Podiatric Medicine and Surgery Service Providers

Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Table of Contents

Podiatric Medicine and Surgery Services ...... 2 1.Important Contacts...... 4 1.1. Gainwell Technologies...... 4 1.2. Provider Relations Consultants ...... 5 1.3. Medicaid ...... 6 1.4. Telligen, Inc ...... 7 2.Provider Qualifications ...... 8 2.1. References: Provider Qualifications...... 8 2.1.1. State Regulations...... 8 3.Eligible Participants ...... 9 3.1. References: Eligible Participants...... 9 3.1.1. State Regulations...... 9 3.2. Referrals ...... 10 3.3. EPSDT Services for Participants Under 21...... 11 4.Covered Services and Limitations ...... 12 4.1. References: Covered Services and Limitations ...... 12 4.1.1. CMS Guidance ...... 12 4.1.2. State Regulations...... 12 4.2. Routine Foot Care ...... 14 4.2.1. References: Routine Foot Care ...... 14 4.3. Limitation on Inpatient Care ...... 15 5.Prior Authorizations ...... 16 5.1. References: Prior Authorizations ...... 17 5.1.1. Federal Regulations ...... 17 5.1.2. Idaho Medicaid Publications...... 17 5.2. The Medical Care Unit ...... 19 5.3. Telligen, Inc ...... 20 6.Documentation Requirements...... 21 6.1. References: Documentation Requirements ...... 21 6.1.1. State Regulations...... 21 6.2. Evaluation and Management ...... 22 6.2.1. References: Evaluation and Management ...... 22 7.Reimbursement...... 23 7.1. References: Reimbursement ...... 23 7.1.1. Federal Regulations ...... 23 7.1.2. Idaho Medicaid Publications...... 23 7.2. Site of Service Differential ...... 24 7.2.1. References: Site of Service Differential ...... 24 Appendix A. Preapproved Diagnoses for Routine Foot Care ...... 25 Appendix B. Preapproved Diagnoses for Podiatry Services ...... 26 Appendix C. Podiatric Medicine and Surgery Services, Provider Handbook Modifications . 41

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services

Podiatric Medicine and Surgery Services This section covers Medicaid services rendered by qualified podiatrists as deemed appropriate by the Department of Health and Welfare (DHW). Services must be within the scope of practice, licensure and training of the provider rendering them.

Sections of the Idaho Medicaid Provider Handbook applicable in specific situations are listed throughout the handbook for provider convenience. Handbook sections that always apply to this provider type include the following: • General Billing Instructions; • General Information and Requirements for Providers; and • Glossary.

Handbooks can only be used properly in context. Providers must be familiar with the handbooks that affect them and their services. The numbering in handbooks is also important to make note of as subsections rely on the content of the sections above them.

Example

Section 1.2.3.a The Answer requires the reader to have also read Section 1, Section 1.2 and Section 1.2.3 to be able to properly apply Section 1.2.3.a.

References are included throughout the handbook for provider and staff convenience. Not all applicable references have been incorporated into the handbook. Not all references provided are equal in weight. • Case Law: Includes references to court cases that established interpretations of law that states and providers would be required to follow. • CMS Guidance: These references reflect various Centers for Medicare and Medicaid Services (CMS) publications that Idaho Medicaid reviewed in the formulation of their policy. The publications themselves are not required to be followed for Idaho Medicaid services. • Federal Regulations: These references are regulations from the federal level that affected policy development. Usually these include the Code of Federal Regulations, the Social Security Act and other statutes. They are required to be followed. • Idaho Medicaid Publications: These are communications from Idaho Medicaid to providers that were required to be followed when published. These are included in the handbook for historical reference. The provider handbook supersedes other communications unless the documents are listed in the Department’s Rules, Statutes, and Policies webpage under policies in Medicaid’s department library. • Idaho State Plan: The State Plan is the agreement between the State of Idaho and the Centers for Medicare and Medicaid Services on how the State will administer its medical assistance program. • Professional Organizations: These references reflect various publications of professional organizations that Idaho Medicaid reviewed in the formulation of their policy. Providers may or may not be required to follow these references, depending on the individual reference and its application to a provider’s licensure and scope of practice. • Scholarly Work: These references are publications that Idaho Medicaid reviewed in the formulation of their policy. The publications themselves are not required to be followed for Idaho Medicaid services.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services • State Regulations: These references are regulations from the state level that affected policy development. They usually include statute and IDAPA. They are required to be followed.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 1. Important Contacts The Directory, Idaho Medicaid Provider Handbook contains a comprehensive list of contacts. The following contacts are presented here for provider convenience.

1.1. Gainwell Technologies Gainwell Technologies is Idaho Medicaid’s fiscal agent that handles all claims processing and customer service issues.

Gainwell Technologies Contact Information

Gainwell Technologies Provider Services P.O. Box 70082 Boise, ID 83707 Phone: 1 (888) 686-4272 Fax: 1 (877) 661-0974 [email protected]

The Medicaid Automated Call Service (MACS) is available 24 hours a day, seven days a week. Provider service representatives are available Monday through Friday, 7:00 A.M.-7:00 P.M. MT.

Provider Enrollment P.O. Box 70082 Boise, ID 83707 Phone: 1 (866) 686-4272 Fax: 1 (877) 517-2041 [email protected]

Technical Services Phone: 1 (866) 686-4272 Fax: 1 (877) 517-2040 [email protected]

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 1.2. Provider Relations Consultants Gainwell Technologies Provider Relations Consultants help keep providers up-to-date on billing changes required by program policy changes implemented by the Division of Medicaid. Provider Relations Consultants accomplish this by: • Conducting provider workshops; • Conducting live meetings for training; • Visiting a provider’s site to conduct training; and • Assisting providers with electronic claims submission

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 1.3. Medicaid The Medical Care Unit is Idaho Medicaid’s team that reviews prior authorizations for some services.

Medical Care Unit PO Box 83720 Boise, ID 83720-0009 Phone 1 (866) 205-7403 [email protected]

The status of a prior authorization request submitted to the Medical Care Unit may be checked online at the Gainwell Technologies portal under “Authorization Status”, using your NPI. If you have questions on a Denial, click on the Notes, which will explain the reason for the Denial.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 1.4. Telligen, Inc Telligen, Inc is Idaho Medicaid’s quality improvement organization (QIO) that reviews prior authorization requests for some services and surgical procedures as listed on the Numerical Fee Schedule. They also conducted reviews of inpatient stays and laboratory services.

Telligen 670 E Riverpark Ln. Suite 120 Boise, ID 83706 Phone: 1 (866) 538-9510 Fax: 1 (866) 539-0365 E-mail: [email protected]

See the QIO Provider Manual for a listing of diagnoses and procedures that require PA and details regarding review processes.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 2. Provider Qualifications Podiatrists in any state are eligible to participate in the Idaho Medicaid Program. Podiatrists must have a National Provider Identification (NPI). They must be licensed in the state where the services. Podiatrists must enroll as an Idaho Medicaid provider prior to providing services for Idaho Medicaid participants, however, exceptions may apply for emergency circumstances. Podiatrists acting as contractors for other providers must still enroll and bill directly for their services. Podiatrists are eligible to be ordering, prescribing, referring and rendering providers.

Providers must follow the provider handbook and all applicable state, and federal, rules and regulations. See General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho Medicaid provider.

2.1. References: Provider Qualifications

2.1.1. State Regulations Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(i) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Podiatrist Services: Provider Qualifications.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 544. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 3. Eligible Participants Participants with Medicaid Basic and Enhanced Plans are eligible to receive podiatric services. When billing for participants enrolled in other eligibility segments, refer to General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for coverage. Providers must check participant eligibility prior to delivery of the service by calling Idaho Medicaid Automated Customer Service (MACS) at 1 (866) 686-4272; or through the Trading Partner Account on the Gainwell Technologies Idaho Medicaid website.

