Start By Scanning Every New Patient
We know that when the foot hits the ground, everything changes. Providers must consider the feet, which are the foundation of the patient’s spine when evaluating the musculoskeletal system relative to the patient’s complaints. Best practice is to scan every patient at the beginning of their episode of care.
The valuable data collected with the 3D, digital scan is the most important starting point. Not only does the scan measure the arches of the feet, but also indicates degrees of pronation or supination and many other measurements that demonstrate medical necessity for functional orthotics. Whether the provider elects to order the functional orthotics right away or include them in later recommendations, this important scan provides information to support the prescription of chiropractic care as well. We recommend that your foot scan becomes an integral part of the evaluation, just as vital signs are “automatic.” The following steps are recommended to identify additional, important details to support the provider’s recommendations.
Evaluate Medical Necessity and Document Your Clinical Decision Making
Documentation of medical necessity of care starts with the patient’s history. When considering whether functional orthotics are medically necessary, and therefore a covered service, insurers often look to the patient history to document the following symptoms where present:
- joint pain/stiffness
- limitation of motion
- difficulty walking
- numbness/tingling in the lower extremities
It is important when taking a patient's history to explore both past and current medical conditions that may affect patient care. Chronic conditions and traumatic injuries could each benefit from functional orthotics. Additionally, it may be helpful to ask the patient about other treatments tried or considered and ruled out. Where applicable, document why these prior alternatives did not work out favorably, or why they stopped working.
These are some examples of specific history questions that may be helpful in determining the need for functional orthotics:
- Are your symptoms affected by walking, standing, or climbing stairs?
- Do you avoid activity due to pain in your feet or lower extremities?
- Do you have to elevate your feet to get comfortable?
- Do you use any type of home remedies for your feet and lower extremities?
- Have you tried heel lifts, over the counter (OTC) analgesics, OTC insoles, rigid orthotics, padding, changing your shoes, or injections?
The answers to these questions, when properly documented in the patient record, may help support your assessment that treatment is indicated and there is medical necessity for prescribing functional orthotics.
Examination And Diagnostic Testing
Once the patient's history is established, the next step is the physical examination, with the testing driven by what was learned in the history. The history, combined with documentation of the physical examination and, where called for, diagnostic testing (i.e., X-rays) together provides the objective evidence for medical necessity to support the use of functional orthotics in a treatment program. When orthotics are being considered, your documentation must clearly describe the patients’ symptoms and medical diagnoses. You may also include one or more of the following:
- 5 Red Flags of Pronation
- Global postural distortions
- Structural X-ray anomalies
- Functional squat test
- Range of motion
- Orthopedic/Neurological tests
- Digital foot/posture assessment
Click here to access an excellent Functional Foot Evaluation form to best document clinical findings.
Functional orthotics address not only conditions of the feet, legs, and hips but also conditions of the spine. Most often, insurance coverage is limited to diagnoses specific to extremities vs. spinal conditions. For this reason, we urge providers to be aware of the diagnosis requirements for medical necessity when attempting to assist the patient with receiving reimbursement from a third-party payer. The Medical Review Policy (MRP), published by the payer, should outline all the requirements. If the patient’s condition is not included in the medically necessary diagnosis list, not to worry. The patient still needs functional orthotics! Simply prescribe them as you would otherwise. In this course, we provide a list of diagnosis codes that have appeared in various payer MRP. However, this list is not exhaustive and shouldn’t be relied upon as the definitive list of appropriate diagnosis codes.
To establish medical necessity and the clinical appropriateness of functional orthotics, include your recommendations in the context of a broader treatment plan. A properly written treatment plan should be comprehensive and may include some of the following elements:
- Recommended level of care to include duration and frequency of follow-up visits
- Methods of treatment to be utilized (i.e., adjustments, therapies, functional orthotics, rehab)
- Specific treatment goals, including goals for the functional orthotics
- Objective measures to evaluate treatment effectiveness and the effectiveness of functional orthotics
- Planned modalities and procedures, including those adjunctive treatments to support the necessity of functional orthotics
Finally, ensure that your initial or ongoing assessment indicates the provider’s reasoning for prescribing functional orthotics. This is where providers lay out the analysis of the data obtained throughout this evaluation process, culminating in the recommendation for functional orthotics.
**This is an excellent article and page of information about best practices: https://www.chiroeco.com/custom-orthotics-for-flat-feet/