Section 17b-262-628 - Payment(a) The commissioner shall establish, and may periodically update, the fees for covered services in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.(b) Fees shall be the same for in-state, border and out-of-state podiatrists.(c) Payment shall be made at the lowest of: (1) the podiatrist's usual and customary charge;(2) the lowest Medicare rate;(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or(4) the amount billed by the podiatrist.(d) Notwithstanding the provisions of the regulations of connecticut state agencies or any of the Medical Services Policies to the contrary, the department shall not pay any podiatrist under sections 17b-262-619 through 17b-262-629, inclusive, of the regulations of connecticut state agencies for a client seen at a freestanding clinic enrolled in Medicaid. Only the clinic may bill for such services. As an exception to the foregoing, a podiatrist may bill for covered services for a client seen at an outpatient surgical facility. a podiatrist who is enrolled with medicaid at a location separate from the clinic may bill the department for clients seen at the separate practice location.(e) The department shall not pay interns or residents for their services nor shall the department pay for assistant surgeons in general or chronic disease hospitals staffed by interns and residents, unless the procedure is significantly complicated to justify a full surgeon acting as an assistant. If the surgery is performed by a resident or intern and the supervising surgeon assists, only the assistant's fee shall be paid to the surgeon. The regular surgical fee shall not be paid.(f) If a resident or intern performs the surgery and the supervising surgeon is not present while the procedure is performed, no fee shall be paid to the surgeon even when the surgeon is on call.(g)Payment limitations(1) Fees for initial fittings and adjustments shall be included in the cost of the item or device.(2) The department shall pay a podiatrist for physical therapy only if the podiatrist personally provides the physical therapy.(3) Payment shall be made for a customized item for a client who dies, or is not otherwise eligible on the date of delivery, provided the client was eligible: (A) on the date prior authorization was given by the department; or(B) on the date the client ordered the item, if the item does not require prior authorization. For purposes of this section, the date the client orders the item means the date on which the podiatrist presents the order to the manufacturer or supplier. The podiatrist shall verify to the department the date the client ordered the item.(4) The department shall pay for routine foot care only if the client has a systemic condition. Services are limited to one treatment every sixty days.(5) The fees listed in the department's fee schedule shall be payable only when the services are performed by the podiatrist.(6) The department shall pay for an initial visit by a podiatrist in an office, home, ICF/MR or nursing facility visit only once per client. Initial visits refer to the podiatrist's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the podiatrist-client relationship has been discontinued for three or more years and is then reinstated.(7) Fees for consultations shall apply only when the opinions and advice of a consultant podiatrist are requested by the referring provider or other appropriate source in the evaluation and treatment of the client's illness. After the consultation is provided, the consultant shall prepare a written report of his or her findings and provide a copy of the report to the referring podiatrist or physician. In a consultation, the client's referring provider carries out the plan of care. In a referral, a second provider provides direct service to the client.(h)Surgery(1) When a claim is submitted by a podiatrist for multiple surgical procedures performed on the same date of service, the department will pay for the primary surgical procedure at the Medicaid allowed amount for podiatrists or the billed amount, whichever is lower. The department shall pay for additional surgical procedures performed on that day at fifty percent of the Medicaid allowed amount for podiatrists.(2) When an assistant surgeon, in addition to staff provided by the hospital, is required, the amount payable by the department to the assistant surgeon shall be as indicated on the fee schedule.(3) Subsequent to the decision for surgery, fees for surgical procedures include one related evaluation and management encounter on the date immediately prior to, or on, the date of the procedure, including history and physical.(4) The listed fees for all surgical procedures include the surgery and typical postoperative follow-up care while in the general or chronic disease hospital. Followup visits related to the surgery shall not be payable as office visits.(5) The listed fees for surgery on the musculoskeletal system shall include payment for the application of the first cast or traction device.(i)Radiology(1) The listed fees for all diagnostic radiology procedures shall include consultation and a written report to the referring provider.(2) The listed fees for all diagnostic radiology procedures shall apply only when the podiatrist's own equipment is being used. If the equipment used to perform the procedure is owned directly or indirectly by the general or chronic disease hospital or a related entity, or if a hospital includes the operating expenses of the equipment in its cost reports, the podiatrist shall not be paid for the technical component of the listed fee.(j)Laboratory(1) The following routine laboratory tests shall be included in the fee for an office visit and shall not be payable on the same date of service: urinalysis without microscopy, hemoglobin determination and urine glucose determination.(2) No payment shall be made for tests which are provided free of charge.(3) Payment shall be made for panel or profile tests according to the fees listed in the department's fee schedule for panel tests and not according to the fee for each separate test included in the panel or profile.(k)Drugs(1) The department shall pay the actual acquisition costs for oral medications incident to an office visit as billed by the podiatrist.(2) The department shall pay for legend drugs and legend devices administered by the podiatrist based on a fee schedule determined by the department.(3) No payment shall be made for drugs provided free of charge.(l)Admission to a general hospitalPayment for services provided by the admitting podiatrist in a general hospital shall not be made available if it is determined by the department's utilization review program, either prospectively or retrospectively, that the admission did not fulfill the accepted professional criteria for medical necessity, medical appropriateness, appropriateness of setting or quality of care. Specific requirements are described in section 17-134d-80 of the Regulations of Connecticut State Agencies.
Conn. Agencies Regs. § 17b-262-628
Adopted effective February 11, 2009