Eligible participants can receive podiatric services when: • The participant has a chronic disease where the evidence-based guidelines recommend regular foot care. These chronic diseases include: o Diabetes mellitus; o Peripheral neuropathy involving the feet; o Chronic thrombophlebitis; o Peripheral vascular disease; o Other chronic conditions that require regular podiatric care for the purpose of preventing recurrent wounds, pressure ulcers, or amputation; and o Other foot conditions that have the potential to seriously or irreversibly compromise overall health. • The participant has an acute condition that, if left untreated, may cause an adverse outcome to the participant’s health.

3.1. References: Eligible Participants 3.1.1. State Regulations Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(i) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Participant Eligibility.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 210.01. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Podiatrist Services: Definitions.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 540. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Podiatrist Services: Participant Eligibility.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 541. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 3.2. Referrals Medicaid Participants enrolled in Healthy Connections (HC) may obtain services from a podiatrist without a referral if those services are performed in the podiatrist’s office.

Procedures that are performed in an inpatient or outpatient hospital, or ambulatory surgery center (ASC) require a referral from the primary care provider (PCP) to ensure payment for the facility and the ancillary physicians/providers such as pre-operative examination by a physician. See General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information about HC requirements.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 3.3. EPSDT Services for Participants Under 21 Services identified as a result of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) which correct or ameliorate a defect will not be subject to the existing amount, scope, and duration limitations, but require prior authorization. The prior authorization process for EPSDT is separate from traditional podiatry services. The medical necessity for the additional service must be documented. It must be proven safe, effective and accepted as a medical practice or treatment for the condition being addressed. Additional information for EPSDT may be found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 4. Covered Services and Limitations Coverage for podiatrist services is limited to: • Acute and preventive services that are defined in chronic care guidelines for the foot, ankle and area from the mid-calf down. • Treatment of acute conditions that, if left untreated, will result in chronic damage to the participant’s foot, ankle, or the area from the mid-calf down. An acute foot condition includes any foot/ankle condition that hinders normal function, threatens the individual’s health, or complicates any disease. • Orthotics, see the Supplier, Idaho Medicaid Provider Handbook for requirements on providing durable medical equipment. • Muscle testing and range of motion studies, only when billed at a separate time from evaluation and management visits. Medicaid considers these services part of a routine office visit. • Surgical removal of corns and calluses is covered only when the participant has a chronic disease that makes it necessary for the service to be done by a podiatrist.

See Appendix B. Preapproved Diagnoses for Podiatry Services for a list of preapproved diagnoses.

4.1. References: Covered Services and Limitations 4.1.1. CMS Guidance “Chapter 12 – Physicians/Nonphysician Practitioners.” Medicare Benefit Policy Manual, Centers for Medicare & Medicaid Services, https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

“Chapter 15 – Covered Medical and Other Health Services.” Medicare Benefit Policy Manual, Centers for Medicare & Medicaid Services, https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf.

“Foot Care Coverage Guidelines.” MLN Matters Number: SE1113, 2017, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1113.pdf.

Podiatry Webinar. Noridian Healthcare Solutions, August 2016. Webinar.

4.1.2. State Regulations House Bill 260 Budget Reductions – Podiatric Services, Information Release MA11-12 (5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://www.idmedicaid.com/MedicAide%20Newsletters/June%202011%20MedicAide.pdf.

Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(i) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Podiatrist Services: Coverage and Limitations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 542. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services “Podiatrist Services: Definitions.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 540. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 4.2. Routine Foot Care Routine foot care such as cutting, removal, debridement, or other surgical treatment of toenails (i.e., CPT® procedure codes 11719, 11720, 11721, and G0127), are covered only when the participant has a chronic condition with vascular restrictions such as diabetes or peripheral vascular disease. See Appendix A. Restricted Benefit Diagnoses for Routine Foot Care for a list of covered diagnoses. If a diagnosis is not present on the preapproved list, but the Podiatrist believes it meets the criteria for coverage of routine foot care, a claim may be appended with the KX modifier to pend for review by the Medical Care Unit. Supporting documentation must be attached for review or the claim will be denied. The KX modifier should not be used for unspecified diagnoses when the practitioner can be contacted for additional information to code a more detailed diagnosis.

4.2.1. References: Routine Foot Care

(a) CMS Guidance “Chapter 15 – Covered Medical and Other Health Services.” Medicare Benefit Policy Manual, Centers for Medicare & Medicaid Services, https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf.

“Foot Care Coverage Guidelines.” MLN Matters Number: SE1113, 2017, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1113.pdf.

Podiatry Webinar. Noridian Healthcare Solutions, August 2016. Webinar.

(b) State Regulations House Bill 260 Budget Reductions – Podiatric Services, Information Release MA11-12 (5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://www.idmedicaid.com/MedicAide%20Newsletters/June%202011%20MedicAide.pdf.

Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(i) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 4.3. Limitation on Inpatient Care Daily inpatient care in a skilled nursing facility, ICF/IID, or long-term care facility is generally not covered as the podiatrist is not the attending physician in this setting.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 5. Prior Authorizations A prior authorization (PA) is a written, faxed or electronic approval from the Department that permits payment or coverage of an item or service that is only covered by such an authorization. Some items and services always require a PA, but others may only require a PA under these circumstances: • The participant has exhausted their benefit; • The participant does not meet the established criteria, but can demonstrate a medical need; or • The participant has an alternative benefit such as EPSDT or waiver that can only be accessed through a prior authorization.

Items and services that require a PA must receive approval before they can be delivered to the participant except as otherwise noted. It is the provider’s responsibility to verify the participant’s eligibility on the date of service and to request any required PA. PA requirements specific to a service or item are listed throughout the handbook for the provider’s convenience. For information regarding if a prior authorization is required, providers can: • Check participant eligibility and PA requirements through your Trading Partner Account at www.idmedicaid.com; • Check the Idaho Medicaid Numerical Fee Schedule available online for items that always require a PA and the authorizing entity; and • Check the Appendices of the Hospital, Idaho Medicaid Provider Handbook for ICD-10- PCS codes requiring a prior authorization from the Medical Care Unit or the QIO, Telligen.

Participants with Medicare as their primary insurance do not require a PA from Idaho Medicaid for Medicare approved items and services. If the services are not covered by Medicare, or the participant has another primary payor, Medicaid prior authorizations are required as if the participant had Medicaid primary.

A request for a PA or an approved authorization for services does not guarantee payment. All other Department requirements must be fulfilled. Authorizations only confirm medical necessity criteria for the item or service based on the documentation submitted. The Department’s review of prior authorizations includes general criteria requirements in addition to any item specific criteria. They do not review if a provider or place of service is appropriate or any other considerations. Reimbursement is dependent on the participant being eligible on the date authorized services are rendered and the request must meet any other requirements such as: • Meet medical necessity as established in section 011 or 880 of IDAPA 16.03.09, “Medicaid Basic Plan Benefits”; • Meet all policy requirements; • Be appropriate and effective treatment for the participant’s current medical condition; • Be furnished by providers with the appropriate credentials; • Be the most cost-effective method of meeting the participant’s medical needs; and • Meet all federal and state regulations.

Medicaid issues a written notification of authorization or denial for all written requests for PA. Participants will receive a mailed notice of decision with information on their appeal rights and how to request a hearing if they disagree with the Department’s decision. Providers receive notifications based on their profile’s preferences. If the participant or provider disagrees with the Department’s decision they can consider requesting a reconsideration or file an appeal.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Approved authorizations are valid only for the period between the start and stop dates. If the service is going to be delivered outside of the approved dates, a new PA request must be submitted. Requests should be made before the expiration of the previous request to avoid breaks in care.

When authorized services or items are billed, PA numbers must be included on the appropriate claim line. Effective May 1, 2014, the claim line will be denied if the PA number is not present. Claims for inpatient services must have the prior authorization number on the header or each claim line, or the claim will deny. Some authorizations may also include modifiers as part of the approval. If the modifier listed in the authorization is missing from the claim line it will deny. The PA number and any required modifier are found on the paper Notice of Decision (NOD) letter or online through the Trading Partner Account (TPA) under View Authorizations.

Payment will be denied for any medical item or service that requires a PA from Idaho Medicaid’s designated authorizing entity, but the item or service was provided prior to obtaining authorization. In addition, the provider may not bill the Medicaid participant for services not reimbursed by Medicaid because the PA was not obtained in a timely manner or because the provider failed to verify that a PA was required.

