Presently, peripheral neuropathy, or diabetic sensory neuropathy, is the most common factor leading to amputation in people with diabetes.  In diabetes, sensory 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. When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.

Diabetic sensory neuropathy with LOPS is a localized illness of the feet and falls within the regulation’s exception to the general exclusionary rule.  Foot exams for people with diabetic sensory neuropathy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease. 

An evaluation (examination and treatment) of the feet (G0245, G0246) is covered no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the member has not seen a foot care specialist for some other reason in the interim. 

If the evaluation of the feet is performed more often than every six months, the service will be denied as noncovered.  The provider can bill the member for the denied service.

LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National 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 Disease 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 America Podiatric Medicine Association, an absence of sensation at two or more sites out of five 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.
The examination includes:

1. A patient history
2. A physical examination that must consist of at least the following elements:
   
   

   • Visual inspection of forefoot and hindfoot (including toe web spaces).
   • Evaluation of protective sensation.
   • Evaluation of foot structure and biomechanics.
   • Evaluation of vascular status and skin integrity.
   • Evaluation of the need for special footwear

3. Patient education.

Treatment (G0247) includes, but is not limited to:

• Local care of superficial wounds.
• Debridement of corns and calluses.
• Trimming and debridement of nails.

The diagnosis of diabetic sensory neuropathy with LOPS should be established and documented prior to coverage of foot care.  Other causes of peripheral neuropathy should be considered and investigated by the primary care physician prior to initiating or referring for foot care for persons with LOPS.  Foot care for diagnoses other than diabetic sensory neuropathy with LOPS will be denied as noncovered.  The provider can bill the member for the denied service.

Code G0247 will deny as not eligible if not submitted on the same date of service as G0245 or G0246.  The provider cannot bill the member for the denied service.

Once a member's condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services.  Those services would be considered to be included in the regular exams and treatments afforded to the member on a routine basis.  The provider must then just bill the routine foot care codes.  Codes G0245, G0246, and/or G0247 will reject noncovered when the member's records shows that one of the following routine foot care codes was billed and paid within the prior six months: 11055, 110556, 11057, 11719, 11720 and/or 11721.  The provider cannot bill the member for the denied service.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Use code G0245 to report initial evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in LOPS.

Use code G0246 to report follow-up evaluation and managment of a diabetic patient with diabetic sensory neuropathy resulting in LOPS.

Use code G0247 to report routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in LOPS.

CMS Transmittal 1731, Change Request 6456

CMS Online Manual Pub.100-03, Chapter 1, Section 70.2.1