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08/09/2018    Allen Jacobs, DPM

APMA Value and CMS Proposal on Drastic Change in E/M Guidelines (Adam Siegel, DPM)

Dr. Adam Siegel states that “ looking at the
profession as a whole “......“ a large
proportion of our profession applies 99212 in
addition to the routine foot care codes in an
attempt to suck a few more dollars out of

This is an insult for which Dr. Siegel should
forthwith render an apology and retraction. Many
patients who present to the office of a
podiatric practitioner for nail care do so with
concurrent illnesses such as PAD or diabetes.
The majority of such patients have concurrent
potential limb threatening pathology for which
evaluation and appropriate intervention may
interdict the progression of such pathology.
Utilizing the diabetic patient as an example,
such patients may have risk factors such as
edema, sensory neuropathy, deformities, motor
neuropathy, tinea pedis infections, skin changes
from autonomic neuropathy, degrees of large or
small vessel disease, and so on.

Under such circumstances, it is the duty of the
podiatric practitioner to identify such risk
factors, risk stratify such patients, and
proceed with appropriate therapeutic
interventions. I would argue that the majority,
not the minority, of diabetic patients or
patients with PAD present with comorbid
conditions which if left unattended, over time,
could result in limb loss or worse.

It is the job of the podiatric practitioner to
reduce the incidence of amputation in such
patients. Nail care may be a routine and
unattractive job, but it necessary and should be
properly carried out. There are multiple studies
demonstrating the relationship of onychomycosis
to ulceration, cellulitis, gangrene, and
amputation. This is in part due to the fact that
onychomycosis does not occur in a vacuum, but
rather in a scenario with other risk factors.

With regard to Medicare, we are generally
dealing with the geriatric patient. Gait
analysis, the prescription of ambulatory aids,
risk for falls and institution of appropriate
fall prevention recommendations, As well as the
evaluation and treatment of pathological
conditions associated with aging are an
important part of the office visit and certainly
warrants 99212 or 99213 in many circumstances.

Perhaps Dr. Siegel should turn his attention to
his patients as a whole and examine the patient
beyond the posterior nail fold.

Allen Jacobs, DPM, St. Louis, MO

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