|(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
(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. 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
(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
(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 or advanced
practice nurse. If the services are provided by a physician assistant
or advanced practice nurse, practicing within the scope of their license
and consistent with this chapter and with the rules and laws of the
Texas Medical Board and Texas Nursing Board, as applicable, the physician
services are covered. Services provided by a certified registered
nurse anesthetist must be billed as described in §354.1301 of
this title (relating to Certified Registered Nurse Anesthetists' Services).
(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
(4) The time period for which a physician may bill
for the services of a substitute physician is limited to the following
(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
(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
(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
(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.
|Source Note: The provisions of this §354.1062 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 14, 1984, 9 TexReg 583; amended to be effective October 8, 1984, 9 TexReg 4975; amended to be effective September 1, 1986, 11 TexReg 3301; amended to be effective March 16, 1988, 13 TexReg 1107; amended to be effective August 1, 1988, 13 TexReg 3528; amended to be effective July 1, 1989, 14 TexReg 2685; amended to be effective September 1, 1989, 14 TexReg 4133; amended to be effective November 5, 1990, 16 TexReg 1934; transferred effective September 1, 1993, as publishedin the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective August 24, 1998, 23 TexReg 8681; amended to be effective April 1, 2000, 25 TexReg 2630; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 5, 2009, 34 TexReg 5059; amended to be effective July 14, 2014, 39 TexReg 5353