Current through Reg. 49, No. 38; September 20, 2024
(a) This
rule specifies the conditions under which a physician may bill Texas Medicaid
for covered services. Such conditions include compliance with this rule as well
as compliance with all applicable federal and state laws, rules, regulations
and policies relating to covered services.
(b) Physician services. A physician may bill
for reasonable and medically necessary services that are within the scope of
practice of medicine or osteopathy as defined by state law. Except for services
provided under subsections (c), (d), and (e) of this section, eligible
physician services include those performed by the physician and those medical
acts delegated by the physician to qualified and properly trained persons
acting under the physician's supervision. Delegation and supervision of medical
services must be consistent with this chapter and the rules and laws of the
Texas Medical Board, and supervision of the delegated medical act must be
appropriately documented in the patient's chart. A physician shall not bill the
Texas Medicaid program for services if that billing would result in duplicate
payment for the same services.
(c)
Physician supervising other physicians. A physician supervising other
physicians may bill when the supervision and services are performed in the
context of an accredited graduate medical education program. Facilities and
professional practices do not qualify for reimbursement for services provided
by resident physicians in an outpatient setting unless the facility or
professional practice is owned by, or affiliated with, an accredited graduate
medical education program.
(1) For all
services billed to the Medicaid program, the supervision must be medically
appropriate, as described in this rule, and provided to a resident physician
performing a Medicaid-covered service. The supervision must be either personal
or direct. To qualify for reimbursement, the medical record must clearly
establish:
(A) The nature of the supervisory
role of the billing physician in the delivery of the services provided by the
resident physician; and
(B) That
the supervision complies with the definition of supervision applicable to the
covered service, as defined in §
RSA 354.1060 of this
title (relating to Definitions).
(2) Personal supervision is required during
the key portions of all major surgeries and the key portions of all other
physician services billed to the Medicaid program if the immediate supervision,
participation, or intervention of the supervising physician is medically
prudent in order to assure the health and safety of the patient. Physician
services that require personal supervision may include invasive procedures and
evaluation and management services that require complex medical decision
making. Situations that require personal supervision include those in which:
(A) The clinical condition of the patient is
unstable or will likely become unstable during, or as a result of, the planned
medical intervention; or
(B) The
planned medical intervention, even under optimal conditions, will result in
medically reasonable risk for significant morbidity or death following the
service or procedure; or
(C)
Deviation from expected technique at the time the procedure or service is
performed presents a medically reasonable, causally-related, foreseeable risk
to the patient's life or health.
(3) For surgical services, the supervising
surgeon is responsible for pre-operative, operative, and post-operative care
provided to the patient and billed to the Medicaid program. The supervising
surgeon, however, may delegate the pre- and post-operative care to a resident
if appropriate direct supervision, as defined in §
RSA 354.1060 of this
title, is provided.
(4) For all
services that do not require personal supervision and are billed to the
Medicaid program, the supervising physician must provide direct supervision.
The supervising physician may not provide direct supervision for an activity at
the same time as providing personal supervision for another activity, with the
following exceptions.
(A) The supervising
physician in the outpatient setting may provide personal and direct supervision
concurrently for residents providing evaluation and management services;
and
(B) A supervising surgeon or
supervising anesthesiologist may be involved in two concurrent anesthesia cases
with residents. The supervising surgeon or supervising anesthesiologist must be
present during all key portions of the procedure if the immediate supervision,
participation, or intervention of the supervising physician is medically
prudent in order to assure the health and safety of the patient.
(5) Supervision in the outpatient
setting. A face-to-face encounter between the physician providing direct
supervision and the patient is not required in the outpatient setting in the
context of a graduate medical education program. All other requirements for
personal or direct supervision in this division must be met for the services to
qualify for reimbursement. The supervising physician must document that he/she:
(A) Reviewed the patient's history and
physical examination;
(B) Confirmed
or revised the patient's diagnosis;
(C) Determined the course of treatment to be
followed;
(D) Assured that any
needed supervision of interns or residents was provided; and
(E) Confirmed that the documentation in the
medical record comports with the level of service billed.
