EM w routine foot care procedures

hofm04

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CGS Ohio policy L34246 states 11721, 11055 etc include the global surgical rules.
The global surgery rules will apply to routine foot care procedure codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127. As a result, an E&M service billed on the same day as a routine foot care service is not eligible for reimbursement unless the E&M service is a significant separately identifiable service, indicated by the use of modifier 25, and documented by medical records.

11721 and E/M or not? If yes, why?

Established pt note

male presenting for follow up care as he is a diabetic with no history of foot pain or abnormality. He was diagnosed with diabetes recently since moving to the US xxxxx, taking metformin twice daily, states his post-prandial glucose readings have been 150-170, and 120-130 before meals. No history of ulcer or amputation. No signs of arterial insufficiency. Patient does state that he experiences slight numbness and tingling in bilateral distal toes intermittently, but if he manually massages them, it goes away, denies pain or being woke up at night. Would also like new diabetic shoes, states his shoes from last year work well but are wearing out. Patient states he is scheduled to have his A1C drawn next week, and for his yearly optometrist visit soon as well.

Physical Exam
General:xxxxxxxxxxxxxx is seated comfortably in the examination room. He is alert and oriented to time and place. In no acute distress. Mood and affect are normal and appropriate to situation.xxxx presents well developed, well nourished male. xxxxx presents ambulating with a normal gait and shoe gear.

There were no vitals taken for this visit.
Skin: Normal. No abrasions, lacerations, ecchymosis noted. Nails are dystrophic and elongated.
Musculoskeletal:all joints tested WNL and muscle strength 5/5 for all groups tested.
Neurological:protective sensation grossly intact.
Vascular: temperature warm to warm proximal to distal and DP and PT pulses +2 bilateral.

Imaging Studies: n/a

xxxxx was seen today for diabetic foot care.


Plan: On today's visit I have reviewed with the patient the diagnoses and treatment options for his lower extremity pathology. I have explained to him conservative treatment options. All of his questions were answered regarding this diagnosis.

I did explain to xxxxxxxxxxx the importance of tight blood sugar control and the effects on his lower extremities. I did explain the importance of daily monitoring of his feet and what to look for in terms of increased areas of pressure, cuts and abrasions. I did further explain appropriate shoes and wearing shoes regularly to prevent injury. He does verbalize understanding and will follow up accordingly should there be concern.
Nails 1-5 bilateral were debrided in length and thickness by mechanical means without incident. We will see the patient back in 3 months time. They were instructed to call the office if they were to have any problems prior to their follow up.
 
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