Nurse Practitioners and Physician Assistants as Certifying Physicians for Therapeutic Shoes and Inserts

Joint DME MAC Article
Posted on November 5, 2020

The Centers for Medicare & Medicaid Services (CMS) has recently provided guidance to the DME MACs about the delegation of certifying physician (MD or DO) comprehensive management of diabetes responsibilities to nurse practitioners (NP) and physician assistants (PA) prescribing therapeutic shoes and inserts for persons with diabetes. This clarification is specific to NPs and PAs who are practicing under the supervision of an MD or DO (i.e., "incident to") and does not extend to NPs who practice independently (i.e., bill under their own NPI).

NPs or PAs providing ancillary services as auxiliary personnel could meet the "incident to" requirements in their provision of therapeutic shoes to beneficiaries with diabetes if all of the following criteria are met:

  1. The supervising physician has documented in the medical record that the patient is diabetic and has been, and continues to provide, the patient follow-up under a comprehensive management program of that condition; and,
  2. The NP or PA certifies that the provision of the therapeutic shoes is part of the comprehensive treatment plan being provided to the patient; and,
  3. The supervising physician must review and verify (sign and date) all of the NP or PA notes in the medical record pertaining to the provision of the therapeutic shoes and inserts, acknowledging their agreement with the actions of the NP or PA.

Social Security Act §1861(s)(12) requires that a MD or DO certify that the beneficiary receiving therapeutic shoes and inserts is under a comprehensive plan of care for their diabetes. As a result of the MD or DO restriction, NPs and PAs may not serve in the role of the certifying physician unless practicing "incident to" the supervising physician’s authority, as described above. This updated CMS guidance does not change the situation in those states that allow NPs to practice independently (i.e., without MD or DO supervision). In states where the NP may practice independently, the NP’s employment situation would require compliance with Medicare "incident to" rules in order to serve as the certifying physician. Please refer to your A/B MAC for further information.

This guidance from CMS addresses the situation where the NP or PA is performing the role of the certifying physician but the supervising MD or DO is billing for the service under the MD or DO NPI.

This information will be included in an upcoming revision of the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD)-related Policy Article.

Publication History

Date of Change Description
11/05/20 Originally Published


Last Updated Dec 09 , 2023