(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.
Cont'd...