If an individual was not eligible for Medicaid at the time items requiring a PA were provided but was subsequently found eligible pursuant to IDAPA 16.03.05.051.03, a request must be submitted with all required documentation within 30 days of the date the provider became aware of the individual’s Medicaid eligibility. The medical item or service will be reviewed by the Department retroactively using the same medical necessity guidelines that apply to other prior authorization requests. If approved, the provider should refund to the participant any amount previously collected for the item or service.

See the General Billing Instructions, Idaho Medicaid Provider Handbook for more information on billing prior authorized services.

5.1. References: Prior Authorizations 5.1.1.Federal Regulations Excessive Claims or Furnishing of Unnecessary or Substandard Items and Services, 42 CFR 1001.701 (2019). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR- 2019-title42-vol5/pdf/CFR-2019-title42-vol5-sec1001-701.pdf.

“State Plans for Medical Assistance.” Social Security Act, Sec. 1902(a)(10)(d) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

Sufficiency of Amount, Duration, and Scope, 42 CFR 440.230(d) (2019). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2019-title42-vol4/pdf/CFR-2019- title42-vol4-sec440-230.pdf.

5.1.2. Idaho Medicaid Publications “Modifiers and Prior Authorization (PA).” MedicAide Newsletter, October 2015, https://www.idmedicaid.com/MedicAide%20Newsletters/October%202015%20MedicAide.pd f.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services “Prior Authorization Number on Claims.” MedicAide Newsletter, February 2014, https://www.idmedicaid.com/MedicAide%20Newsletters/February%202014%20MedicAide.p df.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 5.2. The Medical Care Unit Prior authorization requests will be rejected if there is no clear indication that a prior authorization is required. Providers should note the reason for the request on the form if the item or service does not always require a prior authorization. Idaho Medicaid request forms are available at www.idmedicaid.com or by calling Provider Services at 1 (866) 686-4272 to request a paper copy.

The Medical Care Unit is Idaho Medicaid’s team that reviews prior authorization requests for some services and surgical procedures as listed on the Numerical Fee Schedule. Prior authorizations must be submitted on the correct form with documentation supporting the request, and any additional items within the item specific criteria. Requests for codes that do not have a price on file on the Idaho Medicaid Numerical Fee Schedule must include pricing documentation with their request. See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding acceptable documentation for manually priced goods and services.

The Medical Care Unit does not accept requests via phone or e-mail. Submit complete requests by the trading partner account, postal mail or fax to:

Medical Care Unit PO Box 83720 Boise, ID 83720-0009 Fax 1 (877) 314-8779

Medicaid staff may request additional documentation to establish medical necessity for the item. The requested documentation must be received by the Medical Care Unit within two working days or the request may be denied.

Modifications, including transfers to another provider, may be requested via the trading partner account or by faxing the request form with the prior authorization number, requested change and justification to 1 (877) 314-8779. Include any additional documentation if the change is not supported by the original submission. Requests from a provider other than the original requestor must have documentation from the participant or their legal guardian approving the change otherwise a new prior authorization is required.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 5.3. Telligen, Inc Telligen, Inc is Idaho Medicaid’s quality improvement organization (QIO) that reviews prior authorization requests for some services and surgical procedures as listed on the Numerical Fee Schedule. Prior authorization requests through Telligen, Inc. may be submitted through their online portal, fax or mail:

Telligen 670 East Riverpark Lane, Suite 170 Boise, ID 83706 Fax: 1 (800) 826-3836 Telligen provider portal.

To apply for access to the Telligen Portal please fill out the registration packet located in the document library on the Telligen site. The status of a prior authorization request may be checked online at the provider portal, or by contacting Telligen, Inc. customer service at 1 (866) 538-9510.

See the QIO Provider Manual for information about requesting prior authorizations from the QIO, Telligen.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 6. Documentation Requirements Documentation requirements applicable in specific situations are listed throughout the handbook for provider convenience. General documentation requirements are also required and found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

Documentation must be made available to Department personnel acting in their official capacity immediately upon request. Services without documentation are not eligible for reimbursement. Providers should only submit records requested by the Department. Documentation sent unsolicited, or not for a service requiring prior authorization, will not be reviewed by the Department. Unreviewed documentation does not constitute approval or authorization of a service.

6.1. References: Documentation Requirements

6.1.1. State Regulations “Review of Records.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 230.05. Department of Administration, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 6.2. Evaluation and Management Physicians and non-physician practitioners are required to use either the 1995 or 1997 evaluation and management (E&M) documentation guidelines to document E&M office and outpatient visits. Modifications to these guidelines include: • Elimination of the requirement to document the medical necessity of a home visit instead of an office visit; • Elimination of history and physical exam in code determination; • Prioritizing code selection by medical decision-making or total time; • Focusing documentation on changes and persisting problems since the last visit for established patients, provided the physician or non-physician practitioner indicate in the record the patient’s medical record was reviewed and updated if necessary; and • Clarification that practitioners do not need to re-enter the participant’s chief complaint and history into the medical record if ancillary staff or the participant have already updated it. The practitioner only needs to indicate in the medical record that the information has been reviewed and verified.

6.2.1. References: Evaluation and Management (a) CMS Guidance 1995 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/outreach-and-education/medicare-learning-network- mln/mlnedwebguide/downloads/95docguidelines.pdf.

1997 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/outreach-and-education/medicare-learning-network- mln/mlnedwebguide/downloads/97docguidelines.pdf.

Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv- guide-ICN006764.pdf.

“Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List.” MLN Matters MM11063, November 2018, Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf.

(b) Idaho Medicaid Publications “2019 Evaluation and Management (E&M) Documentation Updates.” MedicAide Newsletter, January 2019, https://www.idmedicaid.com/MedicAide%20Newsletters/January%202019%20MedicAide.pd f.

“Evaluation and Management Codes.” MedicAide Newsletter, December 2020, https://www.idmedicaid.com/MedicAide%20Newsletters/December%202020%20MedicAide. pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 7. Reimbursement Providers must be enrolled to receive reimbursement from Idaho Medicaid. Idaho Medicaid reimburses podiatrists on a fee-for-service basis except for services provided in Rural Health Clinics (RHC), Federally Qualified Health Clinic (FQHC), or Indian Health Services (IHS). Usual and customary fees are paid up to the Medicaid maximum allowance listed in the Numerical Fee Schedule. The Medicaid maximum allowance is set at 100% of the Medicare fee schedule for primary care procedures, and 90% of the Medicare fee schedule for all others, when the code becomes covered by Idaho Medicaid, if available. Only claims billed with an approved diagnosis as specified in Appendix A and Appendix B will pay automatically.

See the IHS, FQHC and RHC Services, Idaho Medicaid Provider Handbook for information on encounter fees for services provided in an RHC, FQHC or IHS.

See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding policy on billing, prior authorizations, and requirements for billing all other third party resources before submitting claims to Medicaid.

Some participants may be responsible for a co-pay for podiatry services. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for information on when billing a participant is allowable.

7.1. References: Reimbursement 7.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(6), Sec. 1905(g) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

7.1.2. Idaho Medicaid Publications “Attention: Optometrists, Podiatrists, and Chiropractors.” MedicAide Newsletter, October 2011, https://www.idmedicaid.com/MedicAide%20Newsletters/October%202011%20MedicAide.pd f.

Co-payments (Co-pays), Information Release MA11-26 (11/22/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov.

House Bill 260 Budget Reductions – Provider Payments, Information Release MA11-19 (05/26/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services 7.2. Site of Service Differential Idaho Medicaid reduces reimbursement when certain procedures are provided in a facility setting. For these procedure codes there is a 30 percent reduction of the Idaho Medicaid Numerical Fee Schedule in the following places of service (POS): • 02 Telehealth (Not recognized by Idaho Medicaid); • 19 Outpatient Hospital-Off Campus; • 21 Inpatient Hospital; • 22 Outpatient Hospital; • 23 Emergency Room – Hospital; • 24 Ambulatory Surgical Center; • 26 Military Treatment Facility; • 31 Skilled Nursing Facility; • 34 Hospice – Inpatient Care; • 41 Ambulance – Land; • 42 Ambulance – Air or Water; • 51 Inpatient Psychiatric Facility; • 52 Psychiatric Facility - Partial Hospitalization; • 53 Community Mental Health Center; • 56 Psychiatric Residential Treatment Center; • 61 Comprehensive Inpatient Rehabilitation Facility; and • 62 Comprehensive Outpatient Rehabilitation Facility.

