The Modern Clinical Practice Keeps Asking for More

By Mikel D. Daniels, DPM, MBA, President and Chief Medical Officer, WeTreatFeet Podiatry

In healthcare, one pattern has become hard to ignore. Every time the system identifies a problem, the default solution is to add another task, another field, another attestation, another screen, and another layer of proof for the physician to produce. In podiatry, that pattern is especially visible because so much of what should be straightforward diabetic foot prevention has been converted into a documentation exercise that extends well beyond the actual treatment of the patient.

Whie that same pattern exists across medicine, podiatry gives a clean view of it. We can follow the evolution from paper charts to electronic records, from basic coverage standards to local coverage determinations (LCDs) and policy articles. We see this in every changing clinical judgment that now has a measure set. The resources we have to expend go from caring for a person with diabetes-related foot complications to proving in multiple places that the care met every administrative requirement. The result is not just inconvenience. It is a steady transfer of physician time away from examination, decision-making, patient education, and procedure work toward compliance labor that never seems to shrink once it is created.

The old paper chart had problems. It was harder to search, easier to lose, and often too dependent on the writing habits of the individual physician. But for all of its flaws, the paper chart generally remained a quiet record of the visit, rather than the central object of the visit itself. Modern electronic health records (EHR) changed that relationship. It did not simply digitize documentation. It re-engineered the encounter around things like required fields, structured elements, quality prompts, medication reconciliation tasks, coding support, inbox work, audit defense, and after-hours completion of notes that many physicians now treat as a second shift. Notice what is lost? Patient care.

That change matters because electronic documentation rarely arrives as a one-for-one replacement for paper. It almost always arrives with extra obligations attached. A note is no longer just a clinical record. It is also a billing artifact, a quality-reporting artifact, a legal artifact, a utilization-management artifact, and an interoperability artifact. Once that happens, the chart is no longer written mainly for the next clinician or even for the patient. It is written for auditors, payors, quality programs, dashboards, risk models, and future denials. This is getting ridiculous.

Anyone who has practiced long enough has watched this list grow in real time. First came the digitization push and the broad assumption that moving from paper to electronic records would create efficiency. Instead, it often created a new category of invisible work. Physicians were asked not only to document care, but also to document care in the exact structure needed by the software, the payor, and the reporting program. The burden did not end when the patient left the room. In many practices, the note now gets finished later, after clinic, after dinner, or on weekends, because the in-person patient visit is already too crowded to satisfy both the patient and the screen.

Then came the quality era in its modern form. The Physician Quality Reporting System (PQRS) gave way to the Medicare Access and CHIP Reauthorization Act and the Quality Payment Program (QPP), with the Merit-based Incentive Payment System (MIPS) becoming the reality for many office-based physicians (including podiatrists who meet participation thresholds). The Centers for Medicare & Medicaid Services (CMS) describes the QPP as a two-track program built around MIPS and Advanced Alternative Payment Models, and MIPS itself grades clinicians across quality, promoting interoperability, improvement activities, and cost. On paper, that sounds organized and rational. In daily practice, it often means another layer of measure selection, data capture, denominator management, and exclusions. On top of that, think about the attestations, technology requirements, and performance monitoring that sit on top of the ordinary work of caring for patients.

That burden is not theoretical. A 2023 study found that MIPS participation may increase the after-hours documentation burden for office-based physicians. The American Medical Association has also pointed to the substantial cost and time commitment associated with MIPS compliance and has argued that the process imposes significant burdens on practices, especially smaller ones (like mine). In other words, the promise of rewarding quality has turned into one more reporting metric that requires staff, software, and physician attention before it produces anything that could be recognized as better care.

Outside private practice, the same logic keeps expanding through hospital quality dashboards, Accountable Care Organization (ACO) reporting structures, and star-rating culture. Once a measure can be tracked, it tends to become a managerial target. Once it becomes a target, someone has to enter the data and reconcile the discrepancy. Then comes answering the query or amending documentation so the data will count the right way. That work almost always lands downstream on the clinician or on staff whose entire role becomes helping the clinician survive the documentation system.

Podiatry sees this very clearly in diabetic foot care because the clinical value of prevention is obvious, but the administrative path to coverage becomes more elaborate every few years. Therapeutic shoes for people with diabetes are a good example. The current Noridian clinician checklist ties the process not only to LCD L33369, but also to Policy Article A52501 and the Standard Documentation Requirements Article A55426. That alone tells the story. What should be a simple preventive intervention now resides inside a stack of interlocking rules that require the clinician and supplier to satisfy coverage criteria, order requirements, timing rules, signature rules, delivery rules, and corroborating medical record rules all at once. Never forget, that after all of this, if one data point is missed, there is a claw back.

