Podiatry Coding & Billing Alert

Hint: Correct diagnostic codes are the key to claim acceptance.

You know that Medicare pays for routine foot care for diabetic patients suffering from peripheral neuropathy with loss of protective sensation (LOPS), albeit with riders, but you may still be struggling with related codes for reporting the foot care. However, you can take your podiatry practice over the safety line more often than not by following these handy tips for handling diabetic neuropathy care claims.

1. What is the Need for Routine Foot Care?

Diabetic neuropathy is a common complication of diabetes and causes nerve damage that prevents you from feeling sensations such as pain, especially in the peripheral organs such as the feet and hands. This loss of foot sensation is very dangerous as it increases a patient’s risk of foot injuries. Moreover, the patient may not become aware of injuries and sores on the feet due to lack of sensation until very late. This is all believed to be related to blood sugar being too high for a long period of time.

Medicare has recognized the seriousness of the condition and provides coverage for routine foot care of diabetic patients diagnosed with sensory neuropathy and LOPS. Common examples of covered services are:

• Cutting or removal of corns and calluses;
• nail trimming, cutting, or debriding;
• preventive maintenance foot care;
• and other services that podiatrists perform when there is no visible localized illness, injury, or symptom involving the feet.

The podiatrist can perform these services in the office, outpatient setting, or at the beneficiary’s home.

1. G Codes or CPT® Codes: Which is the Right One?

Usually, Medicare may not pay for treatment of flat feet or treatment of subluxation of the foot, and you should consult your local payer before billing.

For example, Aetna Medicare cases, you have a choice of these G codes to report these encounters:

• G0245 (Initial physician evaluation and management [E/M] of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…) -- You report this code when a diabetic patient sees your podiatrist for the first time. This G code represents routine foot care for patients who have adequate circulation and diabetes but who also have a documented loss of sensation.
• G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…) -- When an established diabetic patient revisits your podiatrist for follow-up care, you may report this code.
• G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS].) -- You can report this code when your podiatrist performs any allowed routine foot care procedure as discussed earlier. Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.
• G0127 (Trimming of dystrophic nails, any number) -- You can report this code for routine nail care for established diabetic patients.
• S0390 (Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions [e.g., diabetes], per visit).

You also have the following CPT® codes that you can employ 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]; 1 to 5)
• 11721 (…6 or more).

Beware: According to The Centers for Medicare and Medicaid Services (CMS) and its National Correct Coding Initiative (CCI) edits, you should consider G0245 a part of E/M code, which means that you can’t claim reimbursement for both G0245 and any one of E/M codes (99201-99215) for the same date of service as they are bundled together.

Also, usually there should be a day’s gap between the initial visit code G0245 and any other foot care service code as the physician should first confirm and document the diagnosis of diabetic sensory neuropathy resulting in a LOPS before billing for foot care.

LOPS can be diagnosed through sensory testing with the 5.07 Semmes-Weinstein monofilament. The physician should test five random sites on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. As suggested by the American Podiatric Medicine Association, 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, the primary care physician should examine other causes of peripheral neuropathy prior to initiating or referring for foot care for persons with LOPS.

After the diagnosis is established, however, you can claim reimbursement for a physician or group practice only once for G0245. 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.

3. Have I Got the Documentation to Back My Codes Up?

If your payer decides to audit your diabetic neuropathy routine foot care claims, you may end up having to pay back a portion of your reimbursement if the podiatrist’s documentation doesn’t meet certain documentation requirements.

To avoid auditing issues, make sure that the medical record contains the patient’s medical history that indicates he has diabetic neuropathy. Your podiatrist’s documentation of the physical examination should include all of the following:

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

Don’t overlook: Be sure your practice documents in the patient’s chart which MD or DO certified the “systemic condition.” Your podiatrist should also be sure to document the date of the patient’s most recent visit with a physician for foot care within the last six months.

Here’s why: 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 for as long as the patient has not seen a foot care specialist in the interim. Make sure that your podiatrist asks the patient if he has received any type of foot care in the past six months. If the patient isn’t sure, have him sign an advance beneficiary notice (ABN) before providing care.

4. Am I Applying the Latest Acceptable Diagnostic Codes?

Various Medicare administrators have their own lists of approved primary diagnostic codes for covering foot care. Please check individual payers before reporting the codes, however, some universally accepted codes may be

• E08.40 (Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified)
• E08.42 (Diabetes mellitus due to underlying condition with diabetic polyneuropathy)
• E08.43 (Diabetes mellitus due to underlying condition with diabetic autonomic [poly] neuropathy)
• E08.44 (Diabetes mellitus due to underlying condition with diabetic amyotrophy)
• E08.49 (Diabetes mellitus due to underlying condition with other diabetic neurological complication)
• E09.42 (Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy)
• E08.59 (Diabetes mellitus due to underlying condition with other circulatory complications)
• E08.51 (Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene)
• E08.52 (Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene).

Caution: Some payers cover CPT® codes 11055, 11056, and 11057 only when billed with one of the diabetes and neurological or vascular disease diagnosis codes listed above plus any one of the following routine foot care diagnosis codes:

• B35.3 (Tinea pedis)
• L84 (Corns and callosities)
• L60.1-L60.5 (Nail disorders)
• L60.8 (Other nail disorders)
• L62 (Nail disorders in diseases classified elsewhere)
• M21.6X9 (Other acquired deformities of unspecified foot).