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I'm working with some USA medical claims data and was asked for a gaps in care report for members of the population with diabetes. The total population is around a million people, with tens of millions of claims. One of the gaps in care measures mentioned was "did the beneficiary have a foot exam in the past year?"

How do I identify diabetic foot exams/LOPS exams using claims data, CPT/ICD-10 codes, etc.? Is there a standard way of doing so in claims data? (I know it won't be perfect, but claims data never is)


Here's what I tried.

  • In the HEDIS Comprehensive Diabetic Care guidelines, foot exams aren't listed.
  • I found a reference that said to use the HCPCS/CPT codes G0245, G0246, and G0247. Unfortunately, none of the claims in my data have these codes, even though there are clearly diabetic beneficiaries in the data (they've filled relevant prescriptions, bought insulin pumps, had regular A1C screenings, etc.)
  • I've found references to CPT II codes, like 2028F, but my claims data don't have those.
  • There are MIPS guidelines that refer to G8404 and G2179, but barely any of those show up in the data either. Ditto for G9226.
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The correct way to bill Medicare patients for a diabetic foot exam performed on the same calendar day as other service is no additional codes.

From the American Academy of Family Physicians:

Medicare does not allow for separate payment of an E/M code and a diabetic foot evaluation on the same date. Should you provide a diabetic foot exam to a patient with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation and not provide significant other E/M services on the same date, it may be beneficial to report this using the codes for the diabetic foot evaluation and treatment.

The payment for the diabetic foot exam is included as part of the reimbursement for the regular visit.

Other payers may theoretically cover this service on the same calendar day, but in my experience, most payers follow Medicare. Thus, because Medicare does not cover paying for the extra service code, physicians are likely not in the habit of spending time applying a code that will not be reimbursed.

You will have to find another way to identify this gap in care.

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  • Thank you. The last paragraph in that section says that "HCPCS codes G0245 (initial service) and G0246 (follow-up service) should be reported. Code G0247 may be reported on the same date if the physician also performs routine foot care including local wound care, debridement of corns and calluses, and trimming and debridement of nails. The following diagnosis codes should be reported in conjunction with this benefit: 250.60, 250.61, 250.62, 250.63 and 357.2." but even though the codes for reporting this technically exist and "should be reported", this explains why physicians rarely do so.
    – Michael A
    Sep 8 at 20:02
  • I had hoped that the reporting guidelines would have been updated since that article was published a while ago but it seems unfortunately not.
    – Michael A
    Sep 8 at 20:03

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