Podiatry Coding & Billing Alert

Question: What are the guidelines for performing and coding a comprehensive diabetic foot exam?

Pennsylvania Subscriber

Answer: There is now no E/M code set aside specifically for a diabetic foot exam, so you will need to determine the E/M level of the exam just as you would any other office visit.

A diabetic foot exam should include a number of factors, such as a vascular assessment (looking for localized edema, assessing digital capillary refill time and pulses, and noting temperature gradients), a neurologic assessment (determining protective sensation with Monofilament 5.07), and an integumentary assessment (noting skin appearance, checking state of nails).

If a Medicare patient is diabetic with loss of protective sensation (LOPS), G codes G0245 (Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] ...), G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] ...), and G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] ...) can also possibly be used to report the patient encounter.