

requires custom fabricating over a model to prevent tissue injury, or

-Beneficiary Documentation or ABN

5. Healing fracture which lacks normal anatomical integrity or

- use the code that most accurately reflects both the type of orthosis and the appropriate level of fitting

anthropometric proportions

AMBULATORY VS NON-AMBULATORY PATIENTS AMBULATORY PATIENTS AFO/KFO items are covered for AMBULATORY patients when the patient is: • Ambulatory (or plan to move to an ambulatory status must be documented in medical record. This is an important point. This had been an issue in the past where cam walkers were being denied if the patient was put non-weight bearing. CMS interpreted this temporary non-weight bearing status to mean that the patient was non-ambulatory and hence not covered. Therefore make sure that your chart states that the patient will be transitioning to a weightbearing status.) • Weakness or deformity of the foot and ankle • Require stabilization for medical reasons • Have the potential to benefit functionally For KAFO’s, the requirements include: • Beneficiaries who meet coverage for an AFO, and • Require additional knee stability

26 |

NON-AMBULATORY PATIENTS For non-ambulatory patients L4396 or L4397 are covered when a beneficiary is non-ambulatory or minimally ambulatory and if all criteria 1-4 or criterion 5 is met: 1) Plantar flexion contracture of ankle (Dx 718.47) with dorsiflexion on PROM testing of at least 10 degrees (i.e., non-fixed contracture); and 2) Reasonable expectation of ability to correct contracture; and 3) Contracture is interfering or expected to interfere significantly with beneficiaries functional abilities; and 4) Used as component of therapy program which includes active stretching of involved muscles and/or tendons OR 5) beneficiary has plantar fasciitis (Dx 728.71). Code L4398 is also used for an ankle-foot orthosis which is worn when a beneficiary is non-ambulatory For non-ambulatory patient custom orthotic coverage is less clear. Documentation is the key here. Make sure you document why a non-ambulatory patient requires a custom device. “Preventative” needs such a preventing a contracture may not be enough to warrant coverage

CUSTOM FABRICATED VS OFF-THE-SHELF DEVICES Custom fabricated orthotics are: • items that are uniquely made for an individual beneficiary. No other beneficiary would be able to use the specific item • items that are individually made from basic raw materials including, but not limited to, plastic, metal, leather or cloth in the form of unshaped sheets, bars or other basic forms and involve substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing prior to fitting on the beneficiary • tems must be individually fabricated over a positive mold of the beneficiary. A positive model may be created using various methods, e.g., traditional casting methodologies or using CAD/ CAM or similar technology (not all-inclusive list). In all cases in order to be considered a custom fabricated, the item must be C P M A | C a l if o r n ia P o diat r ic M e dica l A ss o ciati o n

created over actual physical mold of the body part. • items that require the expertise of a qualified practitioner to custom fabricate

OFF-THE-SHELF DEVICES These types of devices maybe prefabricated or custom fitted Prefabricated Off-The- Shelf devices: • May or may not be supplied as a kit • Requires minimal self adjustment upon delivery; this refers to adjustments made when you first dispense the device not on follow-up examinations. • Does not require expert fitting rather – this can be done by a beneficiary, caretaker or supplier Custom Fitted Off-The-Shelfdevices: • May or may not be supplied as a kit • Requires substantial modification upon delivery: this refers to adjustments made when you first dispense the device not on follow-up examinations, • Requires expert fitting by a physician, certified orthotist or someone with specialized training NOTE: The definition of minimal vs substantial modifications of a device is somewhat unclear. Adding additional padding to protect a bony prominence or adding a heel lift or wedge would not be considered substantial. Documentation here is key to list what adjustments were made to the device and why these adjustments had to be made by a fitting expert. Some examples of common custom fitted vs Off-The-Shelf codes:

– Making adjustments at the time of, or within 90 days of the delivery • Use of additional codes L4002 – L4130, L4392

Repairing orthotic devices • Covered when necessary to make orthosis functional – Must have supporting documentation of reason for repair • If expense for repairs exceeds estimated expense of providing another entire orthosis, no payment will be made for amount in excess • Not covered if item was previously denied • New order not required for repairs L4205 – Repair of orthotic device, labor component, per 15 minutes – Include narrative on claim explaining what was repaired – Can only bill for time involved in actual repair or for medically necessary adjustments made more than 90 days after delivery – Cannot use to bill for time involved in other professional Services L4210 – Repair of orthotic device, repair or replace minor parts – Include narrative on claim describing each item billed Replacement of complete orthosis or component of orthosis is covered if due to:

