(Medicare Claims Processing Manual)

CMS will make payment directly on a fee -for service basis for the routine costs of pancreatic islet cell transplants as well as transplantation and appropriate related items and services, for MA beneficiaries participating in an NIH -sponsored clinical tria l.  MA organizations will not be liable for payment for routine costs of this new clinical trial until MA payments can be appropriately adjusted to take into account the cost of this national coverage decision.  Medicare contractors shall make payment on behalf of MA organizations directly to providers of these islet cell transplants in accordance with Medicare payment rules, except that beneficiaries are not responsible for the Part A and Part B deductibles.  MA enrollees will be liable for any applicable coinsurance amounts MA organizations have in place for clinical trial benefits.   E10.649  Type 1 diabetes mellitus with hypoglycemia without coma  E10.8  Type 1 diabetes mellitus with unspecified complications  80 - Billing of the Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)   Coverage Requirements -  Peripheral neuropathy is the most common factor leading to amputation in people with diabetes.  In diabetes, peripheral neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers; however, distal motor findings may be present in advanced cases.  Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally.  This leads to loss of protective sensation (LOPS), whereby a person is unable to feel minor trauma from mechanical, thermal, or chemical sources.  Wh en foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.  Peripheral neuropathy with LOPS, secondary to diabetes, is a localized illness of the feet and falls within the regulation's exception to the general exclusionary rule (see 42 C.F.R. 411.15(l)(l)(i)).  Foot exams for people with diabetic peripheral neurop athy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.   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.  LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the N ational Institute of Diabetes and Digestive and Kidney Diseases guidelines.  Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.  The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically.  Heavily callused areas should be avoided.  As suggested by the American Podiatric Medicine Association, an  absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes -Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.   80.1 - General Billing Requirements  (Rev. 2783, Issued: 09- 10-13, Effective: 09 -30-13, Implementation: 09- 30-13)  The following providers of service may bill you for these services:   Hospitals; Critical Access Hospitals  Rural Health Clinics; and  Free-Standing Federally Qualified Health Clinics (FQHC).   80.2 - Applicable HCPCS Codes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)   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   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.  NOTE : Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.   The short descriptors for the above HCPCS codes are as follows:   G0245  INITIAL FOOT EXAM PTLOPS   G0246  FOLLOWUP EVAL OF FOOT PT LOP   G0247  ROUTINE FOOTCARE PT W LOPS   80.3 - Diagnosis Codes (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  If ICD -10-CM is applicable --Providers should report one of the following diagnosis codes in conjunction with this benefit:  ICD-10-CM ICD-10 DX Description  E08.40  Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified               E08.42  Diabetes mellitus due to underlying condition with diabetic polyneuropathy               E09.40  Drug or chemical induced diabetes mellitus with neurological complications with diabetic n               E09.42  Drug or chemical induced diabetes mellitus with neurological complications with diabetic p                E10.40  Type 1 diabetes mellitus with diabetic neuropathy, unspecified           E10.41  Type 1 diabetes mellitus with diabetic mononeuropathy           E10.42  Type 1 diabetes mellitus with diabetic polyneuropathy           E10.43  Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy           E10.44  Type 1 diabetes mellitus with diabetic amyotrophy           E10.49  Type 1 diabetes mellitus with other diabetic neurological complication           E10.610  Type 1 diabetes mellitus with diabetic neuropathic arthropathy              E11.40  Type 2 diabetes mellitus with diabetic neuropathy, unspecified         E11.41  Type 2 diabetes mellitus with diabetic mononeuropathy       E11.42  Type 2 diabetes mellitus with diabetic polyneuropathy         E11.43  Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy         E11.44  Type 2 diabetes mellitus with diabetic amyotrophy   E11.49  Type 2 diabetes mellitus with other diabetic neurological complication        E11.610  Type 2 diabetes mellitus with diabetic neuropathic arthropathy  E13.40  Other specified diabetes mellitus with diabetic neuropathy, unspecified  E13.41  Other specified diabetes mellitus with diabetic mononeuropathy         E13.42  Other specified diabetes mellitus with diabetic polyneuropathy         E13.43  Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy         E13.44  Other specified diabetes mellitus with diabetic amyotrophy         E13.49  Other specified diabetes mellitus with other diabetic neurological complication         E13.610  Other specified diabetes mellitus with diabetic neuropathic arthropathy         Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 70.2.1 Diabetic neuropathy w/ LOPs. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp  80.4  Payment  (Rev. 2783, Issued: 09- 10-13, Effective: 09-30-13, Implementation: 09-30-13)    Hospital outpatient departments  OPPS    Critical Access Hospital (CAH) - Method I -- Reasonable cost; Method II --  Technical - reasonable cost, Professional -- 115 percent of the fee schedule   Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) - All inclusive rate.   Deductible and coinsurance apply.   While these physician services may be appropriately provided to patients of Comprehensive Outpatient Rehabilitation Facilities (CORFs), the CORF does not bill.   The services are billed by the physician on a professional claim.   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.  Part B Deductible Not met:  $900 (MPFS allowed amount) -  $100 (Part B deductible) = $800 x 20 percent (co-insurance) = $640 (Medicare reimbursement).  Beneficiary is responsible for $260.   Part B Deductible Met:  $800 (actual charged amount) x 20 percent (co- insurance) = $640 (Medicare Reimbursement), beneficiary is responsible for $160 co- insurance.   Part B Deductible Not Met:  $800 (actual charged amount) -  $100 (Part B deductible) = $700 x 20 percent (co -insurance) = $560 (Medicare reimbursement).  Beneficiary is responsible for $240, ($100 Part B deductible and $140 co- insurance).   Services are paid at 80 percent of the lesser of the fee schedule amount or the actual charges.   This service, when furnished in an RHC/FQHC by a physician or non- physician, is considered an RHC/FQHC service.  RHCs/FQHCs bill you under bill type 71X or 73X with revenue code 940 and HCPCS G0245, G0246, and G0247.   Payment should not be made for this service unless the claim contains a related visit code.  Therefore, install an edit in your system to assure payment is not made for revenue code 940 unless the claim also contains a visit revenue code (520 or 521).   Applicable Revenue Codes   The applicable revenue code is 940, except for hospitals.  This service can be performed in other revenue centers such as a clinic (510) for hospitals.  Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.   80.5 - Applicable Revenue Codes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)   The applicable revenue code is 940, except for hospitals.  This service can be performed in other revenue centers such as a clinic (510) for hospitals.  Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.   80.6 - Editing Instructions for A/B MACs (A)  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Edit 1  - Implement diagnosis to procedure code edits to allow payment only for the LOPS codes, G0245, G0246, and G0247 when submitted with one of the following ICD-10-CM diagnosis codes   If ICD -10-CM is applicable: