“I think it is time for this topic to resurface. Being a coder/biller for a number of podiatrists around the U.S., I am finding that some are still scheduling “annual diabetic foot exams” as a routine on all of their diabetic patients. They are then performing a “full physical exam” and trying to bill an E/M. Sometimes this coincides with callus or nail treatment, at which time they want to add the 25 modifier. Of course, I am telling them that Medicare does not pay for an “annual diabetic foot exam” and that it is not a benefit and as such should be CASH. Has anything changed?”
There are two different approaches to this really important question. The first approach is whether or not Medicare pays for an annual diabetic foot examination. Well, Medicare Part B covers foot exams every 6 months if the patient has diabetic peripheral neuropathy and loss of protective sensation, as long as the patient has not seen a foot care professional for another reason between visits.
The following HCPCS Codes are to be used:
G0245 Initial Physician Evaluation and Management of a diabetic patient with LOPS which must include:
1. The diagnosis of LOPS
2. A patient history
3. A physical examination that consists of 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
4. Patient education
G0246 Follow-up Physician Evaluation and Management of a diabetic with LOPS to include at least the following:
1. patient history
2. physical examination that includes;
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
3. Patient education
From a treatment standpoint, G0247 Routine Foot Care by a Physician for a diabetic patient with diabetic sensory neuropathy resulting in LOPS to include, if present, at least the following:
1. Local care of superficial wounds
2. Debridement of corns and calluses
3. Trimming and debridement of nails
Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment. None of the Covered Routine Foot Care modifiers is appropriate, required or needed. The use of a Q7, Q8 Q9 modifier with these codes may result in non-payment. LOPS codes (G0245, G0246, G0247) will be denied if Routine Foot Care CPT codes 11055, 11056, 11057, 11719, 11720, and/or 11721 were billed and paid within the prior 6 months.
The second approach deals specifically with whether or not a patient qualifies for extra depth, therapeutic shoes and either heat molded or custom inserts. In order to establish whether or not the patient qualifies for this service, which theoretically can be provided to the patient once every calendar year, shouldn’t a Comprehensive Diabetes Foot Examination be performed annually and be reimbursable? I believe that it should be. I am not an advocate of templates, but there are several templates available online that when COMPLETELY FILLED OUT provide a medically appropriate history, a medically appropriate examination and Medical Decision Making of Low Complexity. When this completed template is supplemented by a summary of the findings within the medical record for the date of service in question, this documentation should support the billing of E/M code 99213. Whether the patient receives diabetic shoes and inserts is based upon, as a result of the Comprehensive Diabetes Foot Examination (ie. CDFE), if the patient is classified as a High Risk Patient or a Low Risk Patient. The High Risk Patient qualifies.
High Risk Patient: One of the following:
Loss of protective sensation
Absent pedal pulses
Foot deformity
History of foot ulcer
Prior amputation
Low Risk Patient: All of the following:
Intact protective sensation
Pedal pulses present
No deformity
No prior foot ulcer
No amputation
As far as billing for “At Risk,” Routine Foot Care on the same date of service when the CDFE is performed, no way! The reason is that the CDFE and the “At Risk,” Routine Foot Care are DIRECTLY RELATED. Both of these services are based upon the fact that the patient has diabetes mellitus. The appending of the 25 modifier to the E/M service would be a classic example of the inappropriate use of the 25 modifier. The 25 modifier is defined as the following: SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE. Clearly, this is not the case here.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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