Podiatry Coverage Policy
Provider Participation Guidelines
To participate in the Medical Assistance Program, providers must be located and performing services in Rhode Island or in a border community. Consideration will be given to out-of-state providers if the covered service is not available in Rhode Island, the recipient is currently residing in another state or if the covered service was performed as an emergency service while the recipient was traveling through another state.
Providers must be licensed by the State of Rhode Island, or the state in which they practice, to perform podiatry services and must also be an enrolled Medicare provider and have a UPIN number.
Podiatrists are annually recertified by the Department of Health (DOH). The license expiration date for Podiatrists is September 30. Providers obtain license renewal through DOH and then forward a copy of the renewal documentation to HP Enterprise Services. HP Enterprise Services should receive this information as soon as possible to prevent suspension from the program.
A provider may appeal to the DOH if the they do not meet the recertification criteria. If the appeal to DOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS).
The reimbursement rates for Podiatrists are listed in the Fee Schedule. Providers must bill the Medical Assistance Program at the same usual and customary rate as charged to the general public and not at the published fee schedule rate. Payments to providers will not exceed the maximum reimbursement rate of the Medical Assistance Program. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to the Medical Assistance Program.
Claims Billing Guidelines
Instructions for completing the CMS 1500 claim form are located on the Claims Processing page.
Covered/Non Covered Services
Only Categorically Needy (CN) and EPSDT program recipients are eligible for podiatry services. These recipients can be identified through the Interactive Web Services. The Medical Assistance Program covers routine foot care, such as debridement of nails and treatment for ingrown toenails. All covered procedure codes for podiatry services are listed in the fee schedule.
The Medical Assistance Program does not reimburse providers for canceled office visits or appointments not kept by the recipient.
Procedures that normally require prior authorization, but were performed on an emergency basis, may receive retroactive authorization if the procedure was medically necessary and meets all other requirements that would have been required for normal authorization .
Any service classified as an emergency must be justified by a physician or podiatrist’s statement. This comprehensive statement must describe the emergency, the patient’s condition and verify that the emergency services were immediately necessary.
Services performed by a podiatrist assisting in a physician performed surgery are not reimbursable by the Medical Assistance Program.
Follow up services
All follow-up services to a surgical procedure, if the follow-up is performed within 30 days of the surgery, are included in the basic reimbursement. Additional services performed more than 30 days after surgery must be billed separately.
Podiatrists performing multiple services in a Nursing Home in a single day will be paid at the full rate for the first patient and a reduced rate for the additional patients.
Multiple surgical procedures are covered by the Medical Assistance Program. Both feet are covered at the same rate when modifier LT or RT (left or right) is used indicating that the procedure was performed on both feet. Modifier 51 is used to indicate multiple surgeries performed on the same foot. Subsequent surgeries will be reimbursed at a lower rate when billed with modifier 51. Medically necessary procedures on each foot are reimbursed as follows: 100% for the first procedure, 50% for the second, 25% for the third, and no reimbursement will be made for the fourth or subsequent procedures. If billing for multiple procedures, providers must clearly indicate the primary procedure first and any other procedures as secondary or subsequent.
Surgical procedures with a cosmetic purpose are only allowed when medically necessary and if the procedure is performed to improve function. If the procedure does not alleviate pain or improve difficulty in ambulation then it is not covered. The surgery must be referred by a specialist, such as an orthopedist. Providers billing for cosmetic surgery must indicate the referring physician’s name and number by completing fields 17 and 17a of the HCFA 1500 claim form.
Flat Feet/High Arches
Only recipients under the age of 21 covered by the EPSDT program are eligible for treatment of flat feet or high arches. This would include reimbursement for related orthotics, such as arch supports.
Injections and Drugs
Podiatrists may bill for injections if the injection is performed in conjunction with a procedure, such as anesthesia for a surgery. They may also prescribe medications if required for treatment of diseases of the feet.
Laboratory and Radiology Services
Podiatrists may perform and bill for a radiology procedure (x-ray) of the foot. Certain laboratory procedures are reimbursable for podiatrists and are listed in the fee schedule.
Local or topical anesthesia is a covered service only when performed at the time that a surgical procedure is performed.
The Medical Assistance Program reimbursement for crossover claims is always capped by the established Medical Assistance Program allowed amount, regardless of coinsurance or deductible amounts. The standard calculation for crossover payments is as follows:
The Medical Assistance Program will pay the lessor of:
- The difference between the Medical Assistance Program allowed amount and the Medicare Payment (Medical Assistance Program allowed minus Medicare paid); or
- The Medicare coinsurance and deductible up to the Medical Assistance Program allowed amount, calculated as follows: (Medicare coinsurance/deductible plus Medicare paid) – (Medical Assistance Program allowed).
The Medical Assistance Program reimbursement is considered payment in full. The provider is not permitted to seek further payment from the recipient in excess of the Medical Assistance Program rate.
Physical therapy treatments, such as foot massage, are not a covered service whether performed by the podiatrist or referred to a Physical Therapist. This service is only covered if performed under a Visiting Nurse Association procedure code or through an outpatient facility.
Orthopedic shoes are a covered if attached to a brace. Molded shoes are a covered benefit for Categorically Needy recipients and EPSDT recipients under the age of 21.
Surgery Coverage: Casts, Strapping Splints and Trays
All medically necessary services and supplies associated with a surgical procedure are considered inclusive in the surgical reimbursement rate. Otherwise, non-surgical items such as crutches and splints are considered Durable Medical Equipment (DME) and will only be paid to DME providers. Other supplies, such as surgical trays, are considered part of a procedure and are not separately reimbursable.
Providers who perform an unlisted procedure code must obtain prior authorization for the service before submitting the claim for payment. Medical justification for the procedure must be included with the request for authorization. Prior Authorization guidelines are defined in Section 200-30 of the Provider Reference Manual.