Peripheral Neuropathy is the most common factor leading to amputation in people with diabetes. In diabetes, peripheral neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers. The distal motor findings may be present in advanced cases. Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally. This leads to the loss of protective sensation (LOPS), whereby a person is unable to feel minor trauma from mechanical, thermal, or chemical sources. When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.
Peripheral neuropathy with LOPS, secondary to diabetes, is a localized illness of the feet. Foot exams for people with diabetic LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics.
Medicare covers, as a physician service, an examination and treatment of the feet every six months for individuals with a documented diabetic LOPS, as long as the patient has not seen a foot care specialist for some other reason in the interim.
LOPS shall be diagnosed through sensory testing with the 5.07 Semmes-Weinstein monofilament wire using established guidelines. Five (5) sites should be tested on the plantar surface of each foot. The areas must be random; heavily callused areas should be avoided. An absence of sensation at two (2) or more sites out of five (5) tested on their foot would allow making the diagnosis.
The most appropriate diagnosis codes to be used for billing this condition are:
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.41 Type 1 diabetes mellitus with diabetic polyneuropathy
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.41 Type 2 diabetes mellitus with diabetic polyneuropathy
*Please confirm the above ICD-10-CM codes with your Medicare Administrative Carrier/Contractor
HCPCS Level II 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, or Q9 modifier with these codes may result in non-payment.
Once a patient’s condition has progressed to the point where Routine Foot Care becomes a covered service, payment will no longer be made for LOPS services. Those services are considered included within the Routine Foot Care service. Physicians must then bill the Routine Foot Care codes along with the appropriate modifier.
LOPS codes (G0245, G0246, G0247) will be denied if Routine Foot Care codes 11055, 11056, 11057, 11719, 11720, and/or 11721 were billed and paid within the prior 6 months.
The following HCPCS Codes are to be used for the treatment of diabetic with LOPS:
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:
a. Visual inspection of the forefoot, hindfoot, and toe web spaces
b. Evaluation of protective sensation
c. Evaluation of foot structure and biomechanics
d. Evaluation of vascular status and skin integrity
e. 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. A patient history
2. A physical examination that includes:
a. Visual inspection of the forefoot, hindfoot, and toe web spaces
b. Evaluation of protective sensation
c. Evaluation of foot structure and biomechanics
d. Evaluation of vascular status and skin integrity
e. Evaluation and recommendation of footwear
3. Patient education
G0247 Routine Foot Care by a Physician for a diabetic patient with diabetic sensory neuropathy resulting in LOPS to include, the local care of superficial wounds (ie. superficial to muscle and fascia), and at least the following if present:
1. Local care of superficial wounds
2. Debridement of corns and calluses
3. Trimming and debridement of nails
This is my opinion.
Michael G. Warshaw
CPM, CPC
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