CHAPTER 1143. PODIATRISTS’ SERVICES
GENERAL PROVISIONS Sec.
1143.1. Policy.
1143.2. Definitions.
SCOPE OF BENEFITS
1143.21. Scope of benefits for the categorically needy.
1143.22. Scope of benefits for the medically needy.
1143.23. Scope of benefits for State Blind Pension recipients.
1143.24. Scope of benefits for General Assistance recipients.
PROVIDER PARTICIPATION
1143.41. Participation requirements.
1143.42. Ongoing responsibilities of providers.
PAYMENT FOR PODIATRISTS’ SERVICES
1143.51. General payment policy.
1143.52. Payment conditions for various services.
1143.53. Payment conditions for outpatient services.
1143.54. Payment conditions for inpatient hospital services.
1143.55. Payment conditions for diagnostic services.
1143.56. Payment conditions for orthopedic shoes, molded shoes and shoe inserts.
1143.57. Limitations on payment.
1143.58. Noncompensable services and items.
UTILIZATION CONTROL
1143.71. Scope of claims review procedures.
ADMINISTRATIVE SANCTIONS
1143.81. Provider misutilization.Authority The provisions of this Chapter 1143 issued under sections 403(a) and (b) and 443.3(2)(ii) of the Public Welfare Code (62 P.S. § § 403(a) and (b) and 443.3(2)(ii)), unless otherwise noted.
Source The provisions of this Chapter 1143 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855, unless otherwise noted.
Cross References This chapter cited in 55 Pa. Code § 1101.31 (relating to scope); 55 Pa. Code § 1101.95 (relating to conflicts between general and specific provisions); 55 Pa. Code § 1150.56b (relating to payment policy for observation services—statement of policy); and 55 Pa. Code § 1163.51 (relating to general payment policy).
GENERAL PROVISIONS
§ 1143.1. Policy.
The MA Program provides payment for specific medically necessary podiatrists’ services rendered to eligible recipients by podiatrists enrolled as providers under the program. Payment for podiatrists’ services is subject to this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule.
Source The provisions of this § 1143.1 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117374).
§ 1143.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Chronic condition—An illness which frequently recurs or persists for a period in excess of 3 months.
Compensable service—A benefit to which a MA recipient is entitled under the MA Program.
Consultation—A medical evaluation conducted by a specialist at the request of the attending practitioner. For the purposes of the MA Program, a consultation includes taking a medical history, examining the patient, and preparing a written report that is incorporated into the patient’s record.
Experimental procedure—A procedure that deviates from customary standards of medical practice, is not routinely used in the medical or surgical treatment of a specific illness or condition, or is not of proven medical value.
Medical justification—Written documentation in the patient’s medical record indicating the specific health condition or risk that makes the particular service the podiatrist renders, orders or prescribes medically necessary.
Medically necessary—A term used to describe those medical conditions for which treatment is necessary, as determined by the Department, and which are compensable under the MA Program.
Molded shoes—Shoes that are constructed from a special last conforming to a specific individual’s feet. Molded shoes are constructed from leather or other durable material.
Noncompensable service—A service a provider furnishes for which there is no provision for payment under this chapter.
Nonemergency medical services—A compensable podiatrists’ service provided for conditions not requiring immediate medical intervention in order to sustain the life of the person or to prevent damage to health.
Orthopedic shoes—Shoes that have a Goodyear welt, steel shank and elongated medial counter which are modified to compensate for an abnormality of the feet.
Shoe insert—A device that is constructed of plexiglass, hard plastic or other rigid material fashioned for the individual feet by a laboratory approved to participate in the MA Program, and is fabricated according to a podiatrist’s prescription.
Source The provisions of this § 1143.2 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (75087) to (75088).
Cross References This section cited in 55 Pa. Code § 1143.58 (relating to noncompensable services and items).
SCOPE OF BENEFITS
§ 1143.21. Scope of benefits for the categorically needy.
