May 13, 2024

On May 6, APMA and Contractor Advisory Committee (CAC) representatives from Palmetto Jurisdiction states met with Palmetto GBA to discuss recent changes to their Local Coverage Article (LCA) related to at-risk foot care. 

In March, Palmetto removed “NPP” from the list of providers who can serve as the active provider of a qualifying condition, which is designated with an asterisk in their LCA. Previously, the LCA stated, “When the patient’s condition is 1 of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy or NPP who documents the condition.” That sentence has been changed to remove “or NPP.”

Palmetto is the Medicare Part B Contractor with jurisdiction over WV, VA, NC, SC, TN, AL, and GA. Palmetto has claimed that these changes were made at the behest of CMS to align the LCA more closely with Sect 290 of the Medicare Benefit Policy Manual. 

APMA and Palmetto CAC representatives indicated how practice patterns have changed and how beneficiaries in rural areas would be impacted by these changes. APMA and the CAC representatives also had several questions as to how the program would be administered, including:

• What developments led Palmetto to require the need to change the LCA?
• Is it appropriate for physicians providing at-risk foot care to code and submit for care that is provided when NPPs (NPs and PAs) are providing the underlying care incident to supervision by an MD/DO?
• How should physicians providing the at-risk foot care identify the physician in box 17 of the CMS claim form where the NPP may be providing care of the asterisked condition incident to supervision by an MD/DO; e.g., should they provide the name and NPI of the NPP (NP or PA) or the name and NPI of the supervising MD/DO?

Palmetto indicated that APMA and the CAC representatives should seek further clarification from CMS on the proper procedures in states where nurse practitioners can practice independently. Palmetto will be providing additional details on the “incident-to” questions.

APMA will provide additional details as we get more information.

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