06/01/2023    Paul Kesselman, DPM

How are NPs and PAs Involved in Diabetic Shoe Documentation? (Josh White, DPM, C.PEd)

It was important to provide an additional response
to the letter I provided in a recent issue of PM
News. I purposely did not expand on the issue of
when the NP PA does the foot exam and prescribes
the shoes (as they have the legal right to) and
thus is the prescribing entity. This circumstance
was purposefully omitted out of an abundance of
creating more confusion. But since Dr. White
brought this up, I feel compelled now to clear that
issue up as well.

Dr. White is correct in that PA and NP under
Medicare are eligible prescribers for therapeutic
shoes and inserts, as well as ordering many other
tests and DMEPOS. That is NP/PA can both prescribe
shoes and inserts working incidents to (under
direct supervision with the MD/DO in the office) or
under general supervision (when the MD/DO is not in
the office but perhaps in another location in the
building). These incident to rules are by
themselves extremely complicated and also subject
to individual state regulations. So to simply
suggest that under all circumstances NP and PA can
see the patient and do the exam is not 100%
accurate. But let's assume for the sake of argument
that the incident to rules do apply. What next must
I consider?

The NP working independently and under the Primary
Care First Initiative (PCFI) can also prescribe
shoes and would not be considered an incident to
issue. So let's assume either of these apply and I,
as the supplier receive the required paperwork for
shoes/inserts including the PA or NP shoe
prescription. Once you receive an Rx from another
health care entity, that entity becomes the
referring/ordering/prescribing entity. And you
cannot fill that Rx unless your facility has
received Facility Accreditation by a CMS approved
entity and Surety Bonding. This is a rather
expensive process.

DPM as with other physicians are exempt from these
two requirements but only when they provide shoes
and other DMEPOS they (the DPM) prescribe for their
own patients. If the foot exam and shoe/insert Rx
is provided by the NP/PA then that patient, even if
your own, for that specific claim, is not
considered your own patient and the NP/PA must be
listed as the referring entity.

That being the case, you would have issues on audit
and you can bet the auditors know this!
Thus having the NP PA do the foot exam and
prescribe, does you no good, in fact it simply
complicates the issue and it should be avoided if
possible. In fact, if the NP PA is referring you a
new patient, with all the aforementioned, I would
simply perform my own examination, write my own
prescription and ask them (and the MD/DO) to sign
off on my foot exam. This all can be included in a
consult note.

If you are the prescribing entity, your notes must
contain the prescription and foot findings and that
note must be cosigned by the MD/DO supervising the
DM (this in addition to the systemic exam). Yes, my
notes and the systemic exam can be signed by the PA
and NP, but their signature must still be signed
off by the MD/DO supervising the DM (of course
unless the NP is working in a PCFI program. Are you
more confused now? Because I am! So are the
auditors and many of you!

Paul Kesselman, DPM, Oceanside, NY

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