Therapeutic Shoe Update:

Both Nurse Practitioners and Physicians Assistants will now under certain limitations, be allowed to certify the patient as diabetic, just as an MD DO. There are two pathways both with significant restrictions on how this can be accomplished. One is effective immediately; the latter will be effective January 1, 2021.

Effective Immediately:

If an NP or PA is working under the “incident to” rules, that is the NP/PA is working under the direct supervision of an MD/DO, then the NP can sign the certification form and sign the progress note that the patient requires therapeutic shoes. The medical record however, must be agreed to, or attested to by the MD/DO by them co-signing the NP or PA note contemporaneous to the date of the exam signed by the NP or PA.

The NP or PA must be billing under the NPI of the MD/DO or their medical group as this does not apply to NP who can practice independent of an MD or DO (see below).

Effective January 1 2021

NP who bill under their own NPI can act as the certifying physician under some very limited circumstances.

NP can sign up for a Primary Care demonstration project in certain states. Only NP enrolled in this demonstration project may certify the patient as diabetic and document in their charts that the patient requires therapeutic shoes. Note that this will not apply to PA because they cannot practice independent of an MD/DO.

There are many questions regarding both of these programs such as:

1. Can the NP or PA sign off on the notes of another eligible prescriber (MD, DO, DPM, PA, NP) in another practice?
2. If the MD/DO signs off on the NP PA notes a week later is that when the 90 day or 6 month count down starts for the timeline of the Certification Statement or Medical records?
3. How will you know if the NP is enrolled in the Primary Care First Demonstration Project?
4. What constitutes proof of the NP PA working incident to? Is the MD/DO simply signing off on the NP/PA notes sufficient?

These and more questions have been submitted to the DME MAC, PDAC medical directors, who have forwarded them to CMS for clarification. There are many rumors that you may hear from your colleagues and even your shoe vendors. Suffice it is to say that there is no clear answer to the above (and other) questions. Hopefully many of the answers to those questions will come soon.