Primary Care Coding Alert

Here are all the combo Dx codes and Medicare rules you need to know.

With a diagnosis of type 1 or type 2 diabetes comes the risk of serious complications, including diabetic neuropathy, which causes numbness and a loss of protective sensation (LOPS) in the areas it affects: the patient’s legs, hands and arms, but most generally, the feet (Source: www.diabetes.org/diabetes/complications/neuropathy/peripheral-neuropathy).

This means that periodic foot exams are vital for your diabetic patients, as LOPS can result in other conditions that may take longer to heal than they would in patients without diabetes.

So, coding precisely for diabetic neuropathy and these exams is extremely important. Here’s how to do it.

Combo Code for the Neuropathy

All the diabetes mellitus (E08-E13) codes feature combination codes that allow you to code for both the diabetes and associated neurological complications such as peripheral neuropathy using the following fourth and fifth characters:

• EXX.40 (… with diabetic neuropathy, unspecified)
• EXX.41 (… with diabetic mononeuropathy)
• EXX.42 (… with diabetic polyneuropathy)
• EXX.43 (… with diabetic autonomic [poly]neuropathy)
• EXX.44 (… with diabetic amyotrophy)
• EXX.49 (… with other diabetic neurological complication)

So, a type 2 diabetic patient with diabetic mononeuropathy (affecting just one nerve group, unlike polyneuropathy, which affects two or more nerve groups) would be coded using E11.41 (Type 2 diabetes mellitus with diabetic mononeuropathy)

Coding alert: Like all diabetes coding, it is vitally important that you select the exact code and not simply code E10 for type 1 as a default. “If your diagnosis doesn’t match the treatments provided, the treatments may not be paid, because physician payment is becoming increasingly value-based and payments are risk-adjusted based on patient conditions” notes Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Code for Foot Care Exams …

Initial diabetic foot examinations for Medicare patients are coded with G0245 (Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]...).

But before you use the code, make sure you read the rest of the descriptor closely, as it contains a number of stipulations your provider will have to meet on first meeting the patient: a LOPS diagnosis using one of the above-mentioned ICD-10 codes; a patient history; patient education; and “a physical examination that consists of at least the following elements” per the code descriptor:

(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.

Follow-up exams are coded with G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]...), which includes the same stipulations.

Coding alert: Per Medicare guidelines, patients with diabetic peripheral neuropathy and LOPS may have their feet examined “every 6 months … as long as [they] haven’t seen a foot care professional for another reason between visits” (Source: www.medicare.gov/coverage/foot-care-for-diabetes).

… and Routine Foot Care

If the exam reveals the patient needs some form of foot care, and your physician takes care of superficial wounds, debrides corns and calluses, or trims or debrides the patient’s nails, you can report G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) …). The care must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment (See chapter 32 section 80.2 of the Medicare Claims Processing Manual at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf).

Depending on the circumstances, you might also use G0127 (Trimming of dystrophic nails, any number) for destructed nail care or 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) for established diabetic patients.

Alternatively, for diabetic patients with commercial insurance, you can use a number of CPT^® codes. For corn or callus removal, there’s 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion), 11056 (… 2 to 4 lesions), and 11057 (…more than 4 lesions).

For these procedures, you should “make sure that the documentation clearly supports the treatment involved, the technique used, and the number of calluses or corns treated, so that you can ensure you are capturing the complete service. In addition, the provider needs to document the medical necessity as well as the instruments used,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

The same is true for 11720 (Debridement of nail(s) by any method(s); 1 to 5) and 11721 (…6 or more). But for 11719 (Trimming of nondystrophic nails, any number), you should remember that “this is for non-deformed nails. Many carriers will not pay for this service, so make sure that your office is aware of the patient’s benefits prior to treatment,” Johnson adds.