11/20/2019     Bryan C. Markinson, DPM

Coding for a Diabetic Foot Check With No Abnormalities

Let me start by saying that I appreciate the
inputs of our APMA-endorsed DPM (only discussing
the DPMs here) coding “experts,” as well as
those DPMs who offer advice as consultants from
private billing or practice management
companies. They provide invaluable advice and
information. However, way too often I come away
with the impression that the advice they are
offering is their opinion, and more often than
not, I come away thinking that they really
aren’t sure of their answer.

Recently, one such designated expert answers a
query regarding billing for a prudent exam on a
diabetic patient referred by the PCP who turns
out to have no complaints, and a normal exam.
The doctor asks if he can get paid with the
diagnosis of diabetes alone.

My initial gut reaction to this question was
that if NOT, then all the well thought out
education of doctors, patients and the lay
public in general about diabetic foot
complications, and all the insurance company
pronouncements about how much they are concerned
about cost-effective “quality” care is all for
naught as well as any pronouncements that
podiatry is invaluable in avoiding diabetic
complications. My next thought was, “Are there
any colleagues out there who tell patients in
this scenario that they are not covered?”

In my practice alone, I can document so many
cases where PCPs missed critical limb ischemia,
while treating their diabetic patients for years
before referring for a foot exam, perhaps one of
the few benefits of meaningful use or whatever
they call it now. Just as importantly as
uncovering a diagnosis like that, is finding no
complications and stratifying risk for both the
patient and the referring PCP, yes, with the
diagnosis of diabetes alone.

Honestly, I expected the answer to be a
resounding and unequivocal “ABSOLUTELY YOU CAN
GET PAID.”

Instead, the expert response, like so many
others, is muted with (paraphrasing) “’I
believe that billing for appropriate level E/M
with the diagnosis of diabetes alone is
appropriate.” The expert is not sure! Like other
experts, use of words and phrases like believe,
suppose, can’t see why not, can be defended,
etc., abound in their responses. Now I
understand the reservation to give absolutes,
especially when many convicted of fraud argue
that “that is what I was taught”… but there are
situations where clearly there is an absolute
yes or no.

In this particular instance, the expert
concluded with the statement “You would most
likely not bill for higher than a Level 2 E&M
service.” It is this statement that clinched my
decision to comment on this whole matter.

Whether anyone agrees with that statement or
not, it indicates a ton of uncertainty, on which
many practitioners will base practice management
decisions.

Bryan C. Markinson, DPM, NY, NY

Other messages in this thread:

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11/29/2019    Allen Jacobs, DPM

Coding for a Diabetic Foot Check With No Abnormalities (Bryan Markinson, DPM)

Thank you for the comments of my friend and
colleague, Dr. Markinson, regarding this matter.
I feel compelled to clarify my position
regarding this issue so that there is no
misunderstanding whatsoever. It is my belief
that this matter is as critical to our
profession and patient care as any issue.

The search for pathology in the examination of
the patient with diabetes is not an effort to
find an ICD-10 code to justify the submission of
billings for reimbursement. That is the E of the
E and M. It is the identification of significant
risk factors with which increased risk of
infection, ulceration, or gangrene is
associated. The M in E and M is equally
critical. Having identified such pathology, what
are you doing about it ?

The correct term is CDFE, that is COMPREHENSIVE
diabetic foot examination. COMPREHENSIVE. Not
cursory.

Allow me to site just a few examples.

Epidemiological studies demonstrate that up to
70% of older diabetic patients have fungal
infection of the foot ( tinea pedis,
interdigital tinea pedis, onychomycosis ).
NUMEROUS studies have demonstrated that in the
patient with diabetes, such fungal infections
are assisted with increased risk of infection
and ulceration. Fungal infection is not a minor
or banal problem in the diabetic patient. It is
a risk factor. I should ask the readers why in
the world would you not identify the problem,
utilize appropriate testing to confirm and
clarify the nature of such infections, educate
the patient regarding the problem, and actively
TREAT such problems ?

Parasthesis and dysestheia is not uncommon in
the diabetic patient. How many patients complain
about symptomatic diabetic neuropathy which
generally is either not treated or under-treated
by primary care healthcare providers ? We all
see this problem daily. It is a quality of life
issue. Pain with ambulation, or the inability to
obtain a restful or restorative nights sleep is
not uncommon. Again I would ask why you would
not actively treat such problems ?