Categorically needy recipients are eligible for medically necessary podiatrists’ services compensable under the MA Program, subject to the conditions and limitations established in this chapter and Chapter 1101 (relating to general provisions).
Source The provisions of this § 1143.21 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
§ 1143.22. Scope of benefits for the medically needy.
Medically needy recipients are eligible for podiatrists’ services compensable under the MA Program, subject to the conditions and limitations established in this chapter and Chapter 1101 (relating to general provisions).
Source The provisions of this § 1143.22 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
§ 1143.23. Scope of benefits for State Blind Pension recipients.
Individuals who receive a State Blind Pension are not eligible for podiatrists’ services under the MA Program, unless the individuals are determined to be either categorically or medically needy, in which case they are eligible for podiatrists’ services compensable under the MA Program.
Source The provisions of this § 1143.23 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
§ 1143.24. Scope of benefits for General Assistance recipients.
General Assistance recipients, age 21 to 65, whose MA benefits are funded solely by State funds, are eligible for medically necessary basic health care benefits as defined in Chapter 1101 (relating to general provisions). See § 1101.31(e) (relating to scope).
Source The provisions of this § 1143.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.
PROVIDER PARTICIPATION
§ 1143.41. Participation requirements.
Participation requirements are established in § § 1101.41—1101.43 (relating to participation).
Source The provisions of this § 1143.41 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
§ 1143.42. Ongoing responsibilities of providers.
Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions).
Source The provisions of this § 1143.42 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
PAYMENT FOR PODIATRISTS’ SERVICES
§ 1143.51. General payment policy.
Payment is made for compensable services provided by participating podiatrists subject to the conditions and limitations established in § § 1143.52—1143.58 and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. Payment will not be made for a compensable podiatrist’s service if full payment as specified in § 1101.62 (relating to maximum fees) is available from another public agency or another insurance or health program.
Source The provisions of this § 1143.51 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (117376) to (117377).
Cross References This section cited in 55 Pa. Code § 1143.52 (relating to payment conditions for various services).
§ 1143.52. Payment conditions for various services.
In order for payment to be made to a podiatrist for compensable services, the services shall meet the applicable conditions of § § 1143.51—1143.57.
Source The provisions of this § 1143.52 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy).
§ 1143.53. Payment conditions for outpatient services.
(a) Services a podiatrist provides in a Short Procedure Unit (SPU) are compensable to the podiatrist only if the SPU is approved by the Department, the podiatrist is not employed by the hospital for inpatient services, and the service cannot be performed in the podiatrist’s office or the emergency room of a hospital without endangering the life or health of the patient.
(b) Specialists’ examinations and consultations require prior authorization from the County Assistance Office as described in § 1101.67 (relating to prior authorization).
Source The provisions of this § 1143.53 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy); and 55 Pa. Code § 1143.52 (relating to payment conditions for various services).
§ 1143.54. Payment conditions for inpatient hospital services.
(a) Payment is made for inpatient medical services if the condition of the patient requires hospitalization, the patient requires medical management by the podiatrist and surgery is not performed.
(b) An inpatient consultation by a second practitioner is compensable if the condition of the patient requires the service and if the consultation is requested by the podiatrist or physician in charge of the case.
Source The provisions of this § 1143.54 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy); and 55 Pa. Code § 1143.52 (relating to payment conditions for various services).
§ 1143.55. Payment conditions for diagnostic services.
Payment is made for diagnostic X-ray services performed in the podiatrist’s office if the following requirements are met:
(1) The podiatrist examines the patient prior to taking or ordering the X-ray.
(2) Initial and follow-up X-rays are taken on the basis of medical justification which is documented in the medical record.
(3) The X-rays are of diagnostic quality and each film photographically records:
(i) The name of the patient.
(ii) The date of the X-ray.
(iii) A designation of right and left.
(4) If an invoice for bilateral X-rays is submitted, the podiatrist includes on the invoice written justification for X-rays of both feet or both ankles, or both feet and ankles.
