Billing of the Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes
Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every 6 months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.
General Billing Requirements
The following providers of service may bill you for these services:
Hospitals;
Rural Health Clinic;
Free-Standing Federally Qualified Health Clinic (FQHC);
Outpatient Rehabilitation Facility (ORF);
Comprehensive Outpatient Rehabilitation Facility (CORF); and
Critical Access Hospitals
Hospitals;
Rural Health Clinic;
Free-Standing Federally Qualified Health Clinic (FQHC);
Outpatient Rehabilitation Facility (ORF);
Comprehensive Outpatient Rehabilitation Facility (CORF); and
Critical Access Hospitals
Applicable HCPCS Codes
G0245 – Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (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 a protective sensation,
(c) evaluation of foot structure and biomechanics,
(d) evaluation of vascular status and skin integrity,
(e) evaluation and recommendation of footwear, and
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 a protective sensation,
(c) evaluation of foot structure and biomechanics,
(d) evaluation of vascular status and skin integrity,
(e) evaluation and recommendation of footwear, and
4. Patient education.
G0246 – Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (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, and
3. patient education.
G0247 – Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a LOPS to include if present, at least the following:
(1) local care of superficial (i.e., superficial to muscle and fascia) wounds;
(2) debridement of corns and calluses; and
(3) trimming and debridement of nails.
(1) local care of superficial (i.e., superficial to muscle and fascia) wounds;
(2) debridement of corns and calluses; and
(3) trimming and debridement of nails.
NOTE: Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.
Diagnosis Codes
Diagnosis Codes.–Providers should report one of the following diagnosis codes in conjunction with this benefit: 250.60, 250.61, 250.62, 250.63, and 357.2.
Payment
• Hospital outpatient departments – OPPS
• Critical Access Hospital (CAH) – Method I — Reasonable cost; Method II — Technical – reasonable cost, Professional — 115 percent of the fee schedule
• Comprehensive Outpatient Rehabilitation Facility – Medicare physician fee schedule (MPFS)
• Skilled Nursing Facility – MPFS
• Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) – All inclusive rate.
• Critical Access Hospital (CAH) – Method I — Reasonable cost; Method II — Technical – reasonable cost, Professional — 115 percent of the fee schedule
• Comprehensive Outpatient Rehabilitation Facility – Medicare physician fee schedule (MPFS)
• Skilled Nursing Facility – MPFS
• Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) – All inclusive rate.
Deductible and coinsurance apply.
Examples of Payment calculation:
Part B Deductible Met: $900 (MPFS allowed amount) x 20 percent (co-insurance) = $720 (Medicare reimbursement). Beneficiary is responsible for $180.
