# diabetic foot exam



## Elizabethchris

If an exam is part of an E&M component that must be obtained and documented by physician, can an MA or RN perform a diabetic foot exam?


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## Chelle-Lynn

The exam must be performed and documented by the provider (physician, NP, PA) for it to be considered part of the E&M leveling criteria.


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## Elizabethchris

Chelle-Lynn said:


> The exam must be performed and documented by the provider (physician, NP, PA) for it to be considered part of the E&M leveling criteria.



Thanks for responding, I guess for further clarification, if the MA works incident to the provider service (E&M) and is trained to perform diabetic foot exams, can the diabetic foot exam performed by the MA be accepted as an exam element to bill the E&M code?  Will the provider have to validate the information?  Or is it non-compliant & provider of service still has to do their own foot exam & document it?


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## Chelle-Lynn

An Medical Assistant is not eligible for "incident to" rules.  The provider will have to complete their own foot exam and document the findings.


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## Elizabethchris

Chelle-Lynn said:


> An Medical Assistant is not eligible for "incident to" rules.  The provider will have to complete their own foot exam and document the findings.



Thanks again for responding, but I'm a little confused by that statement.  According to CMS, "Incident to a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness."  The service can be performed by an Auxiliary personnel which includes a Medical assistant.  In the office setting, the medical assistant performs, under the direct supervision of the physician, clinical duties such as vitals, initial assessment, etc.  The claim still gets billed out under the physician.  But since the exam is considered physician work, it might have to be completed by the physician.  I'm just curious because MA's and RN's are trained to perform diabetic foot exams.


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## Chelle-Lynn

Sorry, let me clarify, the MA is only eligible to assist the provider with documentation under the history portion of the visit for ROS and PSFH.  Exam and MDM must be provided and documented by the provider (physician, NP, PA).


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