This manual is designed to be used in conjunction with other sections of the Utah Medicaid Provider Manual, such as Section I: General Information of the Utah Medicaid Provider Manual (Section I: General Information) and the Physician Services Utah Medicaid Provider Manual.
The information in this manual represents available services when medically necessary. Services may be more limited or may be expanded if the proposed services are medically appropriate and are more cost effective than alternative services.
Practice of Podiatry
The "practice of podiatry" means the examination, diagnosis, or treatment medically, mechanically, or surgically of the ailments of the human foot. In accordance with Utah Code Annotated 58-5a--5-102, the practice of podiatry is limited to the human foot and ankle with some restrictions.
Podiatric services are optional services. However, podiatric services are mandatory for individuals eligible for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) also known in Utah as Child Health Evaluation and Care (CHEC).
The purpose of the podiatry program is to increase the functioning ability of the Medicaid recipient. Podiatric services include the examination, diagnosis and treatment of the human foot through medical, mechanical, or surgical means. Services may be performed by a physician, osteopath, or podiatrist as specified by the respective professional license. Podiatric service may be provided to a Medicaid recipient who has a foot problem that causes:
This manual provides information regarding Medicaid policy and procedures for fee-for-service Medicaid members. A Medicaid member enrolled in an MCP (health, behavioral health, or dental plan) must receive services through that plan with some exceptions called “carve-out services,” which may be billed directly to Medicaid. Medicaid members enrolled in MCPs are entitled to the same Medicaid benefits as fee-for-service members. However, plans may offer more benefits than the Medicaid scope of benefits explained in this section of the provider manual. Contact the Medicaid Member Services hotline at (844) 238-3091 for further information.
Refer to the provider manual, Section I: General Information, for information regarding MCPs.
Medicaid does not process prior authorization requests for services to be provided to a Medicaid member enrolled in an MCP when the services are the responsibility of the plan. Providers requesting prior authorization for services for a member enrolled in an MCP will be referred to that plan.
Medicaid makes every effort to provide complete and accurate information regarding a member’s enrollment in a managed care plan. However, it is the provider’s responsibility to verify eligibility and plan enrollment for a member before providing services. Therefore, if a Medicaid member is enrolled in an MCP, a fee-for-service claim will not be paid unless the claim is for a “carve-out service.”
Eligibility and plan enrollment information for each member is available to providers from these sources:
Definitions of terms used in Medicaid programs are available in Section I: General Information of the Utah Medicaid Provider Manual (Section I: General Information).
Refer to provider manual, Section I: General Information for provider enrollment information.
Confirmation of member eligibility is required prior to each service or at least once per month. The member must present their Medicaid Member Card, and the provider must verify the member’s eligibility before services are rendered. To verify eligibility, contact AccessNow at (800) 662-9651 or on-line at the Medicaid web site Eligibility Lookup Tool: https://medicaid.utah.gov/eligibility. For more information regarding verifying eligibility, refer to provider manual, Section I: General Information, Verifying Medicaid Eligibility.
Procedure Codes
With some exceptions, procedure codes with accompanying criteria and limitations were removed from the manual and are now found on the Medicaid website Coverage and Reimbursement Lookup Tool at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php
Covered podiatric services are limited to examination, diagnosis, and treatment described in this chapter.
Podiatric services include the following:
Shoes and Shoe Repair
For additional non-covered services or limitations, refer to the Coverage and Reimbursement Lookup Tool at the Medicaid website at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
The following services are not covered:
For detailed billing instructions and general information about the co-payment requirement, members required to make a co-pay, exempt members, refer to Section I: General Information, Medicaid Co-payments.
Co-payment
With some exceptions, Medicaid members are required to make a $3.00 co-payment for office visits performed by a podiatrist. The co- payment may be required for MCP and fee-for-service members as well as for services performed in a Federally Qualified Health Center (FQHC). The provider is responsible for determining which members are responsible for a co- payment and to collect the co-payment at the time of service or bill the member. Medicaid automatically deducts the amount of the co-payment from the claim reimbursement.
Pregnant women are exempt from the co- payment requirement. If the system does not indicate the patient is pregnant, add pregnancy diagnosis V22.2 to the claim.
To determine if a co-pay is required, contact AccessNow at (800) 662-9651.
Palliative care coding
Bill palliative care for the specific service code and not by an office call or E&M code.
Some services, particularly surgical services, require the podiatrist to obtain prior authorization (PA) from Medicaid before service. Failure to obtain prior authorization can result in payment denial by Medicaid. Providers must determine if prior authorization is necessary and obtain authorization before providing services. Exceptions may be made, with appropriate documentation, if the service provided is emergent or the member is retroactively eligible for the dates of service requested.
Additional prior authorization information is in the provider manual, Section I: General Information. Code specific coverage and prior authorization requirements are on the Medicaid website, Coverage and Reimbursement Lookup Tool at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
State Plan Amendment, Attachment 3.1-A, Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy
Code of Federal Regulations, Medical or other remedial care provided by licensed practitioners, title 42, sec. 440.60
Updated January 2018