Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 7346 (November 25, 2023).

55 Pa. Code § 1143.58. Noncompensable services and items.

§ 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).



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