Maximize Your Reimbursement: A Guide To Billing In Diabetic Care

By Anthony Poggio, DPM
Unfortunately, many offices get sloppy and have a tendency of listing diabetes as the primary diagnosis for all services performed. Most Medicare computers will focus on the first diagnosis listed box 24E of the HCFA-1500 form (or ECS equivalent). When the computer reads across the billing line and sees a surgical code paired up with a diabetes diagnosis, it may make no sense to the computer (based upon software edits) and the claim will be denied as not medically necessary and reasonable. Here are some key examples to keep in mind. Example 1: When performing a bunionectomy on a diabetic patient, do not list a diabetes-related ICD-9 code in box 24E on the HCFA-1500 (or ECS equivalent). You should instead select a hallux valgus or some related ICD-9 code. From a billing/coding perspective, the patient’s diabetes is inconsequential. True, his or her diabetes may add complexity to the procedure and you may take extra precautions during the perioperative period. However, from a billing perspective, there is no need to list the diabetes in box 24E. Example 2: You perform a posterior tibial nerve block to try to differentiate between a tarsal tunnel or a diabetic neuropathy. The proper ICD-9 code to select in this scenario is a tarsal tunnel/nerve entrapment code. The tarsal tunnel is what you are evaluating during this visit and that is the basis for the injection. A posterior tibial nerve block is not a treatment for the diabetic neuropathy itself. Therefore, if you use the 250.60 ICD-9 code, the claim will probably be denied. Example 3: On an initial visit, the patient presents with a chief complaint of an ulcer of his foot. That is what you will be treating. Although diabetes is a risk factor and it may affect your treatment plan, you will not be treating the diabetes itself—only the ulcer. Therefore, the ICD-9 code for both the E/M and procedure services will be an ulcer code, not a diabetes code. (There may be increased complexity to the examination and decision-making if the patient has risk factors for diabetes. Compare this to the same patient who presents with tinea pedis or a simple digital fracture. In this situation, the risk factors may not necessarily be a complicating factor and wouldn’t warrant a higher level E/M service.) For follow-up visits in which wound debridement is required for this ulcer, your debridement CPT code will still be based on the depth of the ulcer. The secondary diagnosis of diabetes will not change the code selection choice. Keep in mind that with every procedure code fee allowance, there is some E/M component built in. Therefore, once you’ve established the diagnosis and unless there is a significant change in clinical wound presentation and decision making, no separate E/M service may be payable in addition to the procedure code. The Ins And Outs Of Coding For Routine Care Each Medicare carrier may interpret the Medicare regulations differently that allow for periodic nail and callus care for patients with diabetes. The policies of private carriers may resemble the basic Medicare policy but with their own modifications. Keep in mind that the mere fact a patient is diabetic does not automatically qualify the patient for coverage. Generally, the patient must have a neurologic or vascular complicating component to allow coverage for payment. For this reason, do not use ICD-9 codes such as 250.00 on your claim form. Instead, you should use 250.6X and 250.7X ICD-9 codes that are much more specific and can help validate the medical necessity of the services you rendered. Medicare does not cover routine foot care. The risk factors create the basis for coverage. Given this, some carriers’ requirements vary and may require that you list the risk factor as the primary diagnosis (or the secondary diagnosis in some cases) when you submit your claim. You may not bill an additional E/M service when rendering routine foot care services simply to attest to the fact that the patient continues to be an at-risk and/or a diabetic patient. It would be reasonable to bill an E/M service during a covered routine foot care visit if there was a significant change in the patient’s medical status, or possibly on a yearly basis if the situation warranted it. When Longer Treatment Courses And Additional Services Are Necessary Diabetic patients may require longer treatment courses and additional services.

Add new comment