Primary Care Coding Alert

Edits, not diagnosis, trigger case study denial.

If your FP provides an office visit and an initial foot exam for a LOPS patient, you should include G0245 in the E/M service or Medicare will deny the foot care.

-Avert Foot Exam Denials in 1, 2, 3 Steps- in Family Practice Coding Alert 2008 Vol.11, No.1, incorrectly attributed denials for 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 ...) with 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 the procedure or other service) to the subscriber using the wrong diabetes fourth digit.

Problem: -Medicare will not pay for a foot exam (G0245 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 [Correct Coding Initiative] 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. -We used the correct diagnosis -- so it is not a diagnosis situation -- it is a CCI edit.-

-The edit makes sense,- notes Family Practice Coding Alert's consulting editor, Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians in Leawood, Kan. The foot exam is basically an E/M service. So if the physician is otherwise doing an E/M service, CMS considers the work associated with the foot exam  part of the office visit, which is reflected in the CCI edits.