(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.
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