If the space and supplies are provided by the hospital, and are included in the hospital's cost settlement, the podiatrist can bill under their own provider number on the CMS-1500 form, and there is a site of service deduction. The facility fees are billed by the hospital on their UB- 04 form under the hospital provider number.

There is no site of service reduction if office space is rented from the hospital and the podiatrist provides their own supplies. The hospital cannot use the same space, etc. to bill for services under their hospital provider number.

Refer to CMS and their Idaho regional Medicare contractor, Noridian, for a list of codes the differential affects.

7.2.1. References: Site of Service Differential (a) Idaho Medicaid Publications “Places of Service with Site of Service Reductions.” MedicAide Newsletter, August 2019, https://www.idmedicaid.com/MedicAide%20Newsletters/August%202019%20MedicAide.pdf .

“Site of Service Differential.” MedicAide Newsletter, September 2003, https://www.healthandwelfare.gov.

“Site of Service Differential Will Be Applied to Podiatrists’ Claims.” MedicAide Newsletter, August 2015, https://www.idmedicaid.com/MedicAide%20Newsletters/August%202015%20MedicAide.pdf .

“Site of Service Reduction List.” MedicAide Newsletter, April 2018, https://www.idmedicaid.com/MedicAide%20Newsletters/April%202018%20MedicAide.pdf.

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Appendix A. Preapproved Diagnoses for Routine Foot Care The following ICD-10-CM diagnosis codes have been identified as covered chronic conditions with vascular restrictions for dates of service on or after October 1, 2015. Unspecified diagnosis codes within the listed ranges are not covered.

Preapproved Diagnoses for Routine Foot Care E08.00 – G13.0 – G57.00 – G58.8 – I70.211 – A52.15 E13.9 G13.1 G57.93 G65.2 I70.92

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Appendix B. Preapproved Diagnoses for Podiatry Services The following ICD-10-CM diagnosis codes have been identified by the Department as indicating a covered acute or chronic condition for dates of service on or after October 1, 2015. Unspecified diagnosis codes within the listed ranges are not covered.

Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes A30.0 – A30.8 Leprosy [Hansen's disease] A50.41 – A50.49 Late congenital neurosyphilis [juvenile neurosyphilis] A52.11 – A52.2 Symptomatic and asymptomatic neurosyphilis B07.0 – B07.9 Viral warts B08.4 Enteroviral vesicular stomatitis with exanthem B08.8 Other specified viral infections characterized by skin and mucous membrane lesions B35.1 Tinea unguium B35.3 Tinea pedis B37.2 Candidiasis of skin and nail B47.0 – B47.1 Mycetoma B78.1 Cutaneous strongyloidiasis C4A.71 – C4A.72 Merkel cell carcinoma of lower limb, including hip C44.712 – C44.799 Other malignant neoplasm of skin (Unspecified diagnosis codes are not covered) D04.71 – D04.72 Carcinoma in situ of skin of lower limb, including hip D18.01 Hemangioma of skin and subcutaneous tissue D21.20 – D21.22 Benign neoplasm of connective and other soft tissue of lower limb, including hip D23.71 – D23.72 Other benign neoplasm of skin of lower limb, including hip D48.5 Neoplasm of uncertain behavior of skin D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D86.3 Sarcoidosis of skin E08.00 – E08.9 Diabetes mellitus (Unspecified diagnosis codes are not covered) E09.00 – E09.9 Drug or chemical induced diabetes mellitus (Unspecified diagnosis codes are not covered) E10 – E10.9 Type 1 diabetes mellitus (Unspecified diagnosis codes are not covered) E11 – E11.9 Type 2 diabetes mellitus (Unspecified diagnosis codes are not covered) E13 – E13.9 Other specified diabetes mellitus (Unspecified diagnosis codes are not covered) E52 Niacin deficiency [pellagra] E53.1 Pyridoxine deficiency E75.01 – E75.09 GM2 gangliosidosis E75.21 – E75.23 Other sphingolipidosis E75.25 – E75.29 Metachromatic leukodystrophy and other sphingolipidosis E83.2 Disorders of zinc metabolism

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes E85.1 Neuropathic heredofamilial amyloidosis G13.0 – G13.1 Systemic atrophies primarily affecting central nervous system in diseases classified elsewhere G32.0 – G32.89 Other degenerative disorders of nervous system in diseases classified elsewhere G57.01 – G57.93 Mononeuropathies (Unspecified diagnosis codes are not covered) G58.0 – G58.9 Other mononeuropathies G59.0 Mononeuropathy in diseases classified elsewhere G60.0 – G60.9 Hereditary and idiopathic neuropathy G61.0 – G61.8 Inflammatory polyneuropathy G62.0 – G62.89 Other polyneuropathies G63 Polyneuropathy in diseases classified elsewhere G64 Other disorders of peripheral nervous system G65.0 – G65.2 Sequelae of inflammatory and toxic polyneuropathies G99.0 Autonomic neuropathy in diseases classified elsewhere I70.211 – I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication I70.221 – I70.223 Atherosclerosis of native arteries of extremities with rest pain I70.232 – I70.238 Atherosclerosis of native arteries of right leg with ulceration I70.242 – I70.248 Atherosclerosis of native arteries of left leg with ulceration

I70.261 – I70.263 Atherosclerosis of native arteries of extremities with gangrene I70.291 – I70.293 Other atherosclerosis of native arteries of extremities I70.411 – I70.413 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication I70.421 – I70.423 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain I70.432 – I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration I70.442 – I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration I70.461 – I70.463 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene I70.491 – I70.493 Other atherosclerosis of autologous vein bypass graft(s) of the extremities I70.511 – I70.513 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities intermittent claudication I70.521 – I70.523 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain I70.532 – I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration I70.542 – I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration I70.561 – I70.563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes I70.591 – I70.593 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities I70.611 – I70.613 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication I70.621 – I70.623 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain I70.632 – I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration I70.642 – I70.648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration I70.661 – I70.663 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene I70.691 – I70.693 Other atherosclerosis of nonbiological bypass graft(s) of the extremities I70.711 – I70.713 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication I70.721 – I70.723 Atherosclerosis of other type of bypass graft(s) of the extremities

with rest pain

I70.732 – I70.738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration I70.742 – I70.748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration I70.761 – I70.763 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene I70.791 – I70.793 Other atherosclerosis of other type of bypass graft(s) of the extremities I70.92 Chronic total occlusion of artery of the extremities I73.00-I73.89 Other peripheral vascular diseases I78.1 Nevus, non-neoplastic I79.1 Aortitis in diseases classified elsewhere I79.8 Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere I80.01 – I80.93 Phlebitis and thrombophlebitis of lower extremity (Unspecified diagnosis codes are not covered) I82.451 – I82.453 Acute embolism and thrombosis of peroneal vein I82.461 – I82.463 Acute embolism and thrombosis of calf muscular vein I82.551 – I82.553 Chronic embolism and thrombosis of peroneal vein I82.561 – I82.563 Chronic embolism and thrombosis of calf muscular vein I83.011 – I83.028 Varicose veins of lower extremity with ulcer (Unspecified diagnosis codes are not covered) I83.11 – I83.12 Varicose veins of lower extremity with inflammation I83.212 – I83.218 Varicose veins of right lower extremity with both ulcer and inflammation I83.222 – I83.228 Varicose veins of left lower extremity with both ulcer and inflammation I87.811 – I87.813 Varicose veins of lower extremities with pain

