Rule Change Provides More Flexibility to PAs Ordering Diabetic Shoes

New Method is More Permissive, but Process Remains Cumbersome

May 21, 2021

By Trevor Simon, MPP

Numerous policy changes occurred in 2020 that benefited the PA profession. While significant attention has been given to the more prominent PA-positive changes of consequence, such as home health, direct payment, and diagnostic tests, there have also been some positive changes that have not been discussed as frequently. One of these less-covered changes allows PAs and APRNs, in certain circumstances, to order therapeutic shoes when previously they were prohibited entirely from doing so. However, while the ability to order diabetic shoes is now somewhat more permissive, the practice is still cumbersome and continues to contain unnecessary restrictions on PAs and APRNs who perform the service, steeped only in outdated legislative language.

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New policy
While it is understandable to think of therapeutic shoes as a type of durable medical equipment, they are in fact covered under a separate section of the Social Security Act. Social Security Act §1861(s)(12) provides coverage for therapeutic shoes and inserts for persons with diabetes only if 1) they are certified to be medically necessary by a physician, and 2) the patient’s diabetes is being managed by a physician. AAPA has been working to initiate a legislative change that would permit patients being treated by PAs to receive diabetic shoes without having to transfer their diabetic care to a physician. While AAPA continues to advocate for this legislative modification, a new policy was recently created as a regulatory work-around to allow PAs to order diabetic shoes under limited conditions. This change was laid out in a new Coverage Determination with an effective date of November 2020.

[Learn About Significant Policy Changes in 2021 Essential Guide to PA Reimbursement]

Burdensome requirements for PAs and physicians
Medicare policy now allows PAs to be delegated the ability to certify therapeutic shoes, if, and only if, a PA is working under the direct supervision of a physician, meets all “incident to” requirements, and bills subsequent encounters for diabetic management under the physician. To do this, a PA must certify and document that the therapeutic shoes are being ordered as part of the physician’s comprehensive treatment plan for diabetes.

A physician in the practice must treat the patient and establish the diabetes diagnosis and plan of care, provide ongoing care and see the patient on a periodic basis under a “comprehensive management program,” be physically present in the office when the PA is providing subsequent diabetic care, and sign, date, and acknowledge agreement with all actions and medical record documentation related to the diabetic management.

Time will tell if this regulatory flexibility pertaining to the ordering of diabetic shoes is a feasible work-around, but it’s likely the best CMS can do without a legislative change. Meanwhile, AAPA continues to advocate for legislation necessary to authorize PAs to order diabetic shoes without unnecessary restrictions.

Trevor Simon, MPP, is director of regulatory policy at AAPA. For more information or questions, contact AAPA’s reimbursement team at [email protected]. 

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