Edema is common in the diabetic patient,
particularly the older diabetic patient in whom
cardiac, renal, venous insufficiency, and other
fluid or electrolyte abnormalities are common.
Edema, particularly in the presence of
neuropathy, results in poorly fitting shoes,
pressure, and ulceration. There are many
interventions such as prescribing elevation,
compression stockings, intermittent sequential
lymphedema pumps and referral for properly
fitting shoes which may be entertained.

Every podiatrist knows that deformities such as
bunions, hammertoes, bunionette deformities are
associated with pressure induced ulceration in
the presence of neuropathy. Accommodative,
palliative, or corrective surgical therapy in
appropriately selected patients is important if
not critical in such patients.

Arterial disease, particularly in the geriatric
patient with diabetes, is not infrequently
present absent classic signs and symptoms such
as claudication.

The CDFE should properly be titled
CDFEM...examination and MANAGEMENT. It is the
MANAGEMENT of identified risk factors which
results, as demonstrated in multiple published
works, in significant reduction in major limb
amputation.

It is E and M. It is a comprehensive
examination. I would again argue that the
majority of diabetic patients, particularly the
older diabetic patient, are in need of
interventions which may be limb or at times
life-preserving.

Allen Jacobs, DPM, Dt. Louis, MO

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11/27/2019    Bryan C. Markinson, DPM

Coding for a Diabetic Foot Check With No Abnormalities (Lawrence Rubin, DPM)

Dr. Rubin on this subject states that if there
is no symptom or clinical diagnosis, payers
won’t pay or may not pay, or we may be demanded
to pay money back if we get paid. I reject this
simply because If true, than my original
statement that all of our proclamations of
benefit of a diabetic foot exam, or podiatry
involvement in overall diabetic management,
cannot be beneficial only during complications,
but also in risk stratification and patient
education alone, are for naught.

If I am wrong about this, than there is a gaping
chasm in the reality of practice and what we
espouse as a core important contribution of our
profession. Dr. Jacob’s response and
contribution, (with which I fully agree) to the
original query of whether or not we can bill
and get paid for a diabetic foot exam on a
patient with no clinical findings or symptoms,
still fails to answer the question.

Although Dr. Jacobs includes risk stratification
independently as a worthwhile goal of the exam
(which in my opinion is all that should be
needed to justify one), Dr. Jacob’s also
intimates that that if you do a detailed exam as
he suggests, you will find something, with the
justification that findings in diabetics are
“common.” I do not disagree. The issue of
“finding something” has been a ball and chain
on the profession since the beginning, starting
with the ridiculous and never changing
restrictions on routine foot care. I am urged to
participate in the Diabetic Shoe Program (which
I will never do) as a patient with well
controlled diabetes and a asymptomatic bunion
gets $350 worth of shoes and inserts; but
“experts” say my exam to determine that the
circulation and neurosensory status, and skin
and nails are normal may not get paid.

Some experts say you “should” get paid, but keep
it a Level 2 E/M! However in many instances,
diabetics who are newly diagnosed within weeks
(and whose only issue currently is
hyperglycemia) are sent to me for this
evaluation. It’s part of meaningful use, pay for
performance data, and whatever quality measures
they are calling it this week. Some tell me that
I do not understand the difference between
“getting paid,” and “medically appropriate” and
what’s “stated in the carrier LCD.”

What I do understand is that to date, I have
NEVER been denied payment for an exam that
listed diabetes as the only diagnosis in these
patients. To re-iterate, Dr. Jacob’s post in
reality does support that there are typically
podiatric findings considered banal, but in the
face of persistent hyperglycemia are not so
banal and must be addressed. So the small
percentage of “no findings,” and/or “no
podiatric symptoms” in diabetics who are
instructed on diabetic complications and the
benefits of good control do get an exam with
diabetes as the only listed diagnosis and the
appropriate level E/M billed. I never had a
question about it. I have never been denied.

Bryan C. Markinson, DPM, NY, NY

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11/26/2019    Allen Jacobs, DPM

Coding for a Diabetic Foot Check With No Abnormalities

The normal diabetic foot examination
The discussion of how to submit charges for a
“normal foot examination” reminds me of the old
adage “the eye sees what that the mind knows”.
If the examination is cursory, then I suppose
one may lack a diagnosis for the justification
of a diabetic foot examination.

I propose that the ability to diagnose relevant
foot pathology in the diabetic is only as good
as the examination.” There is much more required
than an inspection of toenails, a 10 gram
filament, and a lazy-eyed survey of the foot.