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes I87.891 – I87.893 Varicose veins of lower extremities with other complications I87.2 Venous insufficiency (chronic) (peripheral) I87.00 – I87.8 Other disorders of veins (Unspecified diagnosis codes are not covered) I89.516 – I89.526 Pressure-induced deep tissue damage of ankle I89.616 – I89.626 Pressure-induced deep tissue damage of heel I96 Gangrene, not elsewhere classified K90.0 – K90.1 Intestinal malabsorption L02.415 – L02.416 Cutaneous abscess of lower limb L02.425 – L02.426 Furuncle of lower limb L02.435 – L02.436 Carbuncle of lower limb L02.611 – L02.632 Cutaneous abscess, furuncle and carbuncle of foot (Unspecified diagnosis codes are not covered) L03.031 – L03.042 Cellulitis and acute lymphangitis (Unspecified diagnosis codes are not covered) L03.115 – L03.116 Cellulitis of other parts of limb L03.125 – L03.126 Acute lymphangitis of other parts of limb L08.0 – L08.89 Other local infections of skin and subcutaneous tissue L11.0 Acquired keratosis follicularis L12.0 – L12.2 Pemphigoid L12.31 – L12.35 Acquired epidermolysis bullosa L12.8 Other pemphigoid L26 Exfoliative dermatitis L27.0 – L27.8 Dermatitis due to substances taken internally L28.0 – L28.1 Lichen simplex chronicus and prurigo L30.0 – L30.8 Other dermatitis L43.0 – L43.8 Lichen planus L54 Erythema in diseases classified elsewhere L56.5 Disseminated superficial actinic porokeratosis (DSAP) L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation L60.0 – L60.8 Nail disorders L62 Nail disorders in diseases classified elsewhere L72.0 Epidermal cyst L72.11 – L72.8 Follicular cysts of skin and subcutaneous tissue L74.513 Primary focal hyperhidrosis, soles L84 Corns and callosities L85.0 – L85.8 Other epidermal thickening L86 Keratoderma in diseases classified elsewhere L87.0 – L87.8 Transepidermal elimination disorders L88 Pyoderma gangrenosum

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes L89.510 – L89.624 Pressure ulcer of ankle or heel (Unspecified diagnosis codes are not covered) L89.890 – L89.894 Pressure ulcer of other site L90.5 Scar conditions and fibrosis of skin L90.8 Atrophic disorder of skin, other L91.8 Hypertrophic disorder of the skin, other L92.0 Granuloma annulare L92.1 Necrobiosis lipoidica, not elsewhere classified L92.8 Granulomatous disorders of the skin and subcutaneous tissue, other L94.8 Localized connective tissue disorders, other L95.1 Erythema elevatum diutinum L97.211 – Non-pressure chronic ulcer of calf (Unspecified diagnosis codes are not L97.228 covered) L97.311 – Non-pressure chronic ulcer of ankle (Unspecified diagnosis codes are L97.328 not covered) L97.411 – Non-pressure chronic ulcer of heel and midfoot (Unspecified diagnosis L97.428 codes are not covered) L97.511 – Non-pressure chronic ulcer of other part of the foot (Unspecified L97.528 diagnosis codes are not covered) L97.811 – L97.828 Non-pressure chronic ulcer of lower leg (Unspecified diagnosis codes are not covered) L98.0 Pyogenic granuloma L98.2 Febrile neutrophilic dermatosis [Sweet] L98.3 Eosinophilic cellulitis [Wells] L98.8 Other specified disorders of the skin and subcutaneous tissue M05.071 – Felty's syndrome, ankle and foot M05.072 M05.171 – Rheumatoid lung disease with rheumatoid arthritis of ankle and foot M05.172 M05.271 – Rheumatoid vasculitis with rheumatoid arthritis of ankle and foot M05.272 M05.371 – Rheumatoid heart disease with rheumatoid arthritis of ankle and foot M05.372 M05.471 – Rheumatoid myopathy with rheumatoid arthritis of ankle, foot M05.472 M05.571 – Rheumatoid polyneuropathy with rheumatoid arthritis of ankle and foot M05.572 M05.671 – Rheumatoid arthritis of ankle and foot with involvement of other M05.672 organs and systems M05.771 – Rheumatoid arthritis with rheumatoid factor of ankle and foot without M05.772 organ or systems involvement M05.871 – Other rheumatoid arthritis with rheumatoid factor of ankle and foot M05.872 M06.071 – Rheumatoid arthritis without rheumatoid factor, ankle and foot M06.072

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes M06.271 – Rheumatoid bursitis, ankle and foot M06.272 M06.371 – Rheumatoid nodule, ankle and foot Rheumatoid nodule, ankle and foot M06.372 M06.871 – Other specified rheumatoid arthritis, ankle and foot M06.872 M08.271 – Juvenile rheumatoid arthritis with systemic onset, ankle and foot M08.272 M08.471 – Pauciarticular juvenile rheumatoid arthritis, ankle and foot M08.472 M08.871 – Other juvenile arthritis, ankle and foot M08.872 M1A.710 – Idiopathic chronic gout, ankle and foot M1A.721 M1A.1710 – Lead-induced chronic gout, ankle and foot M1A.1721 M1A.2710 – Drug-induced chronic gout, ankle and foot M1A.2721 M1A.3710 – Chronic gout due to renal impairment, ankle and foot M1A.3721 M1A.4710 – Other secondary chronic gout, ankle and foot M1A.4721 M10.071 – Idiopathic gout, ankle and foot M10.072 M10.171 – Lead-induced gout, ankle and foot M10.172 M10.271 – Drug-induced gout, ankle and foot M10.272 M10.371 – Gout due to renal impairment, ankle and foot M10.372 M10.471 – Other secondary gout, ankle and foot M10.472 M12.071 – Chronic postrheumatic arthropathy [Jaccoud], ankle and foot M12.072 M12.171 – Kaschin-Beck disease, ankle and foot M12.172 M12.271 – Villonodular synovitis (pigmented), ankle and foot M12.272 M12.371 – Palindromic rheumatism, ankle and foot M12.372 M12.471 – Intermittent hydrarthrosis, ankle and foot M12.472 M12.571 – Traumatic arthropathy, ankle and foot M12.572 M12.871 – Other specific arthropathies, not elsewhere classified, ankle and foot M12.872

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes M14.671 – Charcot's joint, ankle and foot M14.672 M19.071 – Primary osteoarthritis ankle and foot M19.072 M19.171 – Post-traumatic osteoarthritis, ankle and foot M19.172 M19.271 – Secondary osteoarthritis, ankle and foot M19.272 M20.11 – M20.5X2 Acquired deformities of toes (Unspecified diagnosis codes are not covered) M21.071 – Valgus deformity, not elsewhere classified, ankle M21.072 M21.171 – Varus deformity, not elsewhere classified, ankle M21.172 M21.371 – Acquired Foot drop M21.372 M21.531 – Acquired clawfoot or clubfoot, Bunion , Bunionette or other acquired M21.6X2 deformities of the foot (Unspecified diagnosis codes are not covered) M24.071 – Loose body in ankle and toe joints (Unspecified diagnosis codes are M24.075 not covered) M24.171 – Other articular cartilage disorders, ankle and foot (Unspecified M24.175 diagnosis codes are not covered) M24.271 – Disorder of ligament, ankle and foot (Unspecified diagnosis codes are M24.275 not covered) M24.371 – Pathological dislocation of ankle and foot, not elsewhere classified M24.375 (Unspecified diagnosis codes are not covered) M24.471 – Recurrent dislocation, ankle, foot and toes (Unspecified diagnosis M24.478 codes are not covered) M24.571 – Contracture, ankle and foot (Unspecified diagnosis codes are not M24.575 covered) M24.671 – Ankylosis, ankle and foot (Unspecified diagnosis codes are not M24.675 covered) M24.871 – Other specific joint derangements of ankle and foot, not elsewhere M24.875 classified (Unspecified diagnosis codes are not covered) M25.271 – Flail joint, ankle and foot (Unspecified diagnosis codes are not M25.272 covered) M25.371 – Other instability, ankle and foot (Unspecified diagnosis codes are not M25.375 covered) M25.471 – Effusion, ankle and foot (Unspecified diagnosis codes are not covered) M25.475 M25.571 – Pain in ankle and joints of foot M25.572 M25.671 – Stiffness of ankle and foot, not elsewhere classified (Unspecified M25.675 diagnosis codes are not covered) M25.771 – Osteophyte, ankle and foot (Unspecified diagnosis codes are not M25.775 covered) M25.87 – M25.872 Other specified joint disorders, ankle and foot

