Primary Care Coding Alert

Swift payment might be as easy as switching your diabetes fourth digit

To get diabetic peripheral neuropathy foot care claims paid the first time around, you-ve got to nail down Medicare's required diagnoses for this condition.

Test your savvy with the following claim typical of ones that family physician practices have been trying to get paid and Medicare carriers have been denying. A common submission contains:

- 99213-25 with diagnosis of back pain and hypertension

- G0245 (foot exam) with diagnosis code 250.70.

1. Adhere to Unbreakable Bundle

To avoid denial, you should report only the office visit: 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient -; Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service). -Medicare will not pay for a foot exam (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 - or G0246, Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] -) with an E/M code with any modifier according to CCI edits,- Mary Ann Fanning, coding supervisor for East Tennessee Medical Group in Alcoa.

-I checked CCI edits and the two codes cannot be billed using any modifier " the only payable code is G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] -),- Fanning reports.

-The edit makes sense,- notes Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians in Leawood, Ks. The foot exam is basically an evaluation and management service. So if the physician is otherwise doing an E/M service, the work associated with the foot exam should probably be considered part of the E/M service, which is how the CCI edits are structured, he explains.

2. Find Out Medicare's Covered G0245 Diagnoses

Let's suppose instead of treating the patient for back pain, hypertension, and an initial foot exam, the FP in our case study provided only the foot exam. You-ll keep getting denials for initial foot evaluations of Medicare beneficiaries unless you use your carrier's allowed ICD-9 codes. In the E/M-25 foot exam denial example, "they used the incorrect diagnosis code for billing G0245," says Melanie Witt, RN, CPC-OBGYN, MA, a coding consultant in Guadalupita, N.M. The foot exam requires 250.6x (Diabetes with neurological manifestations), not 250.7x (Diabetes with peripheral circulatory disorders).

The G code is designed to help cover routine foot care for patients who have adequate circulation and diabetes but who also have a documented loss of sensation, explains Richard D. Odom DPM, CPC, in AudioEducator.com's "Coding and Reimbursement Essentials for the Diabetic Foot."

CMS will cover, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation (LOPS), as long as the patient has not seen a foot care specialist in the interim, according to the Medicare National Coverage Determinations Manual (MNDCM) Chapter 1, Part 1, Section 70.2.1 (www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf). "Foot exams for people with diabetic sensory neuropathy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease."

Key: Diabetic sensory neuropathy and LOPS goes with 250.6x, 357.2 (Polyneuropathy in diabetes [code first underlying disease (250.6x)]). "The diagnosis of diabetic sensory neuropathy with LOPS should be established and documented prior to coverage of foot care," the MNDCM stipulates.

The same medical necessity diagnoses apply to coverage of follow-up exams (G0246) and treatment (G0247). According to Medicare, codes G0245-G0247 should be reported with one of the following diagnosis codes:

- 250.60 - Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled

- 250.61 - type I (juvenile type), not stated as uncontrolled

- 250.62 - type II or unspecified type, uncontrolled

- 250.63 - type I (juvenile type), uncontrolled.

3: Check for Exam Notes With Treatment

If your FP trims and debrides nails for a diabetic peripheral neuropathy patient, make sure you use G0247, not the corresponding CPT codes 11719 (Trimming of nondystrophic nails, any number) and 11720-11721 (Debridement of nail[s] by any method[s] -). G0247 includes, if present, at least the following routine foot care treatments:

- local care of superficial wounds
- debridement of corns and calluses
- trimming and debridement of nails.

Error averted: And don't forget to always bill G0247 with an exam code. "G0247 is always applied with G0245 or G0246," stresses Odom, who is a consultant and past assistant professor at Texas A&M Health Science Center Scott & White Hospital/Clinic in Temple.

Code G0246 has the same parameters as G0245 but for a follow-up exam with patients who have established LOPS, Odom says. If the chart ever comes up for review, the auditor will look for the notes to include these items:

- a patient history

- a physical examination consisting of findings regarding at least the following elements:

- visual inspection of the forefoot, hindfoot, and toe
web spaces

- evaluation of protective sensation

- evaluation of foot structure and biomechanics

- evaluation of vascular status and skin integrity

- evaluation and recommendation of footwear

- patient education.

4. Beware of Past Podiatry Visit

You should ask the beneficiary if she's received any podiatry care in your carrier's past interim period. "Most Medicare carriers make no reimbursement for G0245-G0247 that occurs within 60 days of previous foot care," Odom says.

If a diabetic LOPS beneficiary doesn't know or remember whether she had care within that time frame, play it safe and have her sign an advance beneficiary notice (ABN). Otherwise, your practice could end up footing the bill.