Off-The-Shelf

– Lost, stolen, irreparable accidental damage

L4360

→

L4361

• RA modifier required

L4386

→

L4387

– Significant change in beneficiary’s condition

L4396

→

L4397

• New order required for any replacement

For items without a designated HCPCS code, e.g., L2999 you must include a narrative description of the item or manufacturers name and model name/ number. The suggested manufacturer suggested retail prices and for replacement components, the HCPCS code or manufacturer name and model number of base orthotic Non-Payable Services Time involved with: – Evaluating the beneficiary for the brace (Services to evaluate and treat the patient’s condition are separately payable per medical necessity) – Taking measurements, making a cast, making a model, use of CAD/CAM

– Follow-up visits specifically for the brace (Services to evaluate and treat the patient’s condition are separately payable per medical necessity)

→

For the classic cam walker that we would dispense for a fracture, the Off-The-Shelf codes would be the most correct

– Making modifications to a prefabricated item to fit it to the individual beneficiary

Custom fitted

Currently both custom fitted and Off-The-Shelf devices are reimbursed at the same. This could change in the future

• Supplier’s record must document reason for any replacement • Replacement components provided on a routine basis, without regard to whether the original item is worn out, are not covered. • The padding/lining of an AFO can be replaced if reasonable and necessary.

January 2015 Noridian Jurisdiction D DME MAC 22 MODIFIERS: • LT – Left side • RT – Right side • KX – Coverage criteria met and supporting documentation is on file • GA – Coverage criteria not met and ABN obtained • GZ – Coverage criteria not met, valid ABN not obtained • EY – No physician or other licensed health care provider order for this item. See on your toes on Page 29

J a n ua r y | F e b r ua r y | M a r ch | 2015

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Volunteers Needed: Podiatric Physicians, Residents and Students, the Special Olympics Need You! Podiatric medical specialists will once again be “stepping up” to donate their time and expertise at the 2015 Special Olympics Summer World Games. Los Angeles will be the host of the 14th Special Olympics Summer Games and the first on American soil in 16 years. July 25 through August 2, Los Angeles will be honored to host tens of thousands of athletes, their coaches, event volunteers and supporters to participate and cheer on the skills and accomplishments of athletes with intellectual disabilities. Special Olympics were a project of Eunice Kennedy Shriver who saw that people with intellectual disabilities were treated unfairly. She decided to take action, and a summer day camp held in her backyard became the inspiration behind the Special Olympics. With her drive, the first Special Olympics summer games were held in 1968. One thousand athletes were in attendance. Since then, many improvements have been made, including a new Special Olympics initiative in 1997, called Healthy Athletes. Healthy Athletes continues to provide health care services to Special Olympics athletes worldwide. In 2003, Fit Feet, a podiatric screening, became the newest discipline to Healthy Athletes. Fit Feet has been a popular foot and ankle clinic, with summer and winter athletes, both nationally and at the local Southern California Special Olympics for years.

July 25 through August 2 Los Angeles If interested or have questions please contact drgraves@drrichardgraves.com 28 |

In preparation for this summer’s World Games, the podiatric medical community is already banding together to welcome these athletes. By recruiting dedicated Fit Feet clinical directors and podiatric medical specialists along with the best local area podiatric medical students and residents, Fit Feet is preparing to provide another excellent screening service at the World Games’ Healthy Athletes Fit Feet clinic. Nearly 50 percent of Special Olympics athletes experience preventable foot concerns, such as flat feet, nail problems, issues with strength and balance to name a few, which may affect their sports participation without proper treatment. In fact, prior to Fit Feet’s involvement, nearly 40% of the athletes were wearing ill-fitting shoes for their sporting events. Fit Feet’s seemingly simple lower extremity screening gathers enough information allowing the specialist to provide the athlete, coach and family valuable feedback, education and even referrals to help as needed. The mission of Special Olympics “is to provide year-round sports training and athletic competition in a variety of Olympic-type sports for children and adults with intellectual disabilities, giving them continuing opportunities to develop physical fitness, demonstrate courage, experience joy and participate in a sharing of gifts, skills and friendship with their families, other Special Olympics athletes and the community.” There are now over four million athletes in over 170 countries around the world participating in sports such as basketball, soccer, and volleyball among others. Special Olympics was the amalgamation of Eunice Shriver’s vision, the diligence of the organizers, the skill of the medical and specialist volunteers and the dedication and heart of the Special Olympics athlete. C P M A | C a l if o r n ia P o diat r ic M e dica l A ss o ciati o n

on your toes from Page 27

January 2015 Noridian Jurisdiction D DME 2015 Noridian Jurisdiction D DME MAC

– Submission – Status Inquiry • PMD Prior Auth Request Status

Additional DME Resources You can also check on the Noridian Website for Training and Events webinars in the education section for topics of interest.

