EM Coding Alert

Remember: Medicare reimburses for some routine foot care services.

What may be routine foot care for most is another story for diabetics — even the slightest complication can have serious ramifications. That’s why Medicare pays for routine foot care for patients with peripheral neuropathy and loss of protective sensation (LOPS) from diabetes and utilizes codes specifically for providers giving routine foot care for these patients. Ensure you’re getting maximum reimbursement for routine foot care for diabetic neuropathy by following these guidelines.

1. Nail Down Correct Codes for Office Visits

Diabetics often develop nerve damage, or neuropathy, in their feet as a side effect of high blood sugars. The effects of neuropathy pose an especially significant risk in the diabetic population.

“Poor circulation, combined with nerve damage, can decrease healing, and increase the chance for infection. When nerves are damaged, the sense of feeling may be decreased or even lost,” says Leshia Howell, RN, BSN, HN-BC, CWHC, CAPRC I, patient experience coordinator at Dupont Hospital in Fort Wayne, Indiana. “Those with peripheral neuropathy may not feel any discomfort from a small cut or blister, but left untreated, these issues can become serious infections, and ultimately result in amputation. Daily and routine foot care is the most effective way to prevent foot complications.”

Because of these serious implications for diabetics, Medicare pays for routine foot care. You can bill a routine foot exam once a year if the patient hasn’t been seen by you or another provider for another reason. Trimming or clipping toenails, corn and callus removal, and hygienic services such as cleaning the feet would also be covered, whether the procedure is done inpatient, outpatient, or at the patient’s home.

Example: A provider performs sensory testing on five random sites on the plantar surface of the feet bilaterally with the 5.07 Semmes-Weinstein monofilament. If two or more sites show an absence of sensation, the provider will then diagnose and document LOPS, then include in the notes contributing factors that may be present in addition to diabetic neuropathy.

For a patient with a LOPS diagnosis on an initial visit — either newly diagnosed or preexisting — you can bill once for G0245 (Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…).

For a follow-up visit of an established patient with LOPS, use G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…).

For routine foot care, use code G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…). According to Centers for Medicare & Medicaid Services (CMS) (>www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57759&ver=12) routine foot care includes the following:

• Cutting or removal of corns and calluses;
• Clipping, trimming, or debridement of toenails (including mycotic);
• Shaving, paring, cutting or removal of keratoma, tyloma, and heloma; and
• Non-definitive simple, palliative treatments like shaving or paring of plantar warts that do not require thermal or chemical cautery and curettage.

Other hygienic and preventive maintenance care, such as: cleaning and soaking the feet; the use of skin creams to maintain skin tone of either ambulatory or bedfast patients; and any other service performed in the absence of localized illness, injury, or symptoms involving the foot

Since routine foot care encompasses several possible procedures, ensure the exact service performed is documented in the notes.

2. Support Coding with Documentation

To correctly bill for LOPS services, CMS guidelines (www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ downloads/r498cp.pdf) state the patient’s chart should document that the podiatrist has performed all of the different clinical responsibilities as outlined in the code descriptors for G0245, G0246, and G0247.

Remember that Medicare allows evaluation and treatment of the feet once every six months, provided the patient has not seen a foot care specialist in between those visits for routine care. Podiatrists should ask the patient if any other provider delivered care in the last six months. If the patient can’t remember, you should consider having an advance beneficiary notice (ABN) signed in case of denials.

Also, be sure any provider in your own practice or a previous provider has diagnosed LOPS, and check that they have also documented the patient’s diabetic neuropathy diagnosis in the chart.

3. Choose the Right Codes for Medical Necessity

There are several codes for diabetic neuropathy, so you need to be very specific and choose the right one. First, you’ll need to select the appropriate category code for the diabetes type from the following:

• E08 (Diabetes mellitus due to underlying condition)
• E09 (Drug or chemical induced diabetes mellitus)
• E10 (Type 1 diabetes mellitus)
• E11 (Type 2 diabetes mellitus)
• E13 (Other specified diabetes mellitus)

Then, you’ll need to identify neurologic complications with a 4th character, “4,” followed by a 5th character to describe the nature of the patient’s neuropathy. If your provider documents mononeuropathy, which involves damage to only one nerve, you’ll use 5th character “1,” while you’ll use 5th character “2” for polyneuropathy if your provider indicates multiple nerves are affected.