11/19/2019    

CODINGLINE CORNER

Query: Coding for a Diabetic Foot Check With No Abnormalities

 

How do we code for a new encounter when the patient has Medicare and the primary care physician sends the patient for a diabetic foot exam? The patient has no pathologies of the feet; only diabetes. The patient does not have peripheral neuropathy; there's no deformity and no skin issues. Can the podiatrist get paid for just using the diabetes without complications code?

 

PM News Subscriber

 

Response: If a primary care physician refers a patient to you for what would most likely be a baseline podiatric evaluation secondary to the diagnosis of diabetes AND you meet all the elements of an E&M service, a history, exam, and medical decision-making, I believe that billing for the appropriate level E&M code with the diagnosis of diabetes, whether Type 1 or Type 2 is appropriate. If there are no abnormalities found during your examination, it is not to say that your medical decision-making for this patient would not consist of counseling for watching for the signs and symptoms of diabetic neuropathy in the future and counseling about following up with you should anything change. You would most likely not bill for higher than a Level 2 E&M service.

 

Alan Bass, DPM, CPC, Manalapan, NJ

 

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