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

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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