DAR File No. 37578

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-11

Podiatry Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 37578
Filed: 05/01/2013 03:44:54 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to broaden client access to podiatric services by allowing podiatrists to perform services within their scope of license to all categorically and medically needy recipients.

Summary of the rule or change:

This amendment broadens client access to podiatric services through a provision that allows podiatrists to perform services within their scope of license to all categorically and medically needy recipients. It also makes other clarifications and refers to the Podiatric Services Provider Manual for descriptions of all non-covered services, covered services and service limitations.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because the increase in revenue for podiatrists comes from the same appropriation of funds that general practitioners continue to receive for podiatric services.

local governments:

There is no impact to local governments because they neither fund nor provide Medicaid services to Medicaid recipients.

small businesses:

General practitioners may see a slight decrease in revenue with the increase in revenue for podiatrists. Nevertheless, there is no data to estimate how much that decrease will be.

persons other than small businesses, businesses, or local governmental entities:

General practitioners may see a slight decrease in revenue with the increase in revenue for podiatrists. Conversely, Medicaid recipients will see nominal savings with the increase in access to podiatric services. Nevertheless, there is no data to estimate the decrease in revenue or the increase in savings.

Compliance costs for affected persons:

A single general practitioner may see a slight decrease in revenue. Nevertheless, there is no data to estimate how much that decrease will be.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule should be revenue neutral for providers. Reductions in one provider class will be offset by increased revenues for podiatrists.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/14/2013

This rule may become effective on:

07/01/2013

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-11. Podiatr[y]ic Services.

R414-11-1. Introduction and Authority.

Podiatr[y]ic services are authorized by 42 CFR 440.[6]50 and include the examination, diagnosis, or treatment of the foot. Podiatr[y]ic services are optional and provided in accordance with 42 CFR 440.225.

 

[R414-11-2. Definitions.

In this rule, "Subluxation" means a structural misalignment or partial dislocation of a joint or joints in the feet.

 

]R414-11-[3]2. Client Eligibility Requirements.

Podiatr[y]ic services are available to categorically and medically needy individuals.

 

R414-11-[4]3. Service Coverage.

[ (1) The Department covers the following podiatry services:

(a) foot incision and drainage of simple abcess;

(b) foot skin debridement;

(c) cutting benign or premalignant lesions;

(d) treatment of nail plate;

(e) injections for ganglion cysts;

(f) foot bone excisions;

(g) walking cast, Unna boots;

(h) radiologic exam of ankle or foot; and

(i) office visits.

(2) The Department covers the following podiatry-related medical supplies and equipment:

(a) shoes attached to a brace or prosthesis;

(b) shoes specially constructed to provide for a totally or partially missing foot; and

(c) additional supplies not regularly used for office surgery procedures.

(3) Shoe repair is covered if it relates to external modification of an existing shoe to accommodate a leg length discrepancy requiring a shoe build up of one inch or more.

]Podiatric services are limited to the services described in the Podiatric Services Utah Medicaid Provider Manual. A physician, osteopath, or podiatrist may provide podiatric services within the scope of their respective professional license.

 

R414-11-[5]4. Limitations.

[ (1) Service limitations that apply to physicians also apply to podiatrists.

(2) Treatment of a fungal (mycotic) infection of the toenail is limited to recipients with documented clinical evidence of mycosis that shows inflammation, infection, erythema, or marked limitation of ambulation.

(3) Podiatry services in long-term care facilities are covered with the following limitations:

(a) podiatry visits are limited to once every 60 days;

(b) debridement of mycotic toenails is limited to once every 60 days;

(c) trimming corns, warts, callouses, or nails is limited to once every 60 days;

(d) podiatry visits that include only evaluation and management are not covered;

(4) Medicaid does not cover the administration of general anesthesia and foot amputations by podiatrists.

(5) The removal of corns, warts, or callouses is limited to patients endangered by diabetes, arteriosclerosis or Buerger's disease.

]Podiatric service limitations are described in the Podiatric Services Utah Medicaid Provider Manual.

 

R414-11-[6]5. Non-Covered Services.

[ (1) The following preventive or routine foot care services are not covered:

(a) the trimming, cutting, clipping, or debridement of nails outside of long-term care facilities;

(b) hygienic and preventive maintenance care, such as cleaning and soaking of the feet, the use of massage or skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness or injury;

(c) any application of topical medication;

(2) Supportive devices that include arch supports, foot pads, foot supports, orthotic devices, or metatarsal head appliances are not covered.

(3) The following subluxation services are not covered:

(a) surgical correction of a subluxated foot structure, or surgical procedures performed to improve foot function and alleviate symptomatic conditions;

(b) treatment that includes evaluations and prescriptions of supporting devices, and the local condition of flattened arches regardless of the underlying pathology.

(4) Internal modification of a shoe is not covered.

(5) Shoes or other supportive devices for the feet that are not an integral part of a leg brace or prosthesis are not covered.

(6) Special shoes are not covered. These include:

(a) mismatched shoes (unless attached to a brace);

(b) shoes to support an overweight individual;

(c) "orthopedic" or "corrective" trade name or brand name shoes; and

(d) "athletic" or "walking" shoes.

(7) Personal comfort items such as "cookies" or other comfort accessories are not covered.

]Non-covered services are described in the Podiatric Services Utah Medicaid Provider Manual.

 

R414-11-[ 7 ] 6 . Reimbursement for Podiatr[y]ic Services.

(1) Reimbursement for services is limited to one podiatr[y]ic office visit per day.

(2) A podiatrist may bill for laboratory procedures necessary for diagnosis and treatment of the patient if equipment necessary for the laboratory procedure is available in the podiatrist's office. Laboratory services requested by a podiatrist but provided by an independent laboratory or hospital outpatient laboratory must be billed directly by the laboratory.

(3) Palliative care is included in the specific service and must be billed by that service only, not through the use of an office call procedure code.

(4) Payments are based on the established fee schedule unless a lower amount is billed. The amount billed cannot exceed usual and customary charges to private pay patients.[ Fees are established by discounting historical charges, and by professional judgment to encourage efficient, effective and economical services.]

 

R414-11-[8]7. Copayment Policy.

Each Medicaid client is responsible to pay a copayment amount that complies with the requirements of the [Utah ]Medicaid State Plan and Rule R414-1.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [May 1, 2010]2013

Notice of Continuation: October 21, 2009

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3