1 Tex. Admin. Code § 354.1062 - Authorized Physician Services
(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 §
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 §
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 §
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 §
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
§
371.1605 and §
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.
Notes
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