Primary Care Coding Alert

Question: Recently, I tried billing G0245 with an E/M code for a diabetic patient that my FP saw for foot care. The claim was denied. When I check through CCI edits, I saw that the two codes are bundled. Is there any way to overcome the edit bundle so that I can claim for both the services for the patient?

Delaware Subscriber

Answer: When your FP performs an initial foot examination for a diabetic patient to evaluate loss of protective sensation (LOPS), you report it with G0245 (Initial physician evaluation and management [E/M] of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…) and a follow-up evaluation with G0246 (Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]...). These codes are typically used with Medicare patients, since the codes were created by the Centers for Medicare & Medicaid Services (CMS) for Medicare coverage and payment purposes. 

If your FP performs an office visit and an initial or a follow-up foot examination on the same calendar date of service, you are not allowed to report the E/M code and G0245/G0246 for the services rendered to the patient. According to Correct Coding Initiative (CCI) edits, you will face bundling if you try reporting these two code sets together on the same calendar date of service. These edits carry the modifier indicator ‘0’ which means that you cannot overcome the edit bundle under any circumstances.These edits reflect the fact that the descriptors for G0245 and G0246 generally include many, if not all, of the elements of a typical E/M service, including “diagnosis,” “patient history,” “physical examination,” “evaluation,” and “patient education.” 

So, you cannot use any modifiers to unbundle the codes that will allow you to report the foot care evaluation and the E/M code on the same calendar date of service. If you try doing so, the claim for G0245/ G0246 will be denied and only the E/M service will be reimbursed.

But, if your clinician is performing routine foot care for a diabetic patient with diabetic sensory neuropathy resulting in LOPS (e.g., debridement of corns or calluses or trimming of nails), you report this with G0247 (Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS]…). You do not face any edits if you are trying to report this code with an E/M code on the same calendar date of service. Like G0245 and G0246, G0247 is typically used with Medicare patients, since it was created by CMS for Medicare coverage and payment purposes.