Medicare to Allow Nurse Practitioners and Physician Assistants to Certify the Medical Need for Diabetic Shoes in Limited Circumstances

AOPA, in collaboration with other healthcare organizations, has actively supported the inclusion of nurse practitioners (NPs) and physician assistants (PAs) to serve as certifying practitioners under the Medicare diabetic shoe benefit.  The Social Security Act states that the certifying physician must be the MD or DO that is managing the patient’s systemic diabetic condition.  This has led to significant access issues as the delivery of healthcare has evolved and non-physician practitioners have become more prevalent as primary care providers.

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) recently announced two separate pathways that expand the ability of NPs and PAs to certify the medical need for diabetic shoes provided to Medicare beneficiaries.

The first pathway only applies to NPs and is being coordinated by the Center for Medicare and Medicaid Innovation through the Primary Care First (PCF) demonstration project.  The PCF demonstration project will be implemented on January 1, 2021 and will run through December 31, 2025.  NPs that are participating in the PCF demonstration project in one of the 26 states/regions that it will be implemented in may serve as the certifying practitioner for diabetic shoes covered by Medicare.  The PCF model does not require the NP to operate under the direct supervision of a physician, but it does not apply to physician assistants.  The announcement of the expansion of the role of NPs under the PCF demonstration project may be viewed HERE.

The second pathway is effective immediately and applies to both NPs and PAs that are providing healthcare services under the direct supervision of an MD or DO through “incident to” provisions.  The DME MACs have indicated that CMS has offered guidance that allows NPs and PAs to certify the medical need for diabetic shoes when ALL the following conditions 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.

It is important to note that this pathway does not apply to NPs that are practicing independently (billing under their own NPI).  They must be practicing under the direct supervision of an MD or DO.  The announcement of the “incident to” clarification may be viewed HERE.

AOPA is encouraged by the announcements above and is pleased that CMS has acknowledged the expanding role of NPs and PAs in the delivery of primary healthcare.  We will provide additional details on these policy changes as they become available.

Questions regarding this issue may be directed to Joe McTernan at or Devon Bernard at