Does G0245 require prior authorization?

No, G0245 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0245?

Medicare facility rate: $34.74. Non-facility rate: $65.47. Work RVU: 0.86.

Verity

`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

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.86

Facility

$34.74

Non-Facility

$65.47

Documentation Required

For diabetic patients with LOPS, documentation elements for G0245 (Initial physician evaluation) must include: (1) the diagnosis of LOPS, (2) a patient history, (3) a physical examination that consists of at least: (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.

For follow-up visits (G0246), documentation must include: (1) a patient history, (2) a physical examination that includes: (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 (3) patient education.

For routine foot care by a physician of a diabetic patient with LOPS (G0247), documentation must include local care of superficial wounds (if present) and, if present: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails.

When arguing medical necessity because non-professional performance would be hazardous, document the underlying condition(s) and the specific hazard (e.g., severe circulatory embarrassment, areas of desensitization) and why non-professional care would pose a hazard.

When coverage is claimed because foot care is integral to an otherwise covered service, document how the foot care is necessary and integral to that covered procedure (e.g., debriding a nail to expose a subungual ulcer).

For debridement of mycotic nails, document evidence that mycosis/dystrophy is causing secondary infection and/or pain, documentation that the condition results or would result in marked limitation of ambulation, and that the professional skills of a provider are required.

Key Coverage Criteria

Other disorder of circulatory system (ICD-10: I99.8).
Ingrowing nail (ICD-10: L60.0).
Non-pressure chronic ulcer of foot (ICD-10: L97.501 - L97.529).
Injury of blood vessels at lower leg level (ICD-10: S85.001+ - S85.999+).
Injury of blood vessels at ankle and foot level (ICD-10: S95.001+ - S95.999+).
Diabetes mellitus in pregnancy, childbirth, and the puerperium (ICD-10: O24.011 - O24.93).

1 Active Policy

AETNA-CPB-0046 — Routine Foot Care

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