Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)

Policy #:07.03.15d

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

The evaluation and management (E&M) of diabetic peripheral neuropathy with loss of protective sensation (LOPS) is considered medically necessary and, therefore, covered every six months for individuals who have a documented diagnosis of diabetic peripheral neuropathy with LOPS.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, evaluation and management (E&M) of diabetic peripheral neuropathy with loss of protective sensation (LOPS) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

BILLING GUIDELINES

Procedure codes G0245 and G0246 are not eligible for separate reimbursement when they are billed in addition to an evaluation and management (E&M) code, a consultation code, and/or a routine foot care code (e.g., trimming of nondystrophic nails).

When reporting procedure codes G0245 and G0246, the documentation in the medical record should contain the following:
  • The individual's history
  • A physical examination that includes all of the following:
    • Visual inspection of the 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
  • Patient education for foot care specific to the needs of the individual

Description

Peripheral neuropathy is a nerve disorder that can affect the upper and lower extremities of individuals with diabetes. This diffuse condition primarily affects the sensory and autonomic nerve fibers and can lead to weakness, pain, numbness, and loss of feeling in the arms, hands, legs, and feet. Typically, the lower extremities are affected before the upper extremities. Peripheral neuropathy is the most common cause of lower-extremity amputation in individuals with diabetes.

Many individuals with diabetes may be asymptomatic but, upon examination, have signs of neuropathy. Long nerves are affected first, with symptoms appearing gradually, first in the toes and then advancing upwards to the foot and leg. Some of the symptoms related to peripheral neuropathy may include: difficulty with coordination and balance; cramps or sharp pains; burning, tingling, or prickling sensations; insensitivity to temperature and pain; numbness; and extreme sensitivity to touch. These symptoms may be more intense at night.

Peripheral neuropathy leads to loss of protective sensation (LOPS), whereby an individual is unable to feel minor trauma from mechanical, thermal, or chemical sources. Peripheral neuropathy with LOPS, secondary to diabetes, is a localized disorder of the feet. Sores or blisters may appear on the foot and may go unnoticed due to numbness or loss of sensation. When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing. Injuries to the foot that are not promptly treated may lead to amputation due to the spread of infection to the bone. Amputation of the lower extremities may be prevented if areas of minor trauma are identified and treated promptly. Regular foot examinations are necessary to allow for early interventions to offset these serious complications.

Peripheral neuropathy with LOPS is diagnosed through sensory testing using established guidelines such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases. Five sites should be tested on the plantar surface of each foot. Heavily callused areas should be avoided. The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the individual may get clues if the test is done rhythmically. As suggested by the American Podiatric Medicine Association, a diagnosis of peripheral neuropathy with LOPS is confirmed when two or more of the five sites on either foot are tested with the Semmes-Weinstein 5.07 monofilament and present with an absence of sensation. The American Diabetes Association, the American Orthopaedic Foot and Ankle Society, and the American Podiatric Medicine Association acknowledge that foot ulcerations and amputations resulting from foot injuries associated with LOPS are largely preventable and that individuals with diabetic peripheral neuropathy with LOPS should undergo regular examinations.

In 2002, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage determination (NCD) for services provided for the diagnosis and treatment of diabetic sensory neuropathy with loss of protective sensation and provided coverage for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, for no more often than every six months.
References


Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Pub 100-04: Medicare Claims Processing. Transmittal 498: Billing of the diagnosis and treatment of peripheral neuropathy with loss of protective sensation in people with diabetes. [CMS Web site]. 03/11/05. Available at: http://www.cms.hhs.gov/transmittals/downloads/R498CP.pdf. Accessed February 21, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services. 80: Billing of the diagnosis and treatment of peripheral neuropathy with loss of protective sensation in people with diabetes. [CMS Web site]. 03/11/2005. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c32.pdf. Accessed February 21, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 70.2.1: Services provided for the diagnosis and treatment of diabetic sensory neuropathy with loss of protective sensation (aka diabetic peripheral neuropathy). [CMS Web site]. 07/01/02. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=171&ncdver=1&DocID=70.2.1&ncd_id=70.2.1&ncd_version=1&basket=ncd*3a%2470.2.1*3a%241*3a%24Services+Provided+for+the+Diagnosis+and+Treatment+of+Diabetic+Sensory+Neuropathy+with+Loss+of+Protective+Sensation+(aka+Diabetic+Peripheral+Neuropathy)&bc=gAAAABAAAAAA&. Accessed February 21, 2018.

Levin M. Pathogenesis and general management of foot lesions in the diabetic patient. In: Bowker JH, Pfeifer MA, eds. Levin and O'Neal's The Diabetic Foot. 6th ed. St. Louis, MO: Mosby, Inc.; 2001: 231-236.

McCulloch DK. Evaluation of the diabetic foot. 02/02/2018. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed February 21, 2018.

National Diabetes Education Program (NDEP). Working Together to Manage Diabetes: A Guide for Pharmacy, Podiatry, Optometry, and Dental Professionals. January 2014. Available at: http://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide.pdf. Accessed February 21, 2018.

National Diabetes Information Clearinghouse (NDIC). Prevent diabetes problems: Keep your nervous system healthy. National Institutes of Health (NIH) Publication No. 14–4284. [NDIC Web site]. February 2014. Available at: https://sp-web.niddk.nih.gov/health-information/health-topics/Diabetes/prevent-diabetes-problems/Pages/keep-your-nervous-system-healthy.aspx. [The link to this reference is no longer active on the NDIC Web site]. Accessed December 21, 2016. ​​​​​​​​​​​​​​​​

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Diabetic neuropathies: The nerve damage of diabetes. NIH Publication No. 09–3185. [National Diabetes Information Clearinghouse (NDIC) Web site]. February 2009. Available at: https://www.niddk.nih.gov/-/media/Files/Diabetes/Neuropathies_508.pdf?la=en. Accessed February 21, 2018.

Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE and Bennett PH, eds. Diabetes in America. 2nd ed. Bethesda, MD: National Institutes of Health; 1995: 409-428. Available at: http://diabetes.niddk.nih.gov/dm/pubs/america/pdf/chapter18.pdf. Accessed February 21, 2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified

E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy

E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy

E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy

E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified

E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy

E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy

E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy

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




HCPCS Level II Code Number(s)



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, and (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, and (e) evaluation and recommendation of footwear, and (3) patient education


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 07.03.15d
05/23/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on the Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS).

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 06/28/2017
Version Issued Date: 06/28/2017
Version Reissued Date: 05/23/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.