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes M34.0 – M34.89 Systemic sclerosis [scleroderma] M63.871 – Disorders of muscle in diseases classified elsewhere, ankle and foot M63.872 M65.061 – Abscess of tendon sheath, lower leg, ankle or foot M65.072 M65.171 – Other infective (teno)synovitis, ankle and foot M65.172 M65.261 – Calcific tendinitis, lower leg, ankle and foot (Unspecified diagnosis M65.272 codes are not covered) M65.861 – Other synovitis and tenosynovitis, lower leg, ankle and foot M65.872 (Unspecified diagnosis codes are not covered) M66.271 – Spontaneous rupture of extensor tendons, ankle and foot M66.272 M66.361 – Spontaneous rupture of flexor tendons, lower leg, ankle or foot M66.372 (Unspecified diagnosis codes are not covered) M66.861 – Spontaneous rupture of other tendons, lower leg, ankle or foot M66.872 (Unspecified diagnosis codes are not covered) M67.01 – M67.02 Short Achilles tendon (acquired) M67.261 – Synovial hypertrophy, not elsewhere classified, lower leg, ankle or foot M67.272 (Unspecified diagnosis codes are not covered) M67.371 – Transient synovitis, ankle and foot M67.372 M67.471 – Ganglion, ankle and foot M67.472 M67.871 – Other specified disorders of synovium and tendon, ankle and foot M67.874 M71.071 – Abscess of bursa, ankle and foot M71.072 M71.171 – Other infective bursitis, ankle and foot M71.172 M71.371 – Other bursal cyst, ankle and foot M71.372 M71.471 – Calcium deposit in bursa, ankle and foot M71.472 M71.571 – Other bursitis, not elsewhere classified, ankle and foot M71.572 M71.871 – Other specified bursopathies, ankle and foot M71.872 M72.2 Plantar fascial fibromatosis M76.61 – M76.899 Achilles , peroneal, posterior tibial tendinitis, and other enthesopathies of the lower limb (Unspecified diagnosis codes are not covered) M77.31 – M77.8 Calcaneal spur, metatarsalgia and Other enthesopathy of foot (Unspecified diagnosis codes are not covered) M79.5 Residual foreign body in soft tissue M79.661 – Pain in lower leg, foot or toes (Unspecified diagnosis codes are not M79.675 covered)

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes M80.061A – Age-related osteoporosis with current pathological fracture, lower leg M80.062S M80.071A – Age-related osteoporosis with current pathological fracture ankle and M80.072S foot M80.861A – Other osteoporosis with current pathological fracture, lower leg M80.862S M80.871A – Other osteoporosis with current pathological fracture, ankle and foot M80.872S M84.361A – Stress fracture, tibia or fibula M84.364S M84.371A – Stress fracture, ankle M84.372S M84.374A – Stress fracture, foot M84.375S M84.377A – Stress fracture, toes M84.378S M84.461A – Pathological fracture, tibia or fibula M84.464S M84.471A – Pathological fracture, ankle M84.472S M84.474A – Pathological fracture, foot M84.475S M84.477A – Pathological fracture, toes M84.478S M84.561A – Pathological fracture in neoplastic disease, tibia or fibula M84.564S M84.571A – Pathological fracture in neoplastic disease, ankle M84.572S M84.574A – Pathological fracture in neoplastic disease, foot M84.575S M84.661A – Pathological fracture in other disease, tibia or fibula M84.664S M84.671A – Pathological fracture in other disease, ankle M84.672S M84.674A – Pathological fracture in other disease, foot M84.675S M84.861 – Other disorders of continuity of bone, tibia or fibula M84.864 M84.871 – Other disorders of continuity of bone, ankle and foot M84.872 M85.061 – Fibrous dysplasia (monostotic), lower leg, ankle or foot (Unspecified M85.072 diagnosis codes are not covered) M85.161 – Skeletal fluorosis, lower leg, ankle or foot (Unspecified diagnosis codes M85.172 are not covered) M85.461 – Solitary bone cyst, tibia, fibula or ankle and foot (Unspecified diagnosis M85.472 codes are not covered)

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes M85.561 – Aneurysmal bone cyst, lower leg, ankle or foot (Unspecified diagnosis M85.572 codes are not covered) M85.661 – Other cyst of bone, leg or ankle and foot (Unspecified diagnosis codes M85.672 are not covered) M85.861 – Other specified disorders of bone density and structure, lower leg or M85.872 ankle and foot (Unspecified diagnosis codes are not covered) M86.061 – Acute hematogenous osteomyelitis, tibia and fibula, ankle and foot M86.072 (Unspecified diagnosis codes are not covered) M86.161 – Other acute osteomyelitis, tibia and fibula, ankle and foot (Unspecified M86.172 diagnosis codes are not covered) M86.261 – Subacute osteomyelitis, tibia and fibula, ankle and foot (Unspecified M86.272 diagnosis codes are not covered) M86.361 – Chronic multifocal osteomyelitis, tibia and fibula, ankle and foot M86.372 (Unspecified diagnosis codes are not covered) M86.461 – Chronic osteomyelitis with draining sinus, tibia and fibula, ankle and M86.472 foot (Unspecified diagnosis codes are not covered) M86.561 – Other chronic hematogenous osteomyelitis, tibia and fibula, ankle and M86.572 foot (Unspecified diagnosis codes are not covered) M86.661 – Other chronic osteomyelitis, tibia and fibula, ankle and foot M86.672 (Unspecified diagnosis codes are not covered) M86.8X6 – Other osteomyelitis, lower leg, or ankle and foot M86.8X7 M89.160 – Physeal arrest, lower leg M89.168 M89.261 – Other disorders of bone development and growth, tibia or fibula, ankle M89.272 and foot (Unspecified diagnosis codes are not covered) M89.361 – Hypertrophy of bone, tibia or fibula, ankle and foot (Unspecified M89.372 diagnosis codes are not covered) M89.461 – Other hypertrophic osteoarthropathy, lower leg, ankle and foot M89.472 (Unspecified diagnosis codes are not covered) M89.561 – Osteolysis, lower leg, ankle and foot (Unspecified diagnosis codes are M89.572 not covered) M89.661 – Osteopathy after poliomyelitis, lower leg, ankle and foot (Unspecified M89.672 diagnosis codes are not covered) M89.761 – Major osseous defect, lower leg, ankle and foot (Unspecified diagnosis M89.772 codes are not covered) M89.8X6 – Other specified disorders of bone, lower leg, or ankle and foot M89.8X7 M92.51 – M92.8 Juvenile osteochondrosis (Unspecified diagnosis codes are not covered) M93.271 – Osteochondritis dissecans of ankle and joints of foot M93.272 M93.861 – Other specified osteochondropathies lower leg, ankle and foot M93.872 (Unspecified diagnosis codes are not covered) M94.271 – Chondromalacia, ankle and joints of foot M94.272 M94.8X6 – Other specified disorders of cartilage, lower leg, or ankle and foot M94.8X7