The underlying clinical question is not complicated. Does the patient have diabetes, and does the patient have one of the qualifying foot risk conditions that make therapeutic footwear medically appropriate? But the documentation path is much more involved. The checklist requires confirmation of an in-person visit with the certifying physician within six months before delivery, documentation of diabetes, documentation of one or more qualifying conditions, and a certifying physician, specifically a medical doctor (MD) or doctor of osteopathic medicine (DO), who is responsible for managing the systemic diabetic condition under a comprehensive care plan. The same checklist also makes clear that the certifying physician may not be the podiatrist, and that nurse practitioner or physician assistant involvement carries its own incident-to and supervisory documentation conditions.

That is exactly the kind of regulatory layering physicians are talking about when they say every fix adds more to the doctor’s plate. The podiatrist may identify the risk, perform the foot exam, prescribe the shoe, document the deformity (callus, neuropathy, prior ulcer history, or circulatory findings), and coordinate the treatment plan. Yet, the process still depends on obtaining separate qualifying documentation from another clinician who manages the diabetes, and on making sure that the clinician’s note contains the right language. Also did the MD or DO sign the note in the right way and did this fall within the required time frame? If the care is medically right, but one administrative link in that chain is weak, the claim is still vulnerable. Think about it: the product and indication are secondary to the paperwork.

The language itself has become more exacting over time. The Noridian checklist states that diagnoses such as hypertension, coronary artery disease, congestive heart failure, or edema are not, by themselves, sufficient for poor circulation. That documentation must include objective and quantifying information such as pedal pulses or otherwise clearly describe the condition of the feet. That is a useful example of the broader trend. The system no longer accepts reasonable clinical shorthand. If a more specific phrase, measurement, or corroborating description can be demanded instead, doesn’t that make it more subjective and less objective? Then it is subject to the opinion of a reviewer.

The same drift toward procedural specificity appears in the LCD and policy infrastructure itself. LCD L33369 became effective for services performed on or after October 1, 2015, and shows revisions effective January 1, 2020. Its revision history records repeated changes tied to documentation language, order terminology, coding updates, and added cross-references to the standard documentation article. In 2016, the LCD documentation requirements were revised with new order requirements, corrected coding instructions, and proof-of-delivery revisions. In 2017, standard documentation language was removed from the LCD and replaced with new references and directions to the Standard Documentation Requirements article, effectively pushing providers to another governing document that also evolves over time.

That shift is important because complexity is no longer contained in one policy. It is distributed across the LCD, the related policy article, the standard documentation article, supplier manuals, modifier rules, and separate CMS requirements for face-to-face encounters and written orders prior to delivery. A physician can read one policy and still miss a denial trigger written in a related article. A supplier can satisfy the clinical intent and still fail on proof of delivery, refill documentation, or a signature requirement. The work, therefore, expands not only in volume, but in the number of written documentation a practice must monitor to remain compliant.

Article A55426, the Standard Documentation Requirements article, shows how broad that expansion has become. It requires that all claims for items billed to Medicare have a written order or prescription in the form of a Standard Written Order, and it specifies the elements that order must contain, including beneficiary information, order date, description, quantity (if applicable), practitioner identity, and a signature that must comply with CMS requirements. It also requires suppliers to maintain documentation for seven years, makes clear that supplier-prepared statements and physician attestations alone are not sufficient documentation of medical necessity, and insists that templates and forms must be corroborated by the actual medical record. Translation: you need to literally enter the information in a place specified by the rules, and if you have the correct information but it isn’t in the right location, you will receive claw back.

Again, none of this is a purely podiatric problem. It is just easier to see in the prescription for diabetic shoes because the coverage pathway is so complex. But the same administrative design appears everywhere. A policy concern is identified and then converted into a documentation requirement. A vulnerability in billing is identified and then converted into another attestation. A concern about fraud is identified and then converted into more record retention, more signature rules, more delivery verification, more cross-document consistency demands, and more opportunities for technical denial despite sound clinical care. On top of that, CMS pays companies to scrutinize the records and find a reason to deny the claim or claw back. And CMS pays them specifically to find these subtle issues. If they don’t find anything, no payment. The result is less availability for Medicare patients to these types of services.

