medical necessity?

solocoder

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I could really use some help interpreting/applying a Medicare rule. Imagine that, right?

We are trying to determine whether or not a podiatry e/m service can be billed to Medicare for diabetic patients who do not have a diagnosis of LOPS or any other foot complaints. The NCD regarding these exams (70.2.1) specifies what they DO consider to be medically necessary, but doesn't specify that visits for patients who do NOT have LOPS are NOT covered. Can this be inferred? I can not find any further guidance on the CMS website that gives me a clue.
NCD: Effective for services furnished on or after July 1, 2002, Medicare covers an evaluation (examination and treatment) of the feet no more often than every six months for beneficiaries with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as he or she has not seen a foot care specialist for some other reason in the interim. The diagnosis of diabetic sensory neuropathy with LOPS should be established and documented prior to foot care coverage.

My interpretation is that it is up to their pcp is to screen them, and evaluate their feet to find out IF they need to see a podiatrist, not just refer them automatically because they are diabetic.
But our doctors feel that they should be able to see diabetic patients for at least an initial evaluation even without a prior diagnosis of LOPs, or any other foot complaints, just to make sure there isn't something the pcp has missed, and bill 99202-99203. With no complaints and no diagnosis of LOPS, I am not sure Medicare would consider this a medically necessary service.

Can someone advise, please?
 

Chelle-Lynn

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We render Medicare podiatry services and I believe that the key factor in this requirement from Medicare is the phrase "with a documented diagnosis". Without the diagnosis being established it is not a benefit for specialized care by a podiatrist. All initial evaluations and diagnosis determinations should be made by their primary care provider prior to referral.

However, if your provider is willing to gamble, you can always attempt to bill Medicare for routine care and see if you get a denial. However, keep in mind that the patient should not be billed without an ABN clearly noting the risk of the services being a non-benefit.
 
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We render Medicare podiatry services and I believe that the key factor in this requirement from Medicare is the phrase "with a documented diagnosis". Without the diagnosis being established it is not a benefit for specialized care by a podiatrist. All initial evaluations and diagnosis determinations should be made by their primary care provider prior to referral.

However, if your provider is willing to gamble, you can always attempt to bill Medicare for routine care and see if you get a denial. However, keep in mind that the patient should not be billed without an ABN clearly noting the risk of the services being a non-benefit.

I agree with this post. Without a symptom or complaint, there's no medical necessity for the visit, which in turns means it's not billable. I'd say the referral is the best way to go.
 
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