The purpose of the diabetic foot examination is
the identification of risk factors, risk
stratification, patient education, and
interventions to lower the risk of ulceration,
infection, amputation. It is for improvement in
quality of life.

Statistics alone establish the frequency of skin
disorders such as tinea pedis, xerosis,
onychomycosis in the majority of diabetic
patients. Add in other skin disorders not unique
to diabetes, such as pressure induced calluses.
Skin pathology, encountered with increased
frequency in the patient with diabetes, is
common.

Ask yourself as to the extent of your
neurological examination. Are you evaluating for
entrapment neuropathy? Lower extremity
manifestations of autonomic neuropathy? Reflexes
and motor neuropathy?

Are you evaluating and treating numbness,
parasthesis or dysesthesia?

Are you evaluating for large and small vessel
arterial disease? Edema? Venous disorders? There
many appropriate podiatric interventions for
these problems other that just referral to
vascular surgery or cardiology.

Are you evaluating fall risk, or gait
instability, problems which occur with increased
frequency in the diabetic patient

Are you evaluating for structural or functional
abnormalities and prescribing appropriate
orthotic, brace, shoe, or physical therapy.

Allen Jacobs, DPM, St. Louis, MO

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11/25/2019    Lawrence Rubin, DPM

Coding for a Diabetic Foot Check with No Abnormalities

I believe the many comments and responses made
on this subject amount to trying to answer this
question: Can you bill a new patient Evaluation
and Management (E/M) service for a preventive
foot examination of a diabetic patient referred
by a physician if there are no present diseases
or disorders of the lower extremities? In
addition, there would presumably not be medical
record documentation of the required E/M "Chief
Complaint" or "Nature of the Presenting
Problem."

On the issue, while a podiatric comprehensive
diabetes foot examination is universally
accepted to be an immensely valuable preventive
screening service, this does not mean that
insurers are willing to pay for it.
Unfortunately, Medicare, Medicaid, and to the
best of my knowledge, most commercial insurance
payers will consider a podiatric foot
examination of a diabetic new patient who does
not presently have a disease or disorder of the
lower extremities to be a non-covered,
preventive screening service.

Billing the service using an ICD diagnosis code
for diabetes that does not also identify a lower
extremity complication (such as diabetic
peripheral neuropathy) is not acceptable. The
claim will be denied because this implies a
podiatrist is treating the diabetes. The
treatment of diabetes is not included within the
insurance industry taxonomy of eligible services
provided by a podiatrist. Some claims billed
this way may pass through an occasional
insurer's payment system, but the end result may
be a future audit and demand for return of an
overpayment.

So, I imagine the answer to the question is,
yes. You can bill for a diabetic foot screening
on a patient who has no lower extremity disease
or symptoms of disease. But don't be surprised
if the patient's insurance does not cover it.

Lawrence Rubin, DPM, Las Vegas, NV

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11/21/2019    Alan L. Bass, DPM

Coding for a Diabetic Foot Check with No Abnormalities (Bryan Markinson, DPM)

In response to Dr. Markinson’s comments on the
coding answers for this question, let me begin
by stating one unequivocal fact. Billing and
coding is not the same as practice. There is
always the unknown on why certain claims are
denied. What we actually perform, and document
sometimes is not the same as what we will
actually get paid for.

I was a student of Dr. Markinson’s at NYCPM and
have the highest respect for his work in
podiatry and dermatopathology, but billing and
coding is not simple and straightforward. Since
obtaining my credentials as a CPC, I have a new
appreciation of what insurance companies look
for when auditing claims.

Do I believe that all diabetic patients should
have a yearly diabetic foot exam? Yes. Do I
believe that patients don’t always tell their
PCPs and endocrinologists everything about their
feet and that some don’t have them take their
shoes and socks off? Also, yes. Do I believe
that we should be paid for a yearly diabetic
foot exam? Absolutely! This is not about what we
do, or even what I believe, it’s about what we
get paid for.

Recently, I was asked the following, why can’t
we use the series of CPT codes for preventive
care for diabetic patients and not and E&M code?
My response to that DPM was the following: in
reviewing the description/verbiage of the CPT
code(s) for preventive care, the elements of the
code are within the scope of practice of all
DPMs and we could use that code, BUT, I have not
seen many DPMs, if any, use that code for the
yearly diabetic foot exam. Listen, we can debate
this topic all day in this forum, but let’s all
agree on one thing, we all want to do the right
thing for our patients and feel we should be
paid for performing our services.

Alan L. Bass, DPM, CPC, Manalapan, NJ