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes N18.1 – N18.6 Chronic kidney disease (CKD) N25.1 Nephrogenic diabetes insipidus Q66.01 – Q66.02 Congenital talipes equinovarus Q66.11 – Q66.12 Congenital talipes calcaneovarus Q66.211 – Congenital metatarsus primus varus Q66.212 Q66.221 – Congenital metatarsus adductus Q66.222 Q66.31 – Q66.32 Other congenital varus deformities of feet Q66.41 – Q66.42 Congenital talipes calcaneovalgus Q66.6 Other congenital deformities of feet Q66.71 – Q66.72 Congenital pes cavus Q66.81 – Q66.82 Congenital vertical talus deformity Q66.89 Other specified congenital deformities of feet Q66.91 – Q66.92 Congenital deformity of feet Q72.21 – Q72.23 Congenital absence of both lower leg and foot Q72.31 – Q72.33 Congenital absence of foot and toe(s) Q72.51 – Q72.73 Longitudinal reduction defect of tibia or fibula, Split foot (Unspecified diagnosis codes are not covered) Q81.0 – Q81.8 Epidermolysis bullosa Q82.8 Other specified congenital malformations of skin R20.0 – R20.8 Disturbances of skin sensation R22.41 – R22.43 Localized swelling, mass and lump, lower limb R60.0 – R60.1 Edema, not elsewhere classified S81.811A – Open wound of lower leg (Unspecified diagnosis codes are not S81.852S covered) S82.221A – Fracture of lower leg, including ankle (Unspecified diagnosis codes are S82.292S not covered) S82.311A – Torus fracture of lower end of tibia S82.312S S82.391A – Other fracture of lower end of tibia S82.392S S82.421A – Fracture of lower leg, including ankle (Unspecified diagnosis codes are S82.65XS not covered) S82.821A – S82. Fracture of lower leg, including ankle (Unspecified diagnosis codes are 892S not covered) S84.01XA – Injury of nerves at lower leg level (Unspecified diagnosis codes are not S84.802S covered) S85.141A – Injury of blood vessels at lower leg level (Unspecified diagnosis codes S85.492S are not covered) S85.811A – Injury of blood vessels at lower leg level (Unspecified diagnosis codes S85.892S are not covered) S86.021A – Injury of Achilles tendon (Unspecified diagnosis codes are not covered) S86.092S

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes S86.121A – Injury of other muscle(s) and tendon(s) of posterior muscle group at S86.192S lower leg level (Unspecified diagnosis codes are not covered) S86.221A – Injury of muscle(s) and tendon(s) of anterior muscle group at lower S86.292S leg level (Unspecified diagnosis codes are not covered) S86.321A – Injury of muscle(s) and tendon(s) of peroneal muscle group at lower S86.392S leg level (Unspecified diagnosis codes are not covered) S86.821A – Injury of other muscle(s) and tendon(s) at lower leg level (Unspecified S86.892S diagnosis codes are not covered) S87.81XA – Crushing injury of lower leg S87.82XS S89.111A – Salter-Harris Type or other physeal fracture of lower end of tibia S89.192S (Unspecified diagnosis codes are not covered) S89.311A – Salter-Harris Type and other physeal fracture of lower end of fibula S89.392S S89.81XA – Other specified injuries of lower leg S89.82XS S90.01XA – Superficial injury of ankle, foot and toes (Unspecified diagnosis codes S90.872S are not covered) S91.011A – S91. Open wound of ankle, foot and toes (Unspecified diagnosis codes are 352S not covered) S92.011A – S92. Fracture of foot and toe, except ankle (Unspecified diagnosis codes are 812S not covered) S93.04XA – Dislocation of ankle joint S93.05XS S93.111A – Dislocation of interphalangeal or metatarsophalangeal joint of toe(s) S93.125S (Unspecified diagnosis codes are not covered) S93.314A – Dislocation of tarsal joint of foot S93.315S S93.324A – Dislocation of tarsometatarsal joint of foot S93.325S S93.334A – Other dislocation of foot S93.335S S96.021A – Laceration of muscle and tendon of long flexor muscle of toe at ankle S96.022S and foot level, foot S96.091A – Other injury of muscle and tendon of long flexor muscle of toe at ankle S96.092S and foot level, foot S96.121A – Laceration of muscle and tendon of long extensor muscle of toe at S96.122S ankle and foot level, foot S96.191A – Other specified injury of muscle and tendon of long extensor muscle of S96.192S toe at ankle and foot level, foot S96.221A – Laceration of intrinsic muscle and tendon at ankle and foot level, foot S96.222S S96.291A – Other specified injury of intrinsic muscle and tendon at ankle and foot S96.292S level, foot S96.821A – Laceration of other specified muscles and tendons at ankle and foot S96.822S level, foot

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes S96.891A – Other specified injury of other specified muscles and tendons at ankle S96.892S and foot level, foot S97.01XA – Crushing injury of ankle S97.02XS S97.111A – Crushing injury of great toe S97.112S S97.121A – Crushing injury of lesser toe(s) S97.122S S97.81XA – Crushing injury of foot S97.82XS S98.011A – Traumatic amputation of ankle and foot (Unspecified diagnosis codes S98.322S are not covered) S99.011A – Salter-Harris Type or other physeal fracture of calcaneus (Unspecified S99.092S diagnosis codes are not covered) S99.111A – Salter-Harris Type or other physeal fracture of metatarsal (Unspecified S99.192S diagnosis codes are not covered) S99.211A – Salter-Harris Type or other physeal fracture of phalanx of toe S99.292S (Unspecified diagnosis codes are not covered) S99.811A – Other specified injuries of ankle S99.812S S99.821A – Other specified injuries of foot S99.822S T25.111A – Burn of ankle and foot (Unspecified diagnosis codes are not covered) T25.392S T25.511A – Corrosion of ankle and foot (Unspecified diagnosis codes are not T25.792S covered) T33.811A – Superficial frostbite of ankle and foot (Unspecified diagnosis codes are T33.832S not covered) T34.811A – Frostbite with tissue necrosis of ankle and foot (Unspecified diagnosis T34.832S codes are not covered) T69.021A – Immersion foot T69.022S T69.1XXA – Chilblains T69.1XXS T81.31XA – T81. Disruption or infection of operation (surgical) wound, not elsewhere 4XXS classified (Unspecified diagnosis codes are not covered) T81.718A – Complication of other artery following a procedure, not elsewhere T81.718S classified T81.72XA – Complication of vein following a procedure, not elsewhere classified T81.72XS T81.89XA – Other complications of procedures, not elsewhere classified T81.89XS T84.018A – Broken internal joint prosthesis, other site T84.018S T84.028A – Dislocation of other internal joint prosthesis T84.028S

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes T84.038A – Mechanical loosening of other internal prosthetic joint T84.038S T84.058A – Periprosthetic osteolysis of other internal prosthetic joint T84.058S T84.068A – Wear of articular bearing surface of other internal prosthetic joint T84.068S T84.098A – Other mechanical complication of other internal joint prosthesis T84.098S T84.116A – Breakdown (mechanical) of internal fixation device of bone of lower leg T84.117S T84.126A – Displacement of internal fixation device of bone of lower leg T84.127S T84.196A – Other mechanical complication of internal fixation device of bone of T84.197S lower leg T84.213A – Breakdown (mechanical) of internal fixation device of bones of foot T84.213S and toes T84.223A – Displacement of internal fixation device of bones of foot and toes T84.223S T84.293A – Other mechanical complication of internal fixation device of bones of T84.293S foot and toes T84.310A – Breakdown (mechanical) of electronic bone stimulator T84.310S T84.318A – Breakdown (mechanical) of other bone devices, implants and grafts T84.318S T84.320A – Displacement of electronic bone stimulator T84.320S T84.328A – Displacement of other bone devices, implants and grafts T84.328S T84.390A – Other mechanical complication of electronic bone stimulator T84.390S T84.398A – Other mechanical complication of other bone devices, implants and T84.398S grafts T84.410A – Breakdown (mechanical) of muscle and tendon graft T84.410S T84.418A – Breakdown (mechanical) of other internal orthopedic devices, implants T84.418S and grafts T84.420A – Displacement of muscle and tendon graft T84.420S T84.428A – Displacement of other internal orthopedic devices, implants and grafts T84.428S T84.490A – Other mechanical complication of muscle and tendon graft T84.490S T84.498A – Other mechanical complication of other internal orthopedic devices, T84.498S implants and grafts T84.622A – Infection and inflammatory reaction due to internal fixation device of T84.625S tibia or fibula

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Preapproved Diagnoses for Podiatry Services Diagnosis Description Codes T84.69XA – Infection and inflammatory reaction due to internal fixation device of T84.69XS other site T84.7XXA – Infection and inflammatory reaction due to other internal orthopedic T84.7XXS prosthetic devices, implants and grafts T84.86XA – Thrombosis due to internal orthopedic prosthetic devices, implants and T84.86XS grafts T87.1X1 – Complications of reattached (part of) lower extremity T87.1X2 T87.33 – T87.34 Neuroma of amputation stump, lower extremity T87.43 – T87.44 Infection of amputation stump, lower extremity T87.53 – T87.54 Necrosis of amputation stump, lower extremity T87.81 Dehiscence of amputation stump T87.89 Other complications of amputation stump Z47.2 Encounter for removal of internal fixation device Z48.00 – Z48.1 Encounter for attention to dressings, sutures and drains Z48.3 Aftercare following surgery for neoplasm Z48.89 Encounter for other specified surgical aftercare Z51.89 Encounter for other specified aftercare Z89.411 – Acquired absence of toe, foot or ankle (Unspecified diagnosis codes are Z89.442 not covered)

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services Appendix C. Podiatric Medicine and Surgery Services, Provider Handbook Modifications This table lists the last three years of changes to this handbook as of the publication date.