(6) Supervision in the inpatient setting. A
physician who supervises other physicians in an inpatient setting must comply
with documentation requirements of paragraph (5)(A) - (E) of this subsection
and must document that he or she has completed a:
(A) Personal examination of the patient not
later than 36 hours after the patient's admission and before the patient's
discharge and, as necessary, based on the patient's condition; and
(B) Face-to-face encounter with the patient
on the same day as any billed services provided by the resident
physician.
(d) Services provided by a physician
assistant, anesthesiologist assistant, or advanced practice registered nurse.
(1) A service performed under a physician's
supervision by a physician assistant or an advanced practice registered nurse
(excluding a certified registered nurse anesthetist), acting within the scope
of the physician assistant's or advanced practice registered nurse's license
and consistent with this chapter and the rules and laws of the Texas Medical
Board and Texas Board of Nursing, as applicable, are reimbursed according to
the reimbursement rule applicable to the supervised practitioner unless the
supervising physician made a decision regarding the patient's care or treatment
on the same date of service as the billable medical visit and documented that
decision in the patient's record.
(A) The
physician's record of patient care must document the physician's
involvement.
(B) If the physician
did not make a decision about the patient's care on the same date of service as
the billable medical visit, the physician must note on the claim that the
service was performed by the physician assistant or advanced practice
registered nurse in accordance with §
RSA
354.1001 of this subchapter (relating to
Claim Information Requirements).
(2) Services provided by a certified
registered nurse anesthetist must be billed as described in §
RSA
354.1301 of this subchapter (relating to
Benefits and Limitations).
(3)
Services provided by an anesthesiologist assistant must be billed as described
in §354.1065 of this division (relating to Anesthesiologist Assistant
Benefits and Limitations).
(e) Substitute physician. A physician may
bill for the services of a substitute physician who sees patients in the
billing physician's practice under either a reciprocal or locum tenens
arrangement. To qualify for reimbursement, the billing physician and substitute
physician must comply with the following requirements:
(1) The substitute physician's name and
address must be documented on the claim.
(2) The substitute physician must be licensed
to practice in the state of Texas.
(3) Consistent with the requirements of
§
RSA
371.1605 and §
RSA 371.1705
of this title (relating to Provider Responsibility and Mandatory Exclusion,
respectively), the substitute physician must be enrolled in Medicaid and not be
on the Medicaid or Title XX provider exclusion list.
(4) The time period for which a physician may
bill for the services of a substitute physician is limited to the following
situations:
(A) Reciprocal Arrangements. When
the substitute physician sees patients in the billing physician's practice
under a reciprocal arrangement, the billing physician may bill for services
furnished by the substitute physician during a period that does not exceed 14
continuous days.
(B) Locum Tenens
Arrangements. When the substitute physician sees patients in the billing
physician's practice under a locum tenens arrangement, the billing physician
may bill for services furnished by the substitute physician during a period
that does not exceed 90 continuous days. Except as provided in clause (iii) of
this subparagraph, services furnished by the substitute physician after the
90th day must be billed under the substitute physician's own Medicaid provider
number.
(i) When the billing physician is
absent for more than 90 days, the billing physician may bill for services
furnished by a different substitute physician for each consecutive continuous
90 day period.
(ii) The billing
physician may only bill for services furnished by a substitute physician on a
temporary basis. Except as provided in clause (iii) of this subparagraph, the
billing physician may not bill for services furnished by a substitute physician
to address long-term vacancies in a physician practice.
(iii) When the billing physician is absent or
unavailable due to active duty as a member of a reserve component of the U.S.
Armed Forces, the billing physician may bill for the services of a substitute
physician for a longer continuous period during all of which the billing
physician has been called or ordered to active duty as a member of a reserve
component of the Armed Forces. Medicaid may reimburse the billing physician for
services provided by the substitute physician until the billing physician is no
longer on active duty as a member of a reserve component of the Armed
Forces.
