“Diabetic pt came in for “At Risk,” Routine foot care. This patient is coded with E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.
Well, the medical assistant went to get a date last seen by an MD or DO which is required in Wisconsin to have on our claim. This patient has not been seen for diabetes by an MD or DO within the past 6 months. Our doctor told her, “That’s ok, he has PVD and it should be covered". To my understanding that is incorrect. So, I sent a message to that Dr stating that per Medicare we cannot switch back and forth between the pt having diabetes E11.51 and just PVD I73.89. To me that would not be good for an audit. So, he sends back the following message:
“I appreciate that, but today's example was different. I saw a patient with PVD which is documented and he sees vascular surgery. He sees them again tomorrow. He had an MRA documenting his PVD. It is not just on my physical exam. That is a covered service and should be covered. He is actively being worked up and treated by vascular surgery for critical limb ischemia. People can have both at the same time.”
Anyway, I don't know what to do. To me it does not seem correct, and I would not know how to go about billing either. Plus, in his note it states: “Other specified peripheral vascular diseases; Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene; Onychomycosis due to dermatophyte.”
I have always understood that E11.51 is (diabetes with PVD bundled together). Am I wrong? Please help....”
It is quite possible for a patient to qualify for "At Risk," Routine Foot Care based upon more than one qualifying systemic disease. An example would be the scenario that you demonstrated above. However, what is billed is based upon the documentation within the medical record. It is possible for a patient to qualify for both E11.51 and I73.89. The bottom line is that the patient is seeing the physician, the podiatrist for "At Risk," Routine Foot Care. In the past, the patient's encounter was billed with E11.51. This is an asterisk systemic disease, and the patient needs to see the treating physician for the systemic disease in question within 6 months prior to the foot care encounter. This is referred to as the Active Care requirement.
ICD-10-CM code I73.89 does not qualify for the Active Care requirement. In other words, the date last seen is not required. It appears that I73.89 was used as the qualifying ICD-10-CM code based upon the fact that the patient had not seen the treating physician within the past 6 months prior to the foot care encounter. Since the medical record on this date of service stated: " Other specified peripheral vascular diseases; Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene; Onychomycosis due to dermatophyte ," it appears that the new, secondary ICD-10-CM code is being used to merely get paid. I feel that this is wrong. If the medical record was audited, the past RFC encounters would support this fact based upon the ICD-10-CM code that was billed, E11.51.
That being said, if the documentation within the medical record for the date of service in question demonstrated the issues that the patient is having regarding the PVD as the podiatrist informed the biller, then for this particular date of service, it would be appropriate to use the covered systemic disease ICD-10-CM code I73.89, the Active Care Requirement would not be a concern and the date last seen would not be needed.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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