Podiatry Coding & Billing Alert
Follow 5 Medicare Rules to Sidestep Common LOPS Errors for Diabetic Patient Claims
You must report an appropriate diabetes ICD-10-CM code on your claim. When your podiatrist sees diabetic patients with peripheral neuropathy with loss of protective sensation (LOPS), you must follow Medicare’s very specific reporting and billing rules if you want to keep your claims on the up and up. For example, you must know how frequently you can report a foot exam and the exact method your podiatrist used to diagnose the patient with LOPS. Take a look at the following rules to keep your LOPS claims in tip-top shape. Rule 1: Foot Exams Are Covered for Diabetic LOPS Patients, Per This Stipulation “Peripheral neuropathy with LOPS, secondary to diabetes, is a localized illness of the feet and falls within the regulation’s exception to the general exclusionary rule (see 42 C.F.R. §411.15(l) (l)(i)),” according to chapter 32, section 80 of the Medicare Claims Processing Manual. Bottom line: Medicare considers foot exams for patients with diabetic peripheral neuropathy with LOPS “reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.” So, Medicare will cover these exams for diabetic LOPS patients, if you also heed the rest of the reporting rules below. What is LOPS? Peripheral neuropathy is the most common contributing factor, which causes amputation for diabetic patients, according to the manuaWhen a diabetic patient has peripheral neuropathy, their sensory and autonomic fibers are affected, as well as distal motor findings for more advanced cases. Long nerves are impacted, and the symptoms usually start gradually in the patient’s toes, then advance proximally. This, in turn, causes loss of protective sensation (LOPS) where the patient cannot feel minor trauma from mechanical, thermal, or chemical sources. Additionally, “when foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing,” per the manual. Rule 2: Mind Foot Exam Frequency for Diabetic Patients You must also know how often a diabetic patient with LOPS can have a covered foot exam to report your claims correctly. According to the manual, a patient with a documented diagnosis of diabetic sensory neuropathy and LOPS can have a foot evaluation, including exam and treatment, no more often than every six months. Remember: The manual also maintains that a foot care specialist must not have seen the diabetic patient for some other reason in the interim, to meet the guidelines for this coverage benefit. Rule 3: Podiatrist Must Diagnosis LOPS Via Certain Guidelines To meet Medicare’s coverage criteria, your podiatrist must diagnose the patient’s LOPS through sensory testing with the 5.07 monofilament using established guidelines, like the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. For example, according to the National Institute of Diabetes and Digestive and Kidney Diseases, your podiatrist should test five sites on the plantar surface of both feet. “The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically,” according to the guidelines. Your podiatrist should also avoid heavily callused areas of the patient’s feet when testing. The American Podiatric Medicine Association suggests that if the patient has an absence of sensation at two or more sites out of the five sites on either foot your podiatrist tests with a method such as the 5.07 Semmes-Weinstein monofilament, then he should document and diagnose these results as peripheral neuropathy with LOPS. Rule 4: Rely on These HCPCS Codes for Diabetic Neuropathy With LOPS You have several HCPCS codes you can report for a diabetic patient with LOPS. To understand which code to report when, you must check the medical documentation and note whether it is an initial or follow-up visit. Initial visit: For example, for the initial foot exam for a diabetic patient with LOPS, you should report code G0245 (Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include: (1) the diagnosis of LOPS, (2) a patient history, (3) a physical examination that consists of at least the following elements: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b) evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear and (4) patient education). Note: As you can see, the code descriptor for G0245 stipulates specific elements of an exam that your podiatrist must perform to be covered. Follow-up visit: On the other hand, for a follow-up evaluation of a diabetic patient with LOPS, you should bill code G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least the following: (1) a patient history, (2) a physical examination that includes: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b) evaluation of protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear, and (3) patient education). Note: As with code G0245, code G0246 also has specific elements of an exam your podiatrist must perform to be considered covered. Routine footcare: You should report code G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include, the local care of superficial wounds (i.e. superficial to muscle and fascia) and at least the following if present: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails) for routine footcare for a diabetic patient with LOPS. Caution: You must report G0247 on the same date of service with either G0245 or G0246 to be considered for payment. Rule 5: Podiatrist Should Include Specific ICD-10-CM Codes Any diabetic patient with LOPS must have a documented diagnosis of diabetes in their medical record. ICD-10-CM gives you many different diabetes diagnosis codes to choose from. Your podiatrist should use the following diabetes ICD-10-CM codes on their LOPS claims, according to the manual:
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