Availability • Eligibility

LCD/Policy Article

– 24 hours/day, 7 days/week

– www.noridianmedicare.com/dme/coverage/lcd.html

• All other functions

• Supplier Manual

– 6 a.m. – 8 p.m. CT, Mon.– Fri.

– Chapter 3-Documentation

– 7 a.m. – 3 p.m. CT, Sat.

– www.noridianmedicare.com/dme/news/manual/index.html

www.noridianmedicare.com/dme/claims/endeavor.html

• Documentation Checklist

Supplier Contact Center – 8:00 a.m. – 6:00 p.m. CT M-F

– AFO – www.noridianmedicare.com/dme/coverage/checklists.html The ENDEAVOR system can be used to check various things in the patient billing history. One is to see if they have had a similar DME device within the past five years. Remember that DME items are covered every five years unless the items is damaged beyond repair or the patient’s condition has significantly changed such that the original DME item does not fit any longer. Below is a list of items that can be checked through the Endeavour system Eligibility • Claim Status • Same or Similar • ALV • Claim-Specific Remittance Advices • Overpayments • Reopening/Redetermination

ICD-10 Cometh! ICD-10

– 1-877-320-0390 • Interactive Voice Response (IVR) – 24/7 Eligibility – 6:00 a.m. – 8:00 p.m. CT M-F for claim status – 1-877-320-0390 • Telephone Reopenings – 8:00 a.m. – 4:30 p.m. CT M-F – 1-888-826-5708

January 2 NOTE: Contact info is changing a little as of March 1, the IVR, contact center and now phone reopenings will be accessible through the same phone number and they’ll all have the same hours of availability https://www.noridianmedicare.com/dme/ news/docs/2015/01_jan/single_toll_free_phone_number_for_ customer_service_and_telephone_reopenings.htmlS015 Noridian Jurisdiction

Ready? Are You

Get your vital ICD-10 checkup at the 2015 Western Foot and Ankle Conference (The Western), June 25 - 28 at the Disneyland® Hotel in Anaheim, CA. Acknowledged coding experts will help you find out where you are, learn where you should be, and give you the necessary information you need to be prepared for the critical October 1, 2015 ICD -10 Implementation date.

2015 Western Foot and Ankle Conference | June 25 - 28, 2015 J a n ua r y | F e b r ua r y | M a r ch | 2015

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April is Foot Health Awareness Month

Foot Health Awareness Month affords the California Podiatric Medical Association (CPMA) the opportunity to spotlight and educate the general public on the critical role podiatric medicine plays in the healthcare system. With this year’s theme of “Play It Safe,” CPMA will be focusing on podiatric physicians as the practitioners of first choice for the treat and prevention of foot and ankle sport injuries by virtue of their long and rigorous medical education and training making them the experts in the diagnosis and treatment of sports injuries affecting the lower extremities, their ability to provide guidance on proper athletic footwear, prescribe custom orthotics and to evaluate individuals’ biomechanics.

Visit CalPMA.org for more information 30 |

C P M A | C a l if o r n ia P o diat r ic M e dica l A ss o ciati o n

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samuelmerritt.edu/ podiatric_medicine

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wmt.com

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www.alliqua.com stryker.com

arthrex.com

pacificadvisors.com/podiatry

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westernu.edu/podiatry

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Support the Companies Who Support You!

California Podiatric Medical Association 2430 K Street Suite 200 Sacramento, CA 95816

Western Foot and Ankle Conference June 25 – 28, 2015 Disneyland Hotel & Convention Center Anaheim, California

Come see what makes

The Western THE BEST • 26 CECH for DPMs • 10+ Radiology CECH • 2 Days of ICD-10 Workshops • PMA Program • Practice Management Track • Hands-On Workshops including Advanced Arthroscopy • PICA Discount • Full Exhibit Hall Just Steps from General Sessions • Healthy Snacks • Award Winning Meeting • Four Diamond Location at Discounted Rates • Family Destination at the Happiest Place on Earth Celebrating 60 Years

visit www.thewestern.org for more information. 2430 K Street • Suite 200 • Sacramento, CA 95816 • (800) 794-8988