Maximize Your Reimbursement: A Guide To Billing In Diabetic Care
- Volume 16 - Issue 3 - March 2003
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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. As stated earlier, the medical necessity for each service should be documented clearly in the chart. We often get into a routine in which we see patients back in the office on a weekly basis. The chart note should indicate the reason for each visit, clinical findings as well as addressing whatever comorbidities the patient may have. This is not only a good idea from a billing perspective and chart documentation but also from a medical/legal perspective.
If you see a patient for many weeks and there is no significant improvement in his or her condition, make sure there is appropriate documentation in the chart acknowledging this fact and also document any consideration of possible changes in the treatment plan. Getting a consult from a vascular surgeon, wound care expert, infectious disease specialist or even another podiatrist may be in order. You should consider obtaining additional diagnostic testing such as MRI or additional X-rays to rule out possible osteomyelitis and document this in the chart as well.
What About Documenting Neurovascular Compromise, Painful Lesions And Home Calls?
Medicare has posted very specific guidelines for what it deems to constitute vascular insufficiency for the patient. You may or may not be required to add a Q7-Q8-Q9 modifier to procedure codes when billing, depending on your carrier’s policy.
There are no specific guidelines posted for what constitutes “neuropathy” in the Medicare system. Medicare has created the new Loss of Protective Sensation (LOPS) policy. Unfortunately, the policy is very confusing and some carriers have yet to fully adopt and implement it. Check with your carrier regarding proper utilization and billing protocols in your area. However, this policy does indicate that Medicare considers LOPS as diagnosed with a 5.07 monofilament, using guidelines recommended by the APMA and the National Institute of Diabetes and Digestive and Kidney Diseases.
Some Medicare carriers have specific allowances for coverage for painful nails and calluses. For the diabetic patient, there may be times when part of the services you render on one given day may fall under the routine care guidelines and the other services fall under coverage guidelines for painful lesions. Each type of coverage will have its specific billing protocols so it is important to bill (and chart) accordingly.
While Medicare allows home calls, be aware that a patient having diabetes does not warrant automatic coverage for home calls. The patient must fit into your carrier’s guidelines for who they deem to be “housebound” in order to qualify for in-home services.