How to obtain reimbursement for diabetic foot exams; when to file an advance beneficiary notice of noncoverage

Key Points

A: The CPT guidelines describe G0245 as "Initial physician evaluation and management [E/M] 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, and e) evaluation and recommendation of footwear, and 4) patient education."

The Centers for Medicare and Medicaid Services (CMS) considers G0245 to be an E/M code, and the Correct Coding Initiatives edits consider G0245 to be a component of E/M, which means that reimbursement for G0245 is included in the office visit code (99201–99215) reimbursement when both the exam and the visit are billed on the same date of service. Therefore, these codes cannot be billed together.

Once the diagnosis is established, however, CMS will pay a physician or group practice once for G0245. If the patient must see a new physician, however, the new physician may bill for G0245 if neither G0245 nor G0246 (follow-up physician E/M of a patient with diabetic sensory neuropathy resulting in a LOPS) has been billed for that patient in the previous 6 months. Bill ICD-9 diagnosis code 250.XX plus an additional diagnosis code for the specific manifestations, per CMS Program Memorandum AB-02–109.

WHEN TO FILE AN ABN

Q: Where can I find the codes that are not covered by Medicare that need an advance beneficiary notice (ABN) of noncoverage?

A: An ABN is required when a provider anticipates that Medicare will not cover a service. An ABN can be, but is not required to be, used for noncovered (or statutorily excluded) Medicare services.

Determining whether a service is covered for a particular patient depends on several variables, including the patient's risk factors and conditions as well as service coverage frequency, so a list of services that would warrant an ABN does not exist. I would suggest reviewing Medicare's preventive services guidelines, which list the frequency with which CMS covers screening services, and local coverage determinations for the diagnosis codes that support medical necessity.

Here's an example of when obtaining a signed ABN would be appropriate. A Medicare-covered patient who is new to your office requests a Pap smear and pelvic exam. You don't have her previous medical records, but you determine that the patient would not be considered at high risk. Medicare covers Pap smears and pelvic exams every 24 months for low-risk patients, but this patient states that she received these services approximately a year ago. Because you can anticipate that Medicare will not cover the service on this date, it would be appropriate to have the patient sign an ABN before undergoing her Pap smear and pelvic exam.

In this situation, bill both code Q0091 (screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory) and G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination), appending the GA modifier (waiver of liability statement issued as required by payer policy).

In 2008, Medicare expanded the use of the ABN on a voluntary basis to include services that are noncovered or statutorily excluded. For such services, append the GX modifier (notice of liability issued, voluntary under payer policy) to the CPT code billed.

Asking a patient to sign an ABN allows you to talk about insurance benefits and financial responsibility with him or her.

The author is a medical consultant based in Indianapolis, Indiana. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to medec@advanstar.com