Imaging for quantifying LLD under medicare in Australia. Can we actually refer under medicare for th

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Hi,

I would like to get advice/clarification regarding what type of imaging we as podiatrists in Aus are able to refer for under medicare for leg length x-ray or CT scanogram etc.

What are the best imaging options? and are these bulk-billed if a podiatrist refers for them?

I have moved to a new area and am having difficulty with the referrals. I was informed podiatrists cannot refer for this type of imaging under medicare by two separate imaging practices despite having no issues in the past with referring for these at other locations.

I hope someone can shed some light on this!

Cheers, Tom

 

Tom

Podiatrists in Australia can refer for plain x-ray views proximally to the head of the femur under Medicare. So, theoretically, you can request standing full leg views from the acetabulum to the ankle. I personally, do not - as it is a larger radiation dose, time consuming, and inappropriate now the CT can do this in a fraction of the time and radiation dose.

You can refer for CT leg lengths, but it just wont be covered under Medicare, unless via a GP or specialist.

You can liaise with you local radiology groups on what the 'cash price' is for this investigation, and then present that figure to the patient to consider. Usually, busy working people will be persuaded that this is worth the extra cost so they can avoid another trip to the GP and further time off work.

LL

 

Tom,

Podiatrists can only reffer, for MBS purposes, plain films of the foot and ankle and diagnostic Ultrasound of same. Most imaging services will bulk bill both thses services, but you will need to check with the service.

for CTs nuclear medicine and images above the ankle, a medical referral is required (Physios and Chiros can order plain film images of the spine) for MBS rebates to apply. The patient, though can always choose to be a private patient and pay the out of pockets themselves.

MRIs needs a consultant referral or patients can pay privately ($300 to $600 usually)

I will try and find the link that confirms the item numbers podiatrists can use.

I can only guess why the previous practice was allowing your refferals through, they may have been attributing them to a medical practicioner in the same building as your podiatry practice?

please see my correction below, Podiatrists can reffer for imaging of the whole lower limb.

 

see page 31 of
Medicare Benefits Catergory 5

and from MBS OnLine
55836; ANKLE OR HIND FOOT (X-Ray)
55840; MID FOOT OR FORE FOOT (X-Ray)
55844; ASSESSMENT OF A MASS ASSOCIATED WITH THE SKIN OR SUBCUTANEOUS STRUCTURES, NOT BEING A PART OF THE MUSCULOSKELETAL SYSTEM (Ultrasound)
57521; ANKLE LEG, KNEE OR FEMUR (so I stand corrected, this may be an addition since I last checked a few years ago)
57527; FOOT AND ANKLE, OR ANKLE AND LEG, OR LEG AND KNEE, OR KNEE AND FEMUR (again another possible addition)


so it is probably worth taking this information to the imaging practice, and using these item numbers on your refferals.

 

Hi Tom,

I often send patients for what is known as a CT scout view to identify any LLD. The CT makes only one pass and produces a film which incorporates both legs from the acetabulum to the toes. The radiology practice bills this as 4 seperate xrays which are bulk billed.

Sam

 

Why not consider the protocol for The Inclined Posture presented on a thread of its own in this matter?

TIP Is a no radiation exposure, clinical approach to LLD that raises the question, Is your patients lower extremity compensating for an LLD at the oints of the ankle.

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=5768&page=2 then scroll down to my posting.

Dennis

 

I've always questioned the clinical and radiological evaluation of LLD and the information it provides:

* None of us are symmetrical
* How much is too much?
* Functional or structural?
* Is it really clinically relevant?
* How is it managed?

Most LLD's I see are managed with heel raises - which again makes little to no sense for a true structural LLD - shouldn't it be the entire foot that is raised? Physios are renowned for it - but why? Lets not start talking about functional LLD's and how they seem to be "magically pseudo managed"....

LLD is a massive conundrum which I do not believe has very good clinical correlation behind it. In the end if most of us have some form of structural LLD and then most of those people again functionally compensate for it what are we treating? LLD is not a disease or pathoogy is it?

Its sort of like saying "you pronate" - well yes sir, yes you do!

Am I getting cynical in my old age?

 

I can always rely on the thoughtful input from fellow pods on this website. Thanks for clarifying things for me.

Sam, I assume that the radiology practice I was using before was billing in a similar manner to what you described.

Paul, I find Im treating a pathology by treating a structural LLD in some cases. E.g If I think an LLD may be contributing to frontal plane compensation in the lumbar spine causing muscular fatigue/splinting then I will incorporate lifts accordingly in an attempt to reduce the need for these compensations. Although for some the compensations may have been ongoing for 40+ years does this mean it is 'normal' and not worth attempting to reduce through lifts?

 

Hi TDC - are you using a heel lift or full foot lift? I agree with your last last comment. Why decompensate the compensated? Maybe a discussion for another thread!

 

Paul, l do a lot of build ups, often from a prescription.

Often the request for heel only comes for one of two reasons

If we only do the heel, the clients theory is their cuff of the pants will cover the heel and the toe has not been altered so others wont notice.

The other clinical reason for heel only, if the client has poor dorsiflextion(bloked) but good plantaflextion, this gives the client some dorsiflextion back by doing heel only= better toe clearance during gait

 

Paul, Im using full lifts where i can but will sometimes just use a heel lift. Although not ideal, some circumstances necessitate it.

One issue i have with using a lift extended to the met heads is that it will actually allow for the hallux and digits to plantarflex past the level of the lift which may reduce some of the stabilising effects of the reverse windlass mechanism.

The best solution is clearly an external lift to their shoes but as mentioned above some pt's don't want the added attention they may receive with a lift visible to the world.

 

Why bother with the expense etc of an MRI?
Is it not possible to assess LLD without an MRI well enough to allow you make a decision on amount of lift to apply.
Surely the decision on the height of lift if any should be made using the patients response/input to it.

 

I guess this was my point. Its simply what works for the patient and quite honestly everytime I have a chiro, physio, podiatrist, GP, student try to explain the "textbook" rationale behind addressing LLD it makes me more skeptical.

Clinically I am more inclined to believe that some people need structural LLD addressing, very few need functional LLD addressing.