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. 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. 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. Be Sure To Document Your Rationale For Diagnostic Tests Medicare and many other insurance companies will not pay for screening type services. There must be a specific reason for ordering each individual test. This applies when ordering neurological tests, such as nerve conduction studies, and/or laboratory tests such as random/fasting blood sugars or HbA1C values, etc.. Similarly, formal vascular testing (which is commonly performed in podiatric offices) is payable for diabetes patients as long as there is a specific reason for this test beyond a screening exam. Keep in mind that most insurance companies will not allow a handheld Doppler unit to qualify for a formal vascular examination. There must be a formal interpretation of results in the chart as well as a printout by the unit. Simply doing a foot vascular examination may not qualify for payment. Many carriers require a complete lower extremity vascular study including the femoral, popliteal as well as the foot and ankle. Dr. Poggio is a California Podiatric Medicine Association Liaison to the National Heritage Insurance Company and a medical consultant to HealthNet Insurance Company. Dr. Poggio is a member of the American College of Podiatric Medical Reviewers and is board-certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.

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