11/25/2020    Paul Kesselman, DPM

Therapeutic Shoe Update

As of November, there is an update to the
Therapeutic Shoe Policy which some of you will be
happy with and others may be troubled by. A
summary is provided below.
Both Nurse Practitioners (NP) and Physicians
Assistants (PA) with certain limitations, are now
afforded the ability to certify patients as
diabetic with respect to their need for
therapeutic shoes/inserts. There are two pathways
both of which have limitations which are
summarized below.

Pathway #1: NP/PA Working Incident to an MD/DO
Effective November 5 2020 If an NP or PA is
working both under the direct supervision of an
MD/DO and billing under the NPI of the MD/DO who
was/is supervising the DM care, then the NP/PA
can perform the examination to demonstrate that
the patient is diabetic and needs therapeutic
shoes. They may also sign the certification form
that the patient requires therapeutic shoes. The
exam records of the NP or PA, however, must be
agreed to, or attested to by the MD/DO by co-
signing their agreement with the NP or PA
findings in a contemporaneous fashion.

Note that this does not apply to NP who can
practice independent of an MD or DO (with the
notable exceptions of Pathway #2 below).

Pathway #2: NP Working Independently in a Primary
Care Demonstration Project: Effective January 1
2021 NP who bill under their own NPI can act as
the certifying physician under some extremely
limited circumstances.

The NP first must enroll into the Primary Care
Demonstration Project. This project is restricted
to certain geographic areas. Only NP enrolled
in this demonstration project and billing under
their own NPI may certify the patient as diabetic
and document in their charts that the patient
requires therapeutic shoes under this pathway. NP
billing under their own NPI not enrolled in the
Primary Care First Demonstration Project in the
approved areas will not be eligible to certify
patients.

This Pathway does not apply to PA because they
cannot practice independently of an MD/DO.
There are many unresolved questions regarding
both these pathways and clarification is pending
from CMS.

The main sticking point is whether the NP/PA is
permitted to co-sign and agree to the findings of
Eligible Prescribers (MD/DO/ PA NP) who are not
treating the DM or that of the DPM.
This provides a welcome relief for many suppliers
who have long sought to allow the NP or PA to
sign off on the required paperwork.

However, the unintended consequences are that it
provides a route for physician extenders to
assume a superior position to the eligible
prescriber (MD/DOwho is not treating the DM) or
the DPM.

Many rumors have been circulating from vendors
and colleagues alike regarding many aspect of
this update. uffice it is to say that there is no
clear answer to the questions posed to the DME
MAC Medical Directors and forwarded to CMS. When
those answers are available in writing , they
will be provided.

DME Medicare Policy Update:
https://www.cgsmedicare.com/jc/pubs/news/2020/11/
cope19408.html

Reference to Primary Care First Demonstration
Project: https://innovation.cms.gov/innovation-
models/primary-care-first-model-options

Paul Kesselman, DPM, Oceanside, NY

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