Podiatry Coding & Billing Alert

Turn to these G codes when you’re treating patients with LOPS.

Medicare announced in its 2016 first quarter Comparative Billing Report that it is cracking down on routine foot care coding errors. But don’t let your caution cost you money: If you are planning on reporting routine foot care for diabetic patients suffering from peripheral neuropathy with loss of protective sensation (LOPS), you should be aware that Medicare pays for this service, even though it has caveats.

Follow these handy (footy?) questions and answers to guarantee that you successfully claim every bit of reimbursement for your diabetic neuropathy care claims.

Remember to Select Diabetes-Specific Codes

The loss of foot sensation from diabetic neuropathy is a common complication of diabetes and causes nerve damage that prevents you from feeling sensations such as pain.

Question: Our podiatrist provides routine foot care for a substantial number of Medicare patients with diabetic neuropathy. What’s covered and what’s not, under Medicare?

Answer: Because of the higher risk for foot injuries with this patient group, Medicare provides diabetic patients with sensory neuropathy and LOPS coverage for routine foot care services usually not covered, such as:

• Cutting or removal of corns and calluses;  
• Nail trimming, cutting, or debriding;
• Preventive maintenance foot care;

Note: Medicare will still typically not cover treatment for pes planus or subluxation of the foot.

You have a choice of these G codes to report these encounters:

• G0127 (Trimming of dystrophic nails, any number)
• G0245 (Initial physician evaluation and management [E/M] of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]...)
  o Coding note:  G0245 is part of an E/M code, so claims including it and another E/M code will likely result in a rejection. There should be a day’s gap between the initial visit code G0245 and any other foot care service code, as your physician should first confirm and document the diagnosis of diabetic sensory neuropathy resulting in a LOPS before billing for foot care.
• G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]...)
• G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]...)
  o Note: Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.

You also have the following CPT^® codes that can be used for routine foot care of diabetic patients:

• 11055 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; single lesion)
• 11056 (… 2 to 4 lesions)
• 11057 (…more than 4 lesions)
• 11719 (Trimming of nondystrophic nails, any number)
• 11720 (Debridement of nail[s] by any method[s]; 1to 5)
• 11721 (…6 or more)

Special case: If your patient has visited another physician for his condition, you may bill for G0245 if neither G0245 nor G0246 has been billed for that patient in the previous 6 months. But, otherwise, you can claim reimbursement for a physician or group practice only once for G0245.

Prove LOPS With Test Results

Your clinician will need to diagnose LOPS with the 5.07 Semmes-Weinstein monofilament, and she should test five random sites on the plantar surface of each foot. An absence of sensation at two or more sites out of five tested on either foot is mandatory and should be documented to diagnose LOPS. According to CMS’s National Coverage Decision (NCD) Section 50-8.1, the primary care physician should examine other causes of peripheral neuropathy prior to initiating or referring for foot care for persons with LOPS.

Better Get That DX and Visit Date in the Notes

Question: Can you outline what’s needed to support medical necessity for Medicare?

Answer: With CMS’s warning of increased routine foot care code scrutiny, you’ll need to focus on three key areas of documentation and ensure those are in the medical record:

1. The patient’s medical history that indicates he has diabetic neuropathy.
2. The date of the patient’s most recent visit with a physician for foot care within the last six months.

Medicare coverage entitles individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS to an evaluation and treatment of the feet once every six months. Make sure that your clinician asks the patient if he has received any type of foot care in the past six months.

Very good idea: “If the patient isn’t sure, have him sign an advance beneficiary notice (ABN) before providing care,” says Dr. Arnold Beresh, DPD, CPC. “It is essential to have an ABN signed to protect yourself for payment.”

3. Which doctor certified the systemic condition (diabetes). Your physician’s documentation of the physical examination should include all of the following:

• Evaluation of protective sensation, foot structure, and biomechanics
• Evaluation of vascular status and skin integrity
• Evaluation of the need for special footwear
• Visual inspection of forefoot and hind foot (including toe web spaces)
• Patient education

Resource: For more on Medicare’s Comparative Billing Report on podiatry services, see https://www.cbrinfo.net/cbr201608-faqs.html.