Podiatric Medicine and Surgery Services, Provider Handbook Modifications

Version Section/ Modification Description Date SME Column 20.0 All Published version 7/19/2021 TQD 19.27 Appendix C. Clarified that only 3 years of 7/9/2021 W Deseron changes are listed. E Garibovic 19.26 1.6. References. Section deleted. References put 7/9/2021 W Deseron under individual sections. E Garibovic 19.25 7.2.1. Site of Service New section. 7/9/2021 W Deseron Differential E Garibovic 19.24 7.2. Site of Service Updated list of sites. 7/9/2021 W Deseron Differential E Garibovic 19.23 7.1. References: Updated references. 7/9/2021 W Deseron Reimbursement E Garibovic 19.22 7. Reimbursement Clarified enrollment requirement, 7/9/2021 W Deseron rate setting and fee schedule. E Garibovic W Deseron E Garibovic 19.21 6.2.1. New section. 7/9/2021 W Deseron References:Evaluation E Garibovic and Management 19.20 6.2. Evaluation and Updated with changes to 7/9/2021 W Deseron Management guidelines. E Garibovic 19.19 6.1. References: Updated references. 7/9/2021 W Deseron Documentation E Garibovic Requirements 19.18 6. Documentation Added information about 7/9/2021 W Deseron Requirements Department's right to inspect. E Garibovic 19.17 5.3. Telligen, Inc New section. 7/9/2021 W Deseron E Garibovic 19.16 5.2. The Medical Care New section. 7/9/2021 W Deseron Unit E Garibovic 19.15 5.1. References: Prior New section. 7/9/2021 W Deseron Authorizations E Garibovic 19.14 5. Prior Authorizations New section. 7/9/2021 W Deseron E Garibovic 19.13 4.2.1. References: New section. 7/9/2021 W Deseron Routine Foot Care E Garibovic 19.12 4.1. References: Updated references. 7/9/2021 W Deseron Covered Services and E Garibovic Limitations 19.11 3.2. Referrals Minor, non-substantive language 7/9/2021 W Deseron change. E Garibovic 19.10 3.1. References: New section. 7/9/2021 W Deseron Eligible Participants E Garibovic 19.9 3. Eligible Participants Minor, non-substantive language 7/9/2021 W Deseron change. E Garibovic

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services

Podiatric Medicine and Surgery Services, Provider Handbook Modifications

Version Section/ Modification Description Date SME Column 19.8 2.1. References: Updated references. 7/9/2021 Provider W Deseron Qualifications E Garibovic 19.7 2. Provider Clarified required qualifications 7/9/2021 W Deseron Qualifications and ability to be ORP. E Garibovic 19.6 1.4. Telligen, Inc New section. 7/9/2021 W Deseron E Garibovic 19.5 1.3. Medicaid New section. 7/9/2021 W Deseron E Garibovic 19.4 1.2. Provider New section. 7/9/2021 W Deseron Relations Consultants E Garibovic 19.3 1.1. Gainwell New section. 7/9/2021 W Deseron Technologies E Garibovic 19.2 1. Important Contacts New section. 7/9/2021 W Deseron E Garibovic 19.1 Podiatric Medicine Added how to use references. 7/9/2021 W Deseron and Surgery Services E Garibovic 19.0 All Published version 12/31/2020 TQD 18.1 All Removed DXC references, 12/31/2020 TQD rebranded to Gainwell Technologies 18.0 All Published version 01/01/2020 TQD 17.9 Appendix B. Updated with October 2019 code 11/26/2019 W Deseron Preapproved release E Garibovic Diagnoses for Podiatry Services 17.8 1.5.2 References: Renamed References: 11/26/2019 W Deseron Site of Service Reimbursement E Garibovic Differential 17.7 1.5 Reimbursement Added reminder of co-pay 11/26/2019 W Deseron requirements E Garibovic 17.6 1.4 Documentation New section 11/26/2019 W Deseron Requirements E Garibovic 17.5 1.3.3 References: New subsection 11/26/2019 W Deseron Covered Services and E Garibovic Limitations 17.4 1.4.2 References: Subsection moved. Renamed 11/26/2019 W Deseron Evaluation and References: Documentation E Garibovic Management Requirements. 17.3 1.4.1 Evaluation and Subsection moved under 11/26/2019 W Deseron Management Documentation Requirements. E Garibovic 17.2 1.2.2. EPSDT Services New subsection 11/26/2019 W Deseron for Participants Under E Garibovic 21 17.1 1.1.1 References: New subsection 11/26/2019 W Deseron Provider E Garibovic Qualifications 17.0 All Published version 8/23/2019 TQD 16.4 Appendix C Renamed from Section 8/21/2019 W Deseron Modifications. Removed changes K Duke dating back prior to three years

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Idaho Medicaid Provider Handbook Podiatric Medicine and Surgery Services

Podiatric Medicine and Surgery Services, Provider Handbook Modifications

Version Section/ Modification Description Date SME Column 16.3 Appendix B Renamed from Conditions That 8/21/2019 W Deseron Allow Automatic Payment of K Duke Claims 16.2 Appendix A Renamed from Restricted Benefit 8/21/2019 W Deseron Diagnoses for Routine Foot Care K Duke 16.1 1.3.2 Routine Foot Added use of KX modifier for a 8/21/2019 W Deseron Care diagnosis not under pre-approved K Duke list 16.0 All Published version 7/1/2019 TQD 15.6 Appendix B Added clarification that unspecified 6/26/2019 W Deseron Conditions That Allow codes in covered code range are K Duke Automatic Payment of not covered. Claims 15.5 Appendix A Restricted Added clarification that unspecified 6/26/2019 W Deseron Benefit Diagnoses for codes in covered code ranges are K Duke Routine Foot Care not covered. 15.4 1.4.1 Site of Service Updated list of Places of Service. 6/26/2019 W Deseron Differential K Duke 15.3 1.3.1 Evaluation and New section. Added CMS 6/26/2019 W Deseron Management guidelines for E&M codes. K Duke 15.2 1.2.1 Referrals Renamed section from Healthy 6/26/2019 W Deseron Connections (HC). K Duke 15.1 1. Podiatric Medicine Added glossary to applicable 6/26/2019 W Deseron and Surgery Service documents. K Duke Providers

15.0 All Published version 11/1/2018 TQD 14.1 All Removed Molina references 11/1/2018 D Baker E Garibovic 14.0 All Published version 8/27/2018 TQD 13.7 Appendix A Changed name of section for 8/27/2018 D Baker Appendix B standards E Garibovic 13.6 2.5. References New Section 8/27/2018 D Baker E Garibovic 13.5 2.4. Reimbursement Section moved from top. Added 8/27/2018 D Baker encounter language E Garibovic 13.4 2.3 Covered Services Updated section titles. Moved 8/27/2018 D Baker and Limitations Routine foot care into own section. E Garibovic Directed to Appendix & Suppliers 13.3 2.2. Eligible Name change of section. Added 8/27/2018 D Baker Participants reference to benefit plans E Garibovic 13.2 2.1. Provider New section 8/27/2018 D Baker Qualifications E Garibovic 13.1 2. Podiatric Medicine Removed General policy heading. 8/27/2018 D Baker and Surgery Service Indicated required handbooks for E Garibovic Providers provider type

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