This is also where the EHR becomes central. Once these requirements multiply, physicians cannot realistically track them through memory alone. The usual response is to build templates, checklists, macros, smart phrases, task queues, reminder flags, and staff workflows. That seems efficient at first, but it turns the EHR into a compliance cockpit rather than a clinical record. The note becomes longer, more repetitive, more structured, and more defensive, because it has to survive both billing and audit scrutiny, in addition to conveying medical thinking. I’m not sure why anyone needs a 14-page podiatry note, but I create them daily!

There is another consequence. Each time a new requirement is added, the burden rarely lands only on the physician in the room. It leads to an ecosystem of employees whose job is to chase signatures, scan records, reconcile dates, verify qualifying visits, confirm delivery timing, maintain proof-of-delivery files to appeal denials, and make sure language in one note matches language in another. That may allow a practice to pass audits, but it is not proof that the system is efficient. It is proof that entire staffing structures are now required to support reimbursement for care that used to demand far less administrative scaffolding. We now employ durable medical equipment (DME) traffic cops!

The revision history in Article A55426 shows this clearly. The article has evolved through repeated changes addressing the same items listed before (proof of delivery, written orders prior to delivery, refill documentation, supplier records, medical record documentation, replacement rules, and face-to-face encounter clarifications). The 2024 revisions removed older certificate of medical necessity (CMN) and DME Information Form (DIF) language, clarified that LCDs and related policy articles supersede the general document when there are differences, and added other documentation clarifications. Even when a revision is called nonsubstantive or merely clarifying, practices still have to read it, interpret it, adjust workflows, retrain staff, and update templates. Think about how much all of this costs a practice.

That constant revision cycle is one of the least appreciated contributors to physician fatigue. It is not only the amount of documentation that wears people down, but also the instability of the rules. A workflow that was compliant three years ago may now be incomplete. A phrase that once passed may now be considered too vague. A document that used to stand on its own may now need corroboration from another part of the record. That means physicians are not just documenting, they are documenting against a moving target.

The research on EHR burden and burnout makes the clinical effect of this hard to dismiss. Reviews of EHR-related burnout identify things like documentation and clerical burden, time demands, complex usability, cognitive load, and inbox volume as major contributors. Newer work has linked after-hours EHR use with burnout among physicians. The broader EHR activity associated with billing and regulatory tasks can crowd out higher-value work such as reviewing outside records and using health information exchange functions that may actually improve care. In plain terms, the more time clinicians spend feeding the system, the less time they have for the parts of medicine that require thought and attention

This is what many younger clinicians are reacting to when they look at medicine now. They do not just see a demanding profession. They see a profession in which every worthy goal seems to arrive carrying new clerical obligation. Better quality means more reporting. Better accountability means more attestation. Better fraud prevention means more paperwork. Better coverage precision means more LCD criteria and cross-referenced articles. Better interoperability means more structured data entry. Better compliance means more people watching the note than caring for the patient.

Podiatry is not unique in this regard, but diabetic foot care shows how backward the incentives can become. Preventive care is repeatedly described as important, financially rational, and limb-saving. However, the administrative apparatus around that preventive care keeps growing. The physician who wants to keep a high-risk patient ulcer-free is asked to be not only a diagnostician and proceduralist, but also a coder, an auditor, a workflow designer, a rules interpreter, and a documentation engineer. This is not a side effect anymore. It is the operating model.

None of this means standards should not exist. It does mean that the current instinct of regulatory bodies, insurance companies, and compliance systems is almost always the same: When in doubt, require more from the provider. If a diagnosis was overused, narrow the wording. If suppliers were inconsistent, add another proof requirement. If quality is hard to measure, build another score. The burden flows in one direction, and it almost never flows back out.

In modern healthcare, making the provider do more has become the default answer to nearly every administrative problem. In lean management, it is called “muda,” a Japanese word meaning “waste,” uselessness,” or “futility”—an activity that does not add value. It is now a defining feature of the practice environment, and it is helping drive physician burnout, discourage students from entering medical fields, and push some graduates away from clinical practice before they ever really begin. Until policymakers, payors, and compliance architects are willing to treat clinician time as a finite clinical resource rather than an endlessly available administrative buffer, the system will keep claiming to solve problems while quietly moving more of the cost onto the people trying to take care of patients.