N.Y. Comp. Codes R. & Regs. tit. 18 § 505.12

Current through Register Vol. 46, No. 45, November 2, 2024

Section 505.12 - Podiatry services

(a) Qualified podiatrist.

(1) A podiatrist providing services under the medical assistance program shall be licensed by and currently registered to practice podiatry in New York State with the State Education Department.

(2) Podiatry services provided to eligible medical assistance patients while temporarily out-of-state shall be provided by podiatrists qualified to practice podiatry by the appropriate licensing agency of the state in which podiatry services are provided.

(b) Podiatry services coverage.

(1) Effective July 1, 1992, podiatry care, services and supplies can only be made available as medically needed and as an integral part of comprehensive medical care to:

(i) a child under the age of 21 eligible to receive services through the program of early and periodic screening and diagnosis. Such podiatry care and services may only be provided upon written referral by a physician, physician's assistant, nurse practitioner or nurse midwife. A referral is valid for a period of six months from the date written; and

(ii) a person eligible for benefits under title XVIII of the Federal Social Security Act as a qualified Medicare beneficiary. Podiatrists may identify such person through the department's Electronic Medicaid Eligibility Verification System (EMEVS) or through written documentation by a fiscal intermediary for title XVIII.

(2) Necessary podiatry care, services and supplies means those services provided by qualified podiatrists.

(3) Podiatry care, services and supplies shall also include the provision of, or ordering of, clinical laboratory tests that are related to the scope of podiatric practice permitted under provisions of the State Education Law and rules and regulations of the State Education Department.

(4) Clinical laboratory tests provided or ordered by qualified podiatrists shall be limited to those tests necessary for the diagnosis or treatment of conditions of the foot. Such tests, when performed in the office of the podiatrist in the course of treatment of his own patients, shall be limited to:

(i) complete blood count or any of the separate components of such analysis, including red cell count, white cell count, or hemoglobin;

(ii) hematocrit;

(iii) sedimentation rate;

(iv) urine analysis, routine chemical; and

(v) urine analysis, routine microscopic.

(5) All other necessary clinical laboratory tests shall be performed, in accordance with the provisions of the New York State Public Health Law, by a clinical laboratory holding a valid clinical laboratory permit, in the categories for which payment is requested. A podiatrist who performs for recipients laboratory procedures other than those listed in paragraph (4) of this subdivision shall possess a laboratory permit issued in accordance with the New York State Public Health Law.

(6) All necessary radiologic procedures shall be made available as a covered benefit. Radiologic procedures mean X-rays used to establish a podiatric diagnosis for a foot-related medical problem, and may be used in conjunction with necessary treatment of foot conditions.

(c) Podiatry service limitations.

(1) The medical assistance program for podiatry care, services and supplies shall not include:

(i) routine hygienic care of the feet in the absence of pathology;

(ii) clinical laboratory tests, except those permitted in paragraphs (b)(4) and (5) of this section;

(iii) radiologic procedures outside the scope of podiatric practice as per paragraph (b)(6) of this section;

(iv) amputations and bunion operations, unless such procedures are provided in a hospital; or

(v) all podiatric prostheses in excess of $100, unless prior approval of the local professional director and prior authorization of the local social services commissioner is given.

(d) State reimbursement shall not exceed fees developed by the New York State Department of Health and approved by the New York State Director of the Budget. Care and services or supplies of podiatrists provided on dates between July 1, 1977 and October 8, 1979 are nonreimbursable under the medical assistance program, except that a local social services official (or the MMIS project director, if a county was listed in section 540.6 of this Chapter at the time service was rendered) may determine to reimburse services rendered after October 1, 1979, in accordance with this Part, if written approval is obtained from the State Commissioner.

(e) Payments under the medical assistance program to podiatrists shall not exceed fees established by the Office of Health Systems Management and promulgated by the Director of the Budget.

(f) Utilization threshold.

(1) This section describes the utilization threshold that the department has established for podiatry services and supplies. Part 503 of this Title authorizes the department to establish a utilization threshold for specific provider types, including podiatry services and supplies. Part 503 also describes the application of utilization thresholds, services and procedures excluded from the utilization threshold for all provider service types subject to a threshold, the method for obtaining an exemption from or increase in the utilization threshold, notices, and the right to a fair hearing in certain situations.

(2) General rule. The department will pay for five podiatry service encounters in a benefit year. For purposes of this section, each discrete visit to a podiatrist or to a podiatry clinic is one encounter, provided that the number of services furnished and procedures performed during the visit does not exceed three.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.12