How Often Can I Submit An E/M With An At-Risk Foot Care Visit?

Physicians often ask me how frequently it is appropriate to code an evaluation and management (E/M) along with an at-risk foot care visit. Many are under the impression there is an “automatic” once-a-year E/M they can submit for patients who are receiving regular foot care. Others think it is every six months.

There is no defined limit on this. There is no such thing as “you can code an E/M with nail care once every X months.” 

You can code an E/M with nail care if, and only if, you performed a separately identifiable, medically necessary, documented E/M. An E/M performed during a foot care encounter requires a chief complaint that is unrelated to the foot care. One can perform an E/M during a foot care encounter as frequently as is medically necessary. What you performed and documented must reflect that it was a medically necessary E/M that was separately identifiable from the foot care. In order for this E/M to be considered separately identifiable, it must stand on its own as a separate service apart from the nail care.

For a patient you are seeing regularly for an at-risk foot exam and nail care, there is no such thing as a “once every X months E/M” to update vascular/neuro findings, and/or to update history. These services are included in the nail care procedure code.

Dr. Lehrman is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM). Follow him on Twitter @DrLehrman

References

1. Centers for Medicare and Medicaid Services Learning Network Medicare Podiatry Services: Information for Medicare Fee-For-Service Health Care Professionals. Available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicarePodiatryServicesSE_FactSheet.pdf .