Maximize Your Reimbursement: A Guide To Billing In Diabetic Care

By Anthony Poggio, DPM

Diabetes is one of the more common conditions that we treat. Our training and expertise in this area make us an integral part of the multidisciplinary team approach. Given that diabetes is a multi-system disorder, diagnosis and treatment tends to be more complicated. Indeed, treating these patients may involve more frequent visits, more detailed examinations and more complex decision making. A significant number of patients in virtually any podiatric practice are diabetic. Given this high volume, errors in billing and coding can have a major financial impact on a practice. Improperly submitted and subsequently denied claims must then be resubmitted or appealed. This will cost any office unnecessary time and money. Unfortunately, many doctor’s offices bill as if the rules regarding claims submission are different for the diabetic patient. They then get frustrated with the resulting denials in payment. The bottom line is there is no difference between billing and coding for diabetics and billing protocols for any other patient. How To Deal With Evaluation And Management Codes There are three components to appropriate billing for an evaluation and management (E/M) service. These include the patient history, your examination of the patient and the complexity of the eventual treatment decision-making. Keep in mind that for an initial visit, all three components must meet the same level of service criteria. Otherwise, you must select a lower service/billing level. For example, a detailed history and examination but only straightforward decision making will not allow for a CPT 99203 level. For a follow-up visit, only two of three components must meet the service billing level requirements. A common misconception in some offices is the belief that the mere fact the patient is diabetic automatically increases the complexity level of the decision making component. A recently diagnosed diabetic patient who presents with a relatively mild problem may not have many risk factors (beyond the diabetes itself) to warrant higher complexity services. Keep in mind that all services will be paid based upon medical necessity and reasonableness. There is no automatic increase for diabetes. We should always perform thorough physical exams on our patients but they should be tailored to the individual and his or her presenting complaints. The patient who was diagnosed a short while ago and may be on oral medications or simply on diet control may not need as thorough a work-up as the patient who has been diabetic for many years and has started to develop complications of diabetes. An otherwise healthy diabetic patient who presents with a simple ingrown nail may still only warrant a CPT 99213 level office visit and not necessarily a CPT 99214 level of service. On a follow-up examination of the same patient who is healing appropriately, you may only need to use a CPT 99212 billing service code. Furthermore, recording an extensive medical or HPI history or performing a more involved examination that is not generally warranted for that actual diagnosis and severity of condition would still fall under the medically necessary and reasonable guidelines. Simply listing information in the chart does not automatically allow you to claim that you have met a certain number of “bullets” that qualifies for a higher level of service. However, I do not want to minimize the importance of charting. Yes, we see a high volume of patients with diabetes and we know they tend to require more services (office visit type services as well as procedures and diagnostic testing), but be aware that this can lead to audits. This is especially true if you get a higher than average number of diabetic referrals or do a large amount of wound care. Even though you may not achieve a higher level of service/reimbursement for what you chart, you still need to document the medical necessity for the services and the need for the frequency of those services to protect yourself in an audit situation. Coding Surgical Procedures For Diabetic Patients: A Few Pertinent Examples Many diabetics will require various surgical procedures to be performed. This could be straightforward services such as injections and matrixectomies as well as more formal surgeries such as arthroplasties, bunionectomies, I&Ds and debridement/amputation. When billing and coding these procedures, the basic rules do not change.

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