Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 17, 2008 PDF

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 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.

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 bill-ing 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 ...)," says Melanie Witt, RN, CPC-OBGYN, MA, a coding consultant in Guadalupita, N.M. The foot exam requires code 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 (found online at

http://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," MNDCM stipulates.

The same medical necessity diagnoses apply to coverage of follow-up exams (G0246, Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] ...)

and treatment (G0247, Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation [LOPS] ...). 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.

If your doctor 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 the following 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.

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.