Source The provisions in this § 1143.55 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy); and 55 Pa. Code § 1143.52 (relating to payment conditions for various services).
§ 1143.56. Payment conditions for orthopedic shoes, molded shoes and shoe inserts.
Payment is made to enrolled medical suppliers in accordance with the conditions and limitations specified in Chapter 1123 (relating to medical supplies), for molded shoes, shoe inserts and, only if the recipient is eligible and 20 years of age or younger, for orthopedic shoes.
Source The provisions in this § 1143.56 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy); and 55 Pa. Code § 1143.52 (relating to payment conditions for various services).
§ 1143.57. Limitations on payment.
The following limits apply to payment for compensable services:
(1) Payment for office visit for podiatric services is limited to the podiatrist’s usual charge to the general public, not to exceed the maximum allowable payment established in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule.
(2) Payment is made to only one podiatrist for a particular service or procedure and services shall be billed in the name of the podiatrist providing the service.
(3) Payment for X-rays taken in the podiatrist’s office during the course of a treatment is limited to the maximum fee per limb specified in the MA Program fee schedule, in addition to the visit fee.
Source The provisions of this § 1143.57 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117379).
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy); and 55 Pa. Code § 1143.52 (relating to payment conditions for various services).
§ 1143.58. Noncompensable services and items.
(a) Payment is not made to a podiatrist for:
(1) Services and items not listed in the MA Program fee schedule.
(2) Fabricating or dispensing orthopedic shoes, shoe inserts and other supportive devices for the feet.
(3) Casting for shoe inserts.
(4) Medical services or surgical procedures performed on an inpatient basis that could have been performed in the podiatrist’s office, the emergency room, or a short procedure unit without endangering the life or health of the patient.
(5) Medical or surgical procedures designated in the fee schedule in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule as outpatient procedures, signified by the letters OP, which are performed on an inpatient basis unless the requirements specified in Chapter 1150 are met.
(6) Medical services or surgical procedures performed on an inpatient basis if the Department denies payment to the hospital for the days during which the podiatrist’s care is rendered. The podiatrist may not bill the recipient for the disallowed services.
(7) Services rendered in the emergency room of a hospital if the recipient is admitted to the hospital as an inpatient on the same day or the service is a nonemergency medical service.
(8) Treatment of flat foot.
(9) Treatment of subluxations of the foot.
(10) Routine foot care, including the cutting or removal of corns, callouses, the trimming of nails and other routine hygienic care.
(11) Physical therapy.
(12) Diagnostic or therapeutic procedures for experimental, research or educational purposes.
(13) Compensable podiatrist’s services if full payment as specified in § 1101.62 (relating to maximum fees) is available from another public agency or another insurance or health program.
(b) Payment is not made for the following items, even if they are prescribed by a podiatrist:
(1) Tennis shoes, sneakers, slippers, sandals or another type of footwear that does not fit the description of the orthopedic or molded shoe established in § 1143.2 (relating to definitions).
(2) Shoe inserts for orthopedic or molded shoes.
(3) Modifications to orthopedic or molded shoes, except those modifications necessary for the application of a brace or splint.
(4) Modification to or repair of nonorthopedic shoes other than for insertion of shoe inserts.
(5) Orthopedic shoes recipients 21 years of age or older.
Source The provisions of this § 1143.58 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (117379) to (117380).
Cross References This section cited in 55 Pa. Code § 1143.51 (relating to general payment policy).
UTILIZATION CONTROL
§ 1143.71. Scope of claims review procedures.
Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).
Source The provisions in this § 1143.71 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
ADMINISTRATIVE SANCTIONS
§ 1143.81. Provider misutilization.
Providers determined to have billed for services inconsistent with this part, to have provided services outside the scope of customary standards of medical practice or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).
Source The provisions in this § 1143.81 adopted August 27, 1982, effective August 28, 1982, 12 Pa.B. 2855.
APPENDIX A. [Reserved]
Source The provisions of this Appendix A reